1
|
Yoon S, Goh H, Lee PC, Tan HC, Teh MM, Lim DST, Kwee A, Suresh C, Carmody D, Swee DS, Tan SYT, Wong AJW, Choo CHM, Wee Z, Bee YM. Assessing the Utility, Impact, and Adoption Challenges of an Artificial Intelligence-Enabled Prescription Advisory Tool for Type 2 Diabetes Management: Qualitative Study. JMIR Hum Factors 2024; 11:e50939. [PMID: 38869934 PMCID: PMC11211700 DOI: 10.2196/50939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/07/2023] [Accepted: 05/05/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND The clinical management of type 2 diabetes mellitus (T2DM) presents a significant challenge due to the constantly evolving clinical practice guidelines and growing array of drug classes available. Evidence suggests that artificial intelligence (AI)-enabled clinical decision support systems (CDSSs) have proven to be effective in assisting clinicians with informed decision-making. Despite the merits of AI-driven CDSSs, a significant research gap exists concerning the early-stage implementation and adoption of AI-enabled CDSSs in T2DM management. OBJECTIVE This study aimed to explore the perspectives of clinicians on the use and impact of the AI-enabled Prescription Advisory (APA) tool, developed using a multi-institution diabetes registry and implemented in specialist endocrinology clinics, and the challenges to its adoption and application. METHODS We conducted focus group discussions using a semistructured interview guide with purposively selected endocrinologists from a tertiary hospital. The focus group discussions were audio-recorded and transcribed verbatim. Data were thematically analyzed. RESULTS A total of 13 clinicians participated in 4 focus group discussions. Our findings suggest that the APA tool offered several useful features to assist clinicians in effectively managing T2DM. Specifically, clinicians viewed the AI-generated medication alterations as a good knowledge resource in supporting the clinician's decision-making on drug modifications at the point of care, particularly for patients with comorbidities. The complication risk prediction was seen as positively impacting patient care by facilitating early doctor-patient communication and initiating prompt clinical responses. However, the interpretability of the risk scores, concerns about overreliance and automation bias, and issues surrounding accountability and liability hindered the adoption of the APA tool in clinical practice. CONCLUSIONS Although the APA tool holds great potential as a valuable resource for improving patient care, further efforts are required to address clinicians' concerns and improve the tool's acceptance and applicability in relevant contexts.
Collapse
Affiliation(s)
- Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Population Health Research and Implementation, SingHealth Regional Health System, SingHealth, Singapore, Singapore
| | - Hendra Goh
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Phong Ching Lee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Hong Chang Tan
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Ming Ming Teh
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Ann Kwee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Chandran Suresh
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - David Carmody
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Du Soon Swee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Sarah Ying Tse Tan
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Andy Jun-Wei Wong
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | | | - Zongwen Wee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
2
|
Fletcher E, Burns A, Wiering B, Lavu D, Shephard E, Hamilton W, Campbell JL, Abel G. Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review. BMC PRIMARY CARE 2023; 24:23. [PMID: 36670354 PMCID: PMC9857918 DOI: 10.1186/s12875-023-01973-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow. METHODS A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed. RESULTS The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue". CONCLUSIONS The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.
Collapse
Affiliation(s)
- Emily Fletcher
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Alex Burns
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Bianca Wiering
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Deepthi Lavu
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Elizabeth Shephard
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Willie Hamilton
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - John L. Campbell
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| | - Gary Abel
- grid.8391.30000 0004 1936 8024College of Medicine and Health, University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, Devon EX1 2LU England
| |
Collapse
|
3
|
Meunier PY, Raynaud C, Guimaraes E, Gueyffier F, Letrilliart L. Barriers and Facilitators to the Use of Clinical Decision Support Systems in Primary Care: A Mixed-Methods Systematic Review. Ann Fam Med 2023; 21:57-69. [PMID: 36690490 PMCID: PMC9870646 DOI: 10.1370/afm.2908] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/08/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To identify and quantify the barriers and facilitators to the use of clinical decision support systems (CDSSs) by primary care professionals (PCPs). METHODS A mixed-methods systematic review was conducted using a sequential synthesis design. PubMed/MEDLINE, PsycInfo, Embase, CINAHL, and the Cochrane library were searched in July 2021. Studies that evaluated CDSSs providing recommendations to PCPs and intended for use during a consultation were included. We excluded CDSSs used only by patients, described as concepts or prototypes, used with simulated cases, and decision supports not considered as CDSSs. A framework synthesis was performed according to the HOT-fit framework (Human, Organizational, Technology, Net Benefits), then a quantitative synthesis evaluated the impact of the HOT-fit categories on CDSS use. RESULTS A total of 48 studies evaluating 45 CDSSs were included, and 186 main barriers or facilitators were identified. Qualitatively, barriers and facilitators were classified as human (eg, perceived usefulness), organizational (eg, disruption of usual workflow), and technological (eg, CDSS user-friendliness), with explanatory elements. The greatest barrier to using CDSSs was an increased workload. Quantitatively, the human and organizational factors had negative impacts on CDSS use, whereas the technological factor had a neutral impact and the net benefits dimension a positive impact. CONCLUSIONS Our findings emphasize the need for CDSS developers to better address human and organizational issues, in addition to technological challenges. We inferred core CDSS features covering these 3 factors, expected to improve their usability in primary care.
Collapse
Affiliation(s)
- Pierre-Yves Meunier
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Camille Raynaud
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
| | - Emmanuelle Guimaraes
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
| | - François Gueyffier
- Laboratoire de biométrie et biologie évolutive, département biostatistiques et modélisation pour la santé et l'environnement, CNRS UMR5558, Université Claude Bernard Lyon 1, Lyon, France
- Fédération de Recherche Santé Lyon Est, PAM Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Laurent Letrilliart
- Collège universitaire de médecine générale, Université Claude Bernard Lyon 1, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
4
|
Johnson LCM, Nikhare K, Jaganathan S, Ali MK, Venkat Narayan KM, Prabhakaran D, Tandon N, Singh K. Stakeholder Perspectives regarding the Acceptability and Sustainability of a Multi-component Diabetes Care Strategy in South Asia: a longitudinal qualitative analysis. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2022; 2:350-360. [PMID: 37745272 PMCID: PMC10516368 DOI: 10.1007/s43477-022-00060-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/29/2022] [Indexed: 09/26/2023]
Affiliation(s)
- Leslie C. M. Johnson
- Emory School of Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | | | | | - Mohammed K. Ali
- Emory School of Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
- Rollins School of Public Health, Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - KM Venkat Narayan
- Rollins School of Public Health, Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, Gurugram, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Nikhil Tandon
- All India Institute of Medical Sciences, Department of Endocrinology & Metabolism, New Delhi, India
| | - Kavita Singh
- Public Health Foundation of India, Gurugram, India
- Centre for Chronic Disease Control, New Delhi, India
| |
Collapse
|
5
|
Chen W, O’Bryan CM, Gorham G, Howard K, Balasubramanya B, Coffey P, Abeyaratne A, Cass A. Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation. Implement Sci Commun 2022; 3:81. [PMID: 35902894 PMCID: PMC9330991 DOI: 10.1186/s43058-022-00326-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS-exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems. METHODS A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach. RESULTS Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care; user confidence gained through training and post training follow-up; external contexts comprised of strong clinical champions, allocated personnel, and technical support; and CDS technical features that are both highly functional, and attractive. CONCLUSION This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research. TRIAL REGISTRATION PROSPERO CRD42020203716.
Collapse
Affiliation(s)
- Winnie Chen
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Claire Maree O’Bryan
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Gillian Gorham
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - Bhavya Balasubramanya
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Patrick Coffey
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Asanga Abeyaratne
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811 Australia
| |
Collapse
|
6
|
Sung M, He J, Zhou Q, Chen Y, Ji JS, Chen H, Li Z. Using an Integrated Framework to Investigate the Facilitators and Barriers of Health Information Technology Implementation in Noncommunicable Disease Management: Systematic Review. J Med Internet Res 2022; 24:e37338. [PMID: 35857364 PMCID: PMC9350822 DOI: 10.2196/37338] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/25/2022] [Accepted: 06/27/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Noncommunicable disease (NCD) management is critical for reducing attributable health burdens. Although health information technology (HIT) is a crucial strategy to improve chronic disease management, many health care systems have failed in implementing HIT. There has been a lack of research on the implementation process of HIT for chronic disease management. OBJECTIVE We aimed to identify the barriers and facilitators of HIT implementation, analyze how these factors influence the implementation process, and identify key areas for future action. We will develop a framework for understanding implementation determinants to synthesize available evidence. METHODS We conducted a systematic review to understand the barriers and facilitators of the implementation process. We searched MEDLINE, Cochrane, Embase, Scopus, and CINAHL for studies published between database inception and May 5, 2022. Original studies involving HIT-related interventions for NCD management published in peer-reviewed journals were included. Studies that did not discuss relevant outcome measures or did not have direct contact with or observation of stakeholders were excluded. The analysis was conducted in 2 parts. In part 1, we analyzed how the intrinsic attributes of HIT interventions affect the successfulness of implementation by using the intervention domain of the Consolidated Framework for Implementation Research (CFIR). In part 2, we focused on the extrinsic factors of HIT using an integrated framework, which was developed based on the CFIR and the levels of change framework by Ferlie and Shortell. RESULTS We identified 51 papers with qualitative, mixed-method, and cross-sectional methodologies. Included studies were heterogeneous regarding disease populations and HIT interventions. In part 1, having a relative advantage over existing health care systems was the most prominent intrinsic facilitator (eg, convenience, improvement in quality of care, and increase in access). Poor usability was the most noted intrinsic barrier of HIT. In part 2, we mapped the various factors of implementation to the integrated framework (the coordinates are shown as level of change-CFIR). The key barriers to the extrinsic factors of HIT included health literacy and lack of digital skills (individual-characteristics of individuals). The key facilitators included physicians' suggestions, cooperation (interpersonal-process), integration into a workflow, and adequate management of data (organizational-inner setting). The importance of health data security was identified. Self-efficacy issues of patients and organizational readiness for implementation were highlighted. CONCLUSIONS Internal factors of HIT and external human factors of implementation interplay in HIT implementation for chronic disease management. Strategies for improvement include ensuring HIT has a relative advantage over existing health care; tackling usability issues; and addressing underlying socioeconomic, interpersonal, and organizational conditions. Further research should focus on studying various stakeholders, such as service providers and administrative workforces; various disease populations, such as those with obesity and mental diseases; and various countries, including low- and middle-income countries.
Collapse
Affiliation(s)
- Meekang Sung
- College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - Jinyu He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Qi Zhou
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - John S Ji
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Haotian Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Zhihui Li
- Vanke School of Public Health, Tsinghua University, Beijing, China.,Institute for Healthy China, Tsinghua Universtiy, Beijing, China
| |
Collapse
|
7
|
Scalia P, Ahmad F, Schubbe D, Forcino R, Durand MA, Barr PJ, Elwyn G. Integrating Option Grid Patient Decision Aids in the Epic Electronic Health Record: Case Study at 5 Health Systems. J Med Internet Res 2021; 23:e22766. [PMID: 33938806 PMCID: PMC8129884 DOI: 10.2196/22766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/20/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Abstract
Background Some researchers argue that the successful implementation of patient decision aids (PDAs) into clinical workflows depends on their integration into electronic health records (EHRs). Anecdotally, we know that EHR integration is a complex and time-consuming task; yet, the process has not been examined in detail. As part of an implementation project, we examined the work involved in integrating an encounter PDA for symptomatic uterine fibroids into Epic EHR systems. Objective This study aims to identify the steps and time required to integrate a PDA into the Epic EHR system and examine facilitators and barriers to the integration effort. Methods We conducted a case study at 5 academic medical centers in the United States. A clinical champion at each institution liaised with their Epic EHR team to initiate the integration of the uterine fibroid Option Grid PDAs into clinician-facing menus. We scheduled regular meetings with the Epic software analysts and an expert Epic technologist to discuss how best to integrate the tools into Epic for use by clinicians with patients. The meetings were then recorded and transcribed. Two researchers independently coded the transcripts and field notes before categorizing the codes and conducting a thematic analysis to identify the facilitators and barriers to EHR integration. The steps were reviewed and edited by an Epic technologist to ensure their accuracy. Results Integrating the uterine fibroid Option Grid PDA into clinician-facing menus required an 18-month timeline and a 6-step process, as follows: task priority negotiation with Epic software teams, security risk assessment, technical review, Epic configuration; troubleshooting, and launch. The key facilitators of the process were the clinical champions who advocated for integration at the institutional level and the presence of an experienced technologist who guided Epic software analysts during the build. Another facilitator was the use of an emerging industry standard app platform (Health Level 7 Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources) as a means of integrating the Option Grid into existing systems. This standard platform enabled clinicians to access the tools by using single sign-on credentials and prevented protected health information from leaving the EHR. Key barriers were the lack of control over the Option Grid product developed by EBSCO (Elton B Stephens Company) Health; the periodic Epic upgrades that can result in a pause on new software configurations; and the unforeseen software problems with Option Grid (ie, inability to print the PDA), which delayed the launch of the PDA. Conclusions The integration of PDAs into the Epic EHR system requires a 6-step process and an 18-month timeline. The process required support and prioritization from a clinical champion, guidance from an experienced technologist, and a willing EHR software developer team.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Glyn Elwyn
- Dartmouth College, Lebanon, NH, United States
| |
Collapse
|
8
|
Alhodaib HI, Antza C, Chandan JS, Hanif W, Sankaranarayanan S, Paul S, Sutcliffe P, Nirantharakumar K. Mobile Clinical Decision Support System for the Management of Diabetic Patients With Kidney Complications in UK Primary Care Settings: Mixed Methods Feasibility Study. JMIR Diabetes 2020; 5:e19650. [PMID: 33206055 PMCID: PMC7710444 DOI: 10.2196/19650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/03/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Attempts to utilize eHealth in diabetes mellitus (DM) management have shown promising outcomes, mostly targeted at patients; however, few solutions have been designed for health care providers. OBJECTIVE The purpose of this study was to conduct a feasibility project developing and evaluating a mobile clinical decision support system (CDSS) tool exclusively for health care providers to manage chronic kidney disease (CKD) in patients with DM. METHODS The design process was based on the 3 key stages of the user-centered design framework. First, an exploratory qualitative study collected the experiences and views of DM specialist nurses regarding the use of mobile apps in clinical practice. Second, a CDSS tool was developed for the management of patients with DM and CKD. Finally, a randomized controlled trial examined the acceptability and impact of the tool. RESULTS We interviewed 15 DM specialist nurses. DM specialist nurses were not currently using eHealth solutions in their clinical practice, while most nurses were not even aware of existing medical apps. However, they appreciated the potential benefits that apps may bring to their clinical practice. Taking into consideration the needs and preferences of end users, a new mobile CDSS app, "Diabetes & CKD," was developed based on guidelines. We recruited 39 junior foundation year 1 doctors (44% male) to evaluate the app. Of them, 44% (17/39) were allocated to the intervention group, and 56% (22/39) were allocated to the control group. There was no significant difference in scores (maximum score=13) assessing the management decisions between the app and paper-based version of the app's algorithm (intervention group: mean 7.24 points, SD 2.46 points; control group: mean 7.39, SD 2.56; t37=-0.19, P=.85). However, 82% (14/17) of the participants were satisfied with using the app. CONCLUSIONS The findings will guide the design of future CDSS apps for the management of DM, aiming to help health care providers with a personalized approach depending on patients' comorbidities, specifically CKD, in accordance with guidelines.
Collapse
Affiliation(s)
- Hala Ibrahim Alhodaib
- Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Christina Antza
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Wasim Hanif
- Diabetes Centre, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Sailesh Sankaranarayanan
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism Centre, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Sunjay Paul
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Paul Sutcliffe
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom.,Health Data Research UK, Birmingham, United Kingdom
| |
Collapse
|
9
|
Manski-Nankervis JA, Biezen R, Thursky K, Boyle D, Clark M, Lo S, Buising K. Developing a Clinical Decision Support Tool for Appropriate Antibiotic Prescribing in Australian General Practice: A Simulation Study. Med Decis Making 2020; 40:428-437. [PMID: 32507028 DOI: 10.1177/0272989x20926136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Inappropriate antibiotic prescribing can lead to antimicrobial resistance and drug side effects. Tools that assist general practitioners (GPs) in prescribing decisions may help to optimize prescribing. The aim of this study was to explore the use, acceptability, and feasibility of a clinical decision support (CDS) tool that incorporates evidence-based guidelines and consumer information that integrates with the electronic medical record (EMR). Methods. Eight GPs completed an interview and brief survey after participating in 2 simulated consultations. The survey consisted of demographic questions, perception of realism and representativeness of consultations, Post-Study System Usability Questionnaire, and System Usability Scale. Qualitative data were analyzed using framework analysis. Video data were reviewed, with length of consultation and time spent using the CDS tool documented. Results. Survey responses indicated that all GPs thought the consultations were "real" and representative of real-life consultations; 7 of 8 GPs were satisfied with usability of the tool. Key qualitative findings included that the tool assisted with clinical decision making and informed appropriate antibiotic prescribing. Accessibility and ease of use, including content (guideline and patient education resources), layout, and format, were key factors that determined whether GPs said that they would access the tool in everyday practice. Integration of the tool at multiple sites within the EMR facilitated access to guidelines and assisted in ensuring that the tool fit the clinical workflow. Conclusion. Our CDS tool was acceptable to GPs. Key features required for the tool were easy navigation, clear and useful guideline content, ability to fit into the clinical workflow, and incorporation into the EMR. Piloting of the tool in general practices to assess the impact and feasibility of use in real-world consultations will now be undertaken.
Collapse
Affiliation(s)
| | - Ruby Biezen
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Thursky
- The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Douglas Boyle
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Malcolm Clark
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Sean Lo
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Kirsty Buising
- The National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| |
Collapse
|
10
|
Mathews R, O'Malley C, Hall JM, Macaden L, MacRury S. Diabetes, Care Homes, and the Influence of Technology on Practice and Care Delivery in Care Homes: Systematic Review and Qualitative Synthesis. JMIR Diabetes 2019; 4:e11526. [PMID: 31008705 PMCID: PMC6658297 DOI: 10.2196/11526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/15/2018] [Accepted: 12/31/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Diabetes is increasing in prevalence and complexity in the care home setting, affecting up to a quarter of care home residents. Health outcomes for these residents are impacted by management of the disease, health care professionals (HCPs)' decision-making skills within the care home setting, and access to specialist services. The use of technology has the potential to recognize opportunities for early intervention that enables efficient responsive care, taking a fundamental role in linking the care home community to wider multidisciplinary teams for support. OBJECTIVE The aim of this paper was to identify evidence that explores factors relevant to the use of technology in and around the care home setting to aid in the management of diabetes. METHODS Databases searched using a structured prespecified approach included: PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), OVID Nursing database, Scopus, MEDLINE, the Cochrane Library, and the King's Fund from 2012 to 2017: handsearching was undertaken additionally for any gray literature. Preferred Reporting Items for Systematic review and Meta-Analysis Protocol was used as protocol with Risk of Bias in Systematic reviews a tool to assess the risk of bias across studies. Studies had to include interventions that combined technology to or from the care home setting to support residents living with diabetes. RESULTS The combined search strategy identified a total of 493 electronic records. Of these, 171 papers were screened for eligibility, 66 full papers were accessed, and 13 have been included in this study. Qualitative synthesis has identified different strands of research evidence in what and how technology is currently being used in and around care homes to enhance diabetes management. New initiatives and implementations of technology and emerging models of care that included the use of technology have also been included. CONCLUSIONS By triangulating the perspectives of HCPs, practitioners, specialists, and members of the care home community, the authors anticipate that this review will represent an up-to-date, evidence-based overview of the potential for using technology within the care home setting for diabetes management as well as stimulate research in this area.
Collapse
Affiliation(s)
- Rebecca Mathews
- Division of Rural Health and Wellbeing, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Chris O'Malley
- Highland Health Sciences Library, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Jenny M Hall
- Division of Rural Health and Wellbeing, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Leah Macaden
- Department of Nursing, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Sandra MacRury
- Division of Rural Health and Wellbeing, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| |
Collapse
|
11
|
Singh K, Johnson L, Devarajan R, Shivashankar R, Sharma P, Kondal D, Ajay VS, Narayan KMV, Prabhakaran D, Ali MK, Tandon N. Acceptability of a decision-support electronic health record system and its impact on diabetes care goals in South Asia: a mixed-methods evaluation of the CARRS trial. Diabet Med 2018; 35:1644-1654. [PMID: 30142228 DOI: 10.1111/dme.13804] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 02/03/2023]
Abstract
AIMS To describe physicians' acceptance of decision-support electronic health record system and its impact on diabetes care goals among people with Type 2 diabetes. METHODS We analysed data from participants in the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, who received the study intervention (care coordinators and use of a decision-support electronic health record system; n=575) using generalized estimating equations to estimate the association between acceptance/rejection of decision-support system prompts and outcomes (mean changes in HbA1c , blood pressure and LDL cholesterol) considering repeated measures across all time points available. We conducted in-depth interviews with physicians to understand the benefits, challenges and value of the decision-support electronic health record system and analysed physicians' interviews using Rogers' diffusion of innovation theory. RESULTS At end-of-trial, participants with diabetes for whom glycaemic, systolic blood pressure, diastolic blood pressure and LDL cholesterol decision-support electronic health record prompts were accepted vs rejected, experienced no reduction in HbA1c [mean difference: -0.05 mmol/mol (95% CI -0.22, 0.13); P=0.599], but statistically significant improvements were observed for systolic blood pressure [mean difference: -11.6 mmHg (95% CI -13.9, -9.3); P ≤ 0.001], diastolic blood pressure [mean difference: -5.2 mmHg (95% CI -6.5, -3.8); P ≤ 0.001] and LDL cholesterol [mean difference: -0.7 mmol/l (95% CI -0.6, -0.8); P ≤0.001], respectively. The relative advantages and compatibility of the decision-support electronic health record system with existing clinic set-ups influenced physicians' acceptance of it. Software complexities and data entry challenges could be overcome by task-sharing. CONCLUSION Wider adherence to decision-support electronic health record prompts could potentially improve diabetes goal achievement, particularly when accompanied by assistance from a non-physician health worker.
Collapse
Affiliation(s)
- K Singh
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - L Johnson
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - R Devarajan
- Centre for Control of Chronic Conditions, New Delhi, India
- Centre of Excellence - Centre for Cardio-metabolic Risk Reduction in South Asia
| | - R Shivashankar
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - P Sharma
- St. Georges Medical University of London, London, UK
- Plovdiv Medical University, Plovdiv, Bulgaria
| | - D Kondal
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - V S Ajay
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - K M V Narayan
- Centre for Control of Chronic Conditions, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - D Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - M K Ali
- Centre for Control of Chronic Conditions, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| |
Collapse
|
12
|
Validación en situaciones clínicas reales del DiaScope®, un software de ayuda al profesional sanitario en la individualización del tratamiento antidiabético en la diabetes tipo 2. ENDOCRINOL DIAB NUTR 2017; 64:128-137. [DOI: 10.1016/j.endinu.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/04/2016] [Accepted: 11/04/2016] [Indexed: 11/21/2022]
|
13
|
Militello LG, Saleem JJ, Borders MR, Sushereba CE, Haverkamp D, Wolf SP, Doebbeling BN. Designing Colorectal Cancer Screening Decision Support: A Cognitive Engineering Enterprise. JOURNAL OF COGNITIVE ENGINEERING AND DECISION MAKING 2016; 10:74-90. [PMID: 26973441 PMCID: PMC4784691 DOI: 10.1177/1555343416630875] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Adoption of clinical decision support has been limited. Important barriers include an emphasis on algorithmic approaches to decision support that do not align well with clinical work flow and human decision strategies, and the expense and challenge of developing, implementing, and refining decision support features in existing electronic health records (EHRs). We applied decision-centered design to create a modular software application to support physicians in managing and tracking colorectal cancer screening. Using decision-centered design facilitates a thorough understanding of cognitive support requirements from an end user perspective as a foundation for design. In this project, we used an iterative design process, including ethnographic observation and cognitive task analysis, to move from an initial design concept to a working modular software application called the Screening & Surveillance App. The beta version is tailored to work with the Veterans Health Administration's EHR Computerized Patient Record System (CPRS). Primary care providers using the beta version Screening & Surveillance App more accurately answered questions about patients and found relevant information more quickly compared to those using CPRS alone. Primary care providers also reported reduced mental effort and rated the Screening & Surveillance App positively for usability.
Collapse
Affiliation(s)
| | | | | | | | - Donald Haverkamp
- Centers for Disease Control and Prevention, Albuquerque, New Mexico
| | | | | |
Collapse
|
14
|
Towards Personalization of Diabetes Therapy Using Computerized Decision Support and Machine Learning: Some Open Problems and Challenges. SMART HEALTH 2015. [DOI: 10.1007/978-3-319-16226-3_10] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
15
|
Lycett K, Wittert G, Gunn J, Hutton C, Clifford SA, Wake M. The challenges of real-world implementation of web-based shared care software: the HopSCOTCH Shared-Care Obesity Trial in Children. BMC Med Inform Decis Mak 2014; 14:61. [PMID: 25056431 PMCID: PMC4115470 DOI: 10.1186/1472-6947-14-61] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND E-health initiatives hold promise to improve shared-care models of health care. In 2008-2011 we developed and trialled web-based software to facilitate a randomised trial of a shared-care approach for childhood obesity involving General Practitioners (GPs) working with tertiary specialists. We describe the software's development, implementation and evaluation, and make recommendations for future e-health initiatives. The web-based software was designed with the goals of allowing both GPs and specialists to communicate and review patient progress; integrating with existing GP software; and supporting GPs to deliver the structured intervention. Specifically, we aimed to highlight the challenges inherent in this process, and report on the extent to which the software ultimately met its implementation and user aims. METHODS The study was conducted at the Royal Children's Hospital and 22 general practices across Melbourne, Australia. Participants comprised 30 GPs delivering the shared-care intervention. Outcomes included the following. (1) GPs' pre-specified software requirements: transcribed from two focus groups and analysed for themes using content analysis. (2) Software implementation and performance based on the experience of the research team and GPs. (3) GP users' evaluation collected via questionnaire. (4) Software usage collected via GP questionnaire and qualified through visual inspection of the software meta-data. RESULTS Software implementation posed difficult and at times disabling technological barriers (e.g. out-dated hardware, poor internet connections). The software's speed and inability to seamlessly link with day-to-day software was a source of considerable frustration. Overall, GPs rated software usability as poor, although most (68%) felt that the structure and functionality of the software was useful. Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed, testing across diverse environments, automated pre-requisite checks and upgrades of processors/memory where necessary, and user-created usernames and passwords. CONCLUSIONS GPs are willing to embrace novel technologies to support their practice. However, implementation remains challenging mainly for technical reasons, and this precludes further evaluation of potential user-specific barriers. These findings could inform future e-health ventures into shared-care, and highlight the need for an appropriate infrastructure. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN126080000553.
Collapse
Affiliation(s)
- Kate Lycett
- Community Health Service Research, Murdoch Childrens Research Institute, Parkville, VIC, Australia.
| | | | | | | | | | | |
Collapse
|
16
|
Zakane SA, Gustafsson LL, Tomson G, Loukanova S, Sié A, Nasiell J, Bastholm-Rahmner P. Guidelines for maternal and neonatal "point of care": needs of and attitudes towards a computerized clinical decision support system in rural Burkina Faso. Int J Med Inform 2014; 83:459-69. [PMID: 24613689 DOI: 10.1016/j.ijmedinf.2014.01.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 01/29/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 2010, 245,000 women died due to pregnancy-related causes in sub-Saharan Africa and southern Asia. Our study is nested into the QUALMAT project and seeks to improve the quality of maternal care services through the introduction of a computerized clinical decision support system (CDSS) to help healthcare workers in rural areas. Healthcare information technology applications in low-income countries may improve healthcare provision but recent studies demonstrate unintended consequences with underuse or resistance to CDSS and that the fit between the system and the clinical needs does present challenges. AIMS To explore and describe perceived needs and attitudes among healthcare workers to access WHO guidelines using CDSS in maternal and neonatal care in rural Burkina Faso. METHODS Data were collected with semi-structured interviews in two rural districts in Burkina Faso with 45 informants. Descriptive statistics were used for the analysis of the quantitative part of the interview corresponding to informants' background. Qualitative data were analyzed using manifest content analysis. RESULTS Four main findings emerged: (a) an appreciable willingness among healthcare workers for and a great interest to adapt and use modern technologies like computers to learn more in the workplace, (b) a positive attitude to easy access of guidelines and implementation of decision-support using computers in the workplace, (c) a fear that the CDSS would require more working time and lead to double-work, and (d) that the CDSS is complicated and requires substantial computer training and extensive instructions to fully implement. CONCLUSIONS The findings can be divided into aspects of motivators and barriers in relation to how the CDSS is perceived and to be used. These aspects are closely connected to each other as the motivating aspects can easily be turned into barriers if not taken care of properly in the final design, during implementation and maintenance of the CDSS at point of care.
Collapse
Affiliation(s)
- S Alphonse Zakane
- Centre de Recherche en Santé de Nouna, BP 02 Nouna, Burkina Faso; Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet at Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet at Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Göran Tomson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre (MMC), Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Svetla Loukanova
- Institute of Public Health, University of Heidelberg, INF 324-69120 Heidelberg, Germany
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, BP 02 Nouna, Burkina Faso
| | - Josefine Nasiell
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institutet at Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Pia Bastholm-Rahmner
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre (MMC), Karolinska Institutet, SE-171 77 Stockholm, Sweden; Public Healthcare Services Committee Administration, Stockholm County Council, SE-118 91 Stockholm, Sweden.
| |
Collapse
|