How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings

Lessons From the Design and Rollout of an Electronic Medical Record System for Cervical Cancer Screening in Rwanda

BACKGROUND

In its commitment to delivering comprehensive women's cancer early detection services, the Rwanda Ministry of Health rolled out a new cervical cancer screening program. The paper-based medical record system that tracked clients at different points in the continuum of cervical cancer care had challenges with storing data, accessing client information for follow-up visits, and fragmenting information on individual clients. To support the rollout of the new cervical cancer screening program, a new electronic medical record system was designed and implemented to ensure clients were followed along the complete continuum of care. We document the development and implementation of the electronic medical record system and highlight challenges and lessons learned during implementation.

METHODS

Implementation took a participatory approach to ensure that the electronic medical record system was efficient in tracking clients along the continuum of care. At every stage, a wide range of stakeholders were engaged, including clinicians, program managers, and software developers. Health facility visits and conversations were conducted with health care providers and data managers to review the existing system and ensure that the design and development of the electronic record system were suitable for the context in which it would be used.

RESULTS

Cervical cancer screening sites are currently using the electronic medical record system to document client information and track women along the continuum of care to reduce loss to follow-up. The system has been rolled out to all newly activated screening sites as part of national scale-up.

CONCLUSION

Planning, collaboration, and adaptability were the key factors in this system's successful rollout and should be the foundation of future data systems development.

Evaluating digital literacy of health professionals in Ethiopian health sectors: A systematic review and meta-analysis

BACKGROUND

Digital literacy refers to the capacity to critically assess digital content, use digital tools in professional settings, and operate digital devices with proficiency. The healthcare sector has rapidly digitized in the last few decades. This systematic review and meta-analysis aimed to assess the digital literacy level of health professionals in the Ethiopian health sector and identify associated factors. The study reviewed relevant literature and analyzed the data to provide a comprehensive understanding of the current state of digital literacy among health professionals in Ethiopia.

METHODS

The study was examined by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Evidence was gathered from the databases of Google Scholar, Pub Med, Cochrane Library, Hinari, CINAHL, and Global Health. Consequently, five articles met the eligible criteria for inclusion. The analysis was carried out using STATA version 11. The heterogeneity was evaluated using the I2 test, while the funnel plot and Egger's regression test statistic were used to examine for potential publication bias. The pooled effect size of each trial is evaluated using a random effect model meta-analysis, which provides a 95% confidence interval.

RESULT

A total of five articles were included in this meta-analysis and the overall pooled prevalence of this study was 49.85% (95% CI: 37.22-62.47). six variables, Monthly incomes AOR = 3.89 (95% CI: 1.03-14.66), computer literacy 2.93 (95% CI: 1.27-6.74), perceived usefulness 1.68 (95% CI: 1.59-4.52), educational status 2.56 (95% CI: 1.59-4.13), attitude 2.23 (95% CI: 1.49-3.35), perceived ease of use 2.22 (95% CI: 1.52-3.23) were significantly associated with the outcome variable.

CONCLUSION

The findings of the study revealed that the overall digital literacy level among health professionals in Ethiopia was relatively low. The study highlights the importance of addressing the digital literacy gap among health professionals in Ethiopia. It suggests the need for targeted interventions, such as increasing monthly incomes, giving computer training, creating a positive attitude, and educational initiatives, to enhance digital literacy skills among health professionals. By improving digital literacy, health professionals can effectively utilize digital technologies and contribute to the advancement of healthcare services in Ethiopia.

Clinicians' Attitudes Toward Electronic Health Records in Saudi Arabia

AIM

 This study explored physicians' and nurses' attitudes toward an electronic health record (EHR) system and examined the features and factors that clinicians associated with the implementation of EHR systems.

METHODS

 A self-administered anonymous questionnaire with high reliability and validity was adopted from existing research to gather clinicians' attitudes toward the EHR system implemented at King Khalid University Hospital, one of the biggest hospitals in Riyadh, Saudi Arabia.

RESULTS

 A total of 438 questionnaire responses were received from the participants; 240 of them were physicians and 198 were nurses. The participants had a mean age of 43.7 years (standard deviation (SD) 17.1), 213 (52.7%) were female and 207 (47.3%) were male. Most participants (424, 96.8%) had one or more years of experience using computers, and a majority (304, 69.4%) had one or more years of experience using EHR systems. Most physicians and nurses (214, 89.5% vs. 174, 87.9%) were satisfied with their hospital's EHR system and felt that the system was highly usable and had the potential to improve communication between staff, facilitate easy storage of and access to information and lead to improved health outcomes for patients. The study found positive attitudes among clinicians concerning the quality of training and education around the new system (178, 74.2% of physicians vs. 142, 71.7% of nurses; p > 0.05) and toward leadership during the transition to HER (222, 92.5% vs. 183, 92.4%). On the other hand, a majority of nurses reported that the EHR system took longer to use and increased their workload compared with the previous analogue system (115 (47.9%) vs. 133 (67.2%); p ≤ 0.01 and 46.7% vs. 112 (64.1%)). A large majority of physicians and nurses surveyed (214 (89.2%) vs. 167 (84.3%)) stated that clinicians should be consulted in the design of such systems as a way to maximise the potential benefits of EHR and mitigate extra workload demands.

CONCLUSION

 Most clinicians expressed overall satisfaction with the EHR system, but there were some areas of dissatisfaction among the respondents, such as increasing workload and stress among nurses. There is scope for further research to continue to explore physicians' and nurses' attitudes toward EHRs and for future experimental studies that examine the impact of EHRs on clinician workloads, patient health outcomes and quality of care.

Electronic medical record implementation in the emergency department in a low-resource country: Lessons learned

OBJECTIVE

There is paucity of information regarding electronic medical record (EMR) implementation in emergency departments in countries outside the United States especially in low-resource settings. The objective of this study is to describe strategies for a successful implementation of an EMR in the emergency department and to examine the impact of this implementation on the department's operations and patient-related metrics.

METHODS

We performed an observational retrospective study at the emergency department of a tertiary care center in Beirut, Lebanon. We assessed the effect of EMR implementation by tracking emergency departments' quality metrics during a one-year baseline period and one year after implementation. End-user satisfaction and patient satisfaction were also assessed.

RESULTS

Our evaluation of the implementation of EMR in a low resource setting showed a transient increase in LOS and visit-to-admission decision, however this returned to baseline after around 6 months. The bounce-back rate also increased. End-users were satisfied with the new EMR and patient satisfaction did not show a significant change.

CONCLUSIONS

Lessons learned from this successful EMR implementation include a mix of strategies recommended by the EMR vendor as well as specific strategies used at our institution. These can be used in future implementation projects in low-resource settings to avoid disruption of workflows.

A clinical informatics approach to bronchopulmonary dysplasia: current barriers and future possibilities

Bronchopulmonary dysplasia (BPD) is a complex, multifactorial lung disease affecting preterm neonates that can result in long-term pulmonary and non-pulmonary complications. Current therapies mainly focus on symptom management after the development of BPD, indicating a need for innovative approaches to predict and identify neonates who would benefit most from targeted or earlier interventions. Clinical informatics, a subfield of biomedical informatics, is transforming healthcare by integrating computational methods with patient data to improve patient outcomes. The application of clinical informatics to develop and enhance clinical therapies for BPD presents opportunities by leveraging electronic health record data, applying machine learning algorithms, and implementing clinical decision support systems. This review highlights the current barriers and the future potential of clinical informatics in identifying clinically relevant BPD phenotypes and developing clinical decision support tools to improve the management of extremely preterm neonates developing or with established BPD. However, the full potential of clinical informatics in advancing our understanding of BPD with the goal of improving patient outcomes cannot be achieved unless we address current challenges such as data collection, storage, privacy, and inherent data bias.

A scoping review on the factors associated with the lost to follow-up (LTFU) amongst patients with chronic disease in ambulatory care of high-income countries (HIC)

BACKGROUND

Despite the importance of long term follow-up care for patients with chronic disease, many patients fail to adhere to their follow-ups, which increase their risk of further health complications. Therefore, the purpose of this scoping review was to find out the factors associated with lost to follow-up (LTFU) amongst patients with chronic disease in the ambulatory care setting of high-income countries (HICs) to gain insights for better quality of care. Understanding the definition of LTFU is imperative in informing patients, health professionals and researchers for clinical and research purposes. This review also provided an overview of the terms and definitions used to describe LTFU.

METHODS

The following databases: CINAHL, EMBASE, Medline, PsycINFO and Web of Science were searched for studies investigating the factors associated to LTFU from the date of inception until 07 January 2022.

RESULTS

Five thousand one hundred and seven records were obtained across the databases and 3,416 articles were screened after removing the duplicates. 25 articles met the inclusion criteria, of which 17 were cohort studies, five were cross-sectional studies and three were case-control studies. A total of 32 factors were found to be associated with LTFU and they were categorised into patient factors, clinical factors and healthcare provider factors.

CONCLUSION

Overall, the factors associated with LTFU were generally inconsistent across studies. However, some factors such as financial factors (i.e., no insurance coverage) and low accessibility of care were consistently associated with LTFU for both mental and physical chronic conditions. The operational definitions of LTFU also varied greatly across studies. Given the mixed findings, future research using qualitative aproaches would be pivotal in understanding LTFU for specific chronic diseases and the development of targeted interventions. Additionally, there is a need to standardise the operational definition of LTFU for research as well as clinical practice purposes.

An examination of large-scale electronic health records implementation in Primary Healthcare Centers in Saudi Arabia: a qualitative study

Introduction

Digital transformation has become a buzzword in almost every industry in the twenti first century. Healthcare is not an exception. In the healthcare industry, digital transformation includes the utilization of electronic health records (EHRs), telemedicine, health information exchange, mobile health, and other interactive platforms. The importance of digital transformation in healthcare cannot be overemphasized as it has proven to be critical in improving patient outcomes, making healthcare delivery more efficient, and reducing costs. The positive impact of electronic health records was noticed almost immediately in the field of primary healthcare. It has been suggested that implementing electronic health records will enhance the accessibility and the process of distribution of health records between authorized users. As part of Saudi vision 2030, all healthcare organizations in Saudi Arabia are going to shift to digital transformation.

Methods

This study follows a qualitative, semi-structure, face-to-face interview approach. The collected data were analyzed using NVivo V10 software. Inductive thematic analysis approach was used to analyse the collected data from the interviews.

Result

Seventeen project team members, from different positions and backgrounds were purposively chosen to be interviewed. Three main themes and 38 codes were generated from the analysis of transcripts. The informants describe the implementation of electronic health records in the PHCs based on two different experiences. The participants reported that a previous attempt failed due to inappropriate infrastructure, lack of technical support, and low level of user acceptance. Therefore, the policymakers adopted several steps to increase the level of success and avoid failure causes. They initially established well-defined requests for proposals followed by continuous commendation among the project team and conducted a consultation on multiple levels (country level; organizational level and individual level).

Conclusion

This study concluded that the main causes that lead to the failure of the large-scale project were lack of connectivity, lack of technical support, and staff changes, particularly those who occupied high-level positions in the Saudi ministry of Health. The success rate of EHRs implementation can be directly impacted by the size of the project. Large-scale projects are complicated and may be subject to numerous challenges compared with small projects. Significant factors such as training, support, legal issues, and organizational workflow and redesign were a concern of the project team during the pre-implementation phase. In addition, other factors related to technology and end-users were included in the EHRs implementation plan.

Clinical information system (CIS) implementation in developing countries: requirements, success factors, and recommendations

OBJECTIVE

Clinical Information System (CIS) usage can reduce healthcare costs over time, improve the quality of medical care and safety, and enhance clinical efficiency. However, CIS implementation in developing countries poses additional, different challenges from the developed countries. Therefore, this research aimed to systematically review the literature, gathering and integrating research findings on Success Factors (SFs) in CIS implementation for developing countries. This helps to integrate past knowledge and develop a set of recommendations, presented as a framework, for implementing CIS in developing countries.

MATERIALS AND METHODS

A systematic literature review was conducted, followed by qualitative data analysis on the published articles related to requirements and SF for CIS implementation. Eighty-three articles met the inclusion criteria and were included in the data analysis. Thematic analysis and cross-case analysis were applied to identify and categorize the requirements and SF for CIS implementation in developing countries.

RESULTS

Six major requirement categories were identified including project management, financial resources, government involvement and support, human resources, organizational, and technical requirements. Subcategories related to SF are classified under each major requirement. A set of recommendations is provided, presented in a framework, based on the project management lifecycle approach.

CONCLUSION

The proposed framework could support CIS implementations in developing countries while enhancing their rate of success. Future studies should focus on identifying barriers to CIS implementation in developing countries. The country-specific empirical studies should also be conducted based on this research's findings to match the local context.

An electronic health record system implementation in a resource limited country-lessons learned

Electronic health records have revolutionized the medical world by improving medical care, refining provider documentation, standardizing care, and minimizing sentinel events. Successful implementation of electronic health records remains a daunting task and requires careful strategic planning and buy-in from key stakeholders. Much has been published in resource-rich settings and high-income countries about implementations of electronic health records. However, little is known about the experience in resource-limited settings where challenges remain unique and distinct from other parts of the world. Our intention is to share lessons learned during implementation of a web-based electronic health record at a tertiary care center in Kenya.

Digital literacy level and associated factors among health professionals in a referral and teaching hospital: An implication for future digital health systems implementation

Background

In Ethiopia and other developing countries, electronic medical record systems and other health information technology are being introduced. However, a small proportion of low-income countries have successfully implemented national health information systems. One cause for this can be the lack of digital literacy among medical practitioners. As a result, this study aimed to assess health professionals' digital literacy level and associated factors in Northwest Ethiopia.

Method

A quantitative cross-sectional study was employed among 423 health professionals working in a teaching and referral hospital in Northwest Ethiopia. We modified and applied the European commission's framework for digital competency to assess the level of digital literacy among health professionals. We used stratified random sampling with proportional allocation to the size of the departments in the hospital to select study participants. Data were collected using a semi-structured, self-administered, and pretested questionnaire. Descriptive and binary logistic regression analysis techniques were used to describe respondents' digital literacy level and identify its associated factor, respectively. The odds ratio with 95% CI and value of p were used to assess the strength of the association and statistical significance, respectively.

Results

Out of 411 participants, 51.8% (95% CI, 46.9-56.6%) of health professionals had adequate digital literacy. Holding a master's degree (Adjusted OR = 2.13, 95% CI: 1.18-3.85), access to digital technology (AOR = 1.89, 95% CI: 1.12-3.17), having training in digital technology (AOR = 1.65, 95% CI: 1.05-2.59), and having a positive attitude towards digital health technology (AOR = 1.64, 95% CI: 1.02-2.68) were found to be significant factors associated with health professionals digital literacy level of health professionals.

Conclusion

Low level of digital literacy among health professionals was observed, with nearly half (48.2%) of them having poor digital literacy levels. Access to digital technology, training on digital technology, and attitude toward digital health technology were significant factors associated with digital literacy. It is suggested to increase computer accessibility, provide a training program on digital health technology, and promote a positive attitude toward this technology to improve the deployment of health information systems.

Management Opportunities and Challenges After Achieving Widespread Health System Digitization

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery - demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead. There are substantive lessons learned from the first era of large-scale adoption of enterprise EHRs and ongoing challenges that organizations are wrestling with - particularly related to the tension between standardization and flexibility/customization of EHR systems and the processes they support. Managing this tension during efforts to implement and optimize enterprise systems is perhaps the core challenge of the past decade, and one that has impeded consistent realization of value from initial EHR investments. We describe these challenges, how they manifest, and organizational strategies to address them, with a specific focus on alignment with broader value-based care transformation. We then look ahead to the AI wave - the massive number of applications of AI to health care delivery, the expected benefits, the risks and challenges, and approaches that health systems can consider to realize the benefits while avoiding the risks.

The impact financial resources on implementation of large-scale electronic health records in the Saudi Arabia's primary healthcare centers: Mixed methods

Introduction

There is worldwide demand for the implementation of electronic health systems and a transformation to electronic transactions in healthcare organizations. This move to e-health transformation stems from the perceived positive impact that e-health systems have in improving the quality of healthcare and, in turn, reducing expenses. Despite this, more than half of previous Electronic Health Record System (EHRS) implementation projects have failed due to several barriers and challenges such as cost.

Aim of the study

To evaluate the impact of financial resources (FR) on the implementation of the EHRS in PHCs in SA.

Methods

A mixed methods approach was implemented. SPSS and AMOS-SEM are used to test reliability and validity and hypotheses. Thirty-one (59%) out of 51 policy makers at the MoH filled and returned the questionnaire while 13 policymakers were interviewed using semi-structure interviews.

Results

Results revealed that both measurement model and structural models met the threshold. All scales are found reliable and valid. Furthermore financial resources have positive impact on EHRS implementation. Findings from both studies show that financial resources have a very positive impact to facilitate large-scale EHRs implementation and overcome barriers that may lead to the failure of the project.

Exploring facilitators of the implementation of electronic health records in Saudi Arabia

INTRODUCTION

The introduction of information technology was one of the key priorities for policy-makers in health care organisations over the last two decades due to the potential benefits of this technology to improve health care services and quality. However, approximately 50% of those projects failed to achieve their intended aims. This was a result of several factors, including the cost of these projects. The Saudi Ministry of Health (MoH) planned to implement an electronic health record system (EHRS) in approximately 2100 primary health care centres nationwide. It was acknowledged that this project may face hurdles, which might result in the failure of the project if implementation facilitators were not first determined. According to the Saudi MoH, previous electronic health record system implementation in primary health care centres failed as a consequence of several barriers, such as poor infrastructure, lack of connectivity and lack of interoperability. However, the facilitators of successful electronic health record system implementation in Saudi primary health care centres are not understood.

AIM

To determine the facilitators that enhance the success of the implementation of an EHRS in public primary health care centres in SA.

METHOD

A mixed methods approach was used with both qualitative and quantitative methods (qualitative using semistructured interviews and quantitative with a closed survey). The purpose of the utilisation of exploratory mixed methods was to identify a wide range of facilitators that may influence EHRS implementation. The data were obtained from two different perspectives, primary health care centre practitioners and project team members. A total of 351 practitioners from 21 primary health care centres participated in the online survey, and 14 key informants at the Saudi Ministry of Health who were directly involved in the electronic health record system implementation in the primary health care centres agreed to be interviewed face to face.

RESULTS

The findings from both studies revealed several facilitators. Among these facilitators, financial resources were found to be the most influential factor that assisted in overcoming some barriers, such as software selection. The size of the primary health care centres was the second facilitator of successful implementation, despite the scale of the project. Perceived usefulness was another facilitator identified in both the interviews and the survey. More than 90% of the participants thought that the electronic health record system was useful and could contribute to improving the quality of health care services. While a high level of satisfaction was expressed towards the electronic health record system's usability and efficiency, low levels of satisfaction were recorded for organisational factors such as user involvement, training and support. Hence, system usability and efficiency were documented to be other facilitators of successful electronic health record system implementation in Saudi primary health care centres.

CONCLUSION

The findings of the present study suggest that sufficient financial support is essential to enhance the success of electronic health record system implementation despite the scale of the project. Additionally, effective leadership and project management are core factors to overcome many obstacles and ensure the success of large-scale projects.

The effects of simulation training on learning of health information systems: A scoping review

One of the most commonly used methods for training is simulation. It is important to examine the effects of simulation training of health information systems on the knowledge, attitude, and skill in trainees. This review provided a summary of relevant literature on how simulation training affects the learning of health information systems and determine the features and functional capabilities of existing simulators. Studies and websites using simulation training to teach health information systems were included. Studies were searched through Medline (via PubMed), Scopus, and ISI Web of Science and websites through Google search by the end of 2019. The characteristics of studies, features, and functional capabilities of simulators and effects on learning outcomes were extracted. The included studies and websites were categorized according to different characteristics including simulation types, learning outcome categories, and the effects of simulation training on learning outcomes. The learning outcomes were categorized into four groups: knowledge, attitude, skill, and satisfaction. The effects of interventions on outcomes were categorized into statistically significant positive, positive without statistical argument, no effect (not statistically significant), negative without statistical argument, or statistically significant negative. Ten studies and eight websites that used simulation training to teach health information systems (mainly electronic health record [EHR]) were included. EHR simulation was performed in 80% of the included studies and trainees in 70% of studies were physicians and nurses. All studies were conducted in three developed countries. In the included studies, four learning outcomes (i.e. skill, attitude, knowledge, and satisfaction) were assessed. Ninety percent of the included studies assessed skill-related outcomes, with more than half mentioning significant improvement. Thirty percent of the included studies assessed outcomes-related knowledge and attitude, all of which reported the positive effects of simulation training. The simulators offered a variety of functional capabilities, while all of which simulated the clinical data entry process. In teaching health information systems, especially EHRs, simulation training enhances skill, attitude, knowledge, and satisfaction of health-care providers and students.

Evaluating Electronic Health Record Limitations and Time Expenditure in a German Medical Center

OBJECTIVES

This study set out to obtain a general profile of physician time expenditure and electronic health record (EHR) limitations in a large university medical center in Germany. We also aim to illustrate the merit of a tool allowing for easier capture and prioritization of specific clinical needs at the point of care for which the current study will inform development in subsequent work.

METHODS

Nineteen physicians across six different departments participated in this study. Direct clinical observations were conducted with 13 out of 19 physicians for a total of 2,205 minutes, and semistructured interviews were conducted with all participants. During observations, time was measured for larger activity categories (searching information, reading information, documenting information, patient interaction, calling, and others). Semistructured interviews focused on perceived limitations, frustrations, and desired improvements regarding the EHR environment.

RESULTS

Of the observed time, 37.1% was spent interacting with the health records (9.0% searching, 7.7% reading, and 20.5% writing), 28.0% was spent interacting with patients corrected for EHR use (26.9% of time in a patient's presence), 6.8% was spent calling, and 28.1% was spent on other activities. Major themes of discontent were a spread of patient information, high and often repeated documentation burden, poor integration of (new) information into workflow, limits in information exchange, and the impact of such problems on patient interaction. Physicians stated limited means to address such issues at the point of care.

CONCLUSION

In the study hospital, over one-third of physicians' time was spent interacting with the EHR, environment, with many aspects of used systems far from optimal and no convenient way for physicians to address issues as they occur at the point of care. A tool facilitating easier identification and registration of issues, as they occur, may aid in generating a more complete overview of limitations in the EHR environment.

Information and communication technology literacy, knowledge and readiness for electronic medical record system adoption among health professionals in a tertiary hospital, Myanmar: A cross-sectional study

Some developing countries are currently introducing and implementing an electronic medical record system (EMRs) for improvement in healthcare delivery services. Availability of information and communication technology (ICT), technical skillful staff, and strong resistance to change by the health professionals impacted the successful adoption of EMRs. This study aimed to assess the ICT literacy, knowledge, and readiness for EMRs adoption among health professionals in a tertiary hospital, Myanmar. A cross-sectional study was conducted among 118 health professionals involving in a tertiary hospital at Nay Pyi Taw, Myanmar from February to April 2020 using a stratified sampling method. The data were collected through face-to-face interviews using a pretested structured questionnaire after getting informed consent. Data were analyzed by using SPSS version 23.0. Chi-square test, Fisher's exact test, and logistic regression analysis were performed to assess the associated factors of ICT literacy, knowledge, and overall readiness for EMRs adoption. The prevalence of high ICT literacy and knowledge on EMRs among health professionals were 20.3% and 24.6% respectively. The factors associated with ICT literacy were professional, education, duration of service, and reported English language skills. Duration of service was associated with knowledge on EMRs. The overall readiness was 54.2% (core readiness 59.3% and engagement readiness 61.9%), and postgraduate [Adjusted Odds Ratio (AOR): 7.32, 95% Confidence Interval (CI): 2.26-23.68] and knowledge on EMRs (AOR: 1.27, 95% CI: 1.13-1.43) were the factors associated with overall readiness for EMRs adoption. Expanding infrastructure and provision of ICT development training are crucial for the improvement of ICT literacy. EMRs training program enabling hands-on experience should be implemented for improvement of knowledge on EMRs. In general, the overall readiness for EMRs adoption was found to be moderate. Enhancing the establishment of comprehensive on-the-job training and contextualization of curriculum in EMRs training program are recommended to improve the health professionals' readiness for EMRs adoption.

Patient Decision Aid Selection for Shared Decision Making: A Multicase Qualitative Study

The patient decision aid (PDA) is a promising patient engagement tool for use in shared decision making (SDM). Selecting a PDA is an essential precursor to successful SDM implementation. Little is known regarding the organizational stakeholder process for assessing and selecting a PDA. We conducted a qualitative, multicase study within the context of a maternal health decision to identify the criteria used by stakeholders to select a PDA. We further explored the perceived value of PDA certification on PDA selection. We reported the PDA selection criteria within the domains of (1) Design and Functionality, (2) User Fit, (3) Context and Climate, (4) Support, and (5) Strategic Vision and found that certification was perceived to be a valuable screening mechanism for smaller health organizations. Health organizations and researchers may use our PDA selection criteria and conceptual model to plan future deployments of PDAs and patient engagement tools.

MHS Genesis Implementation: Strategies in Support of Successful EHR Conversion

INTRODUCTION

The Military Health System (MHS) is implementing a new electronic health record (EHR) which will impact 9.5 million Department of Defense (DoD) beneficiaries and over 205,000 MHS employees globally. The scale and scope of this EHR rollout is unprecedented; however, lessons learned from previous rollouts across smaller contexts in tandem with Kurt Lewin's Change Theory provide insights into critical success factors (CSFs) and critical barriers to implementation (CBIs) in which leadership may leverage to streamline future go-live efforts.

MATERIALS AND METHODS

The researcher conducted a narrative literature review to identify breadth of knowledge currently available surrounding EHR implementation and change management. A Boolean search of UMGC OneSearch was conducted utilizing the search string "electronic health record* OR EHR* AND change* AND implement*" which resulted in 7,084 results. Additional inclusion criteria and limiters were then applied to these results which included full-text, scholarly, and published journal articles, written in English from January 2009 to November 2019, from Europe, the United States, and Canada, in health and medicine, military history and science, and social science and humanities disciplines. 758 articles were identified through database searching. A cursory review of titles and abstracts for goodness of fit eliminated an additional 696 articles leaving 62 for full review. 18 of these articles were used for the final literature review. Through snowballing as well as Google Scholar, eight additional articles were identified and included. Finally, as a result of MHS Genesis being a new, government-backed EHR, the researcher also utilized three pieces of gray literature and non-peer-reviewed articles from professional websites, and three articles for background regarding Lewin's Theory of Change bringing the total references to 32.

RESULTS

The manuscript uncovered two main themes regarding organizational change and EHR implementation. The first theme, coined CSF, includes factors associated with positive outcomes in implementing EHRs. The three CSFs are Process Change Champions, Training, and Feedback, and definitions can be found in Table I. The second theme identified, coined CBI, includes factors associated with hindering EHR implementation. The three CBIs are Technophobia, Resistance from Leaders/Providers, and Insufficient Communication, and definitions can be found in Table II.

CONCLUSIONS

By operationalizing pre-identified CSFs and CBIs, leaders of the MHS are able to streamline future waves of MHS Genesis rollouts utilizing Kurt Lewin's Change Theory and the newly crafted Conceptual Framework of MHS Genesis Implementation presented in Figure 1. Through full acceptance and use of CSFs, adapting to feedback and barriers, and dynamically adjusting strategies, the challenges associated with a large-scale phased EHR implementation can be minimized. The results and implications of this literature review are significant as the MHS Genesis rollout is still in its infancy and evidence-based best practices can still be executed. MHS Genesis continues to be phase implemented and currently only the Pacific Northwest and parts of California have gone operational. Increasing efficiency in this process provides a benefit to stakeholders at all levels: health care providers, patients, leadership, and taxpayers.

Perspectives of Nursing Homes Staff on the Nature of Residents-Initiated Call Lights

Little research has been conducted to capture the perceptions of nursing home staff when using the call light system. There is also a lack of information regarding the effects that these perceptions of the call light system have on their workload, safety, quality of care, or overall satisfaction. In response to the high volume of complaints from residents and their families regarding long response times to call light alarms, we developed this exploratory cross-sectional survey study. This study aims to capture nursing home staff experiences while using a call light system; to investigate the challenges the staff face when using the system; and to determine how these challenges contribute to their workload, performance, and satisfaction. A survey instrument was developed and distributed to all 153 of the nursing staff, certified nursing assistants, and licensed practical nurses in a nursing home in upstate New York. A total of 105 completed surveys were retrieved for an overall response rate of 68.63%. Descriptive analysis, Pearson correlation, and the Kruskal-Wallis test were used to analyze the collected data. The results showed a significant correlation between the processes of being notified and locating call light alarms and workload. The staff reported many usability challenges that may contribute to longer response time such as lack of prioritization, low/no discriminability, noise, and overwrite previous alarm. In addition, 78% of the staff agreed that responding to a call light can prevent serious harm; however, 56% of the staff agreed that call light system is not meaningful; and around 78% think that call light system is disruptive in the environment and source for constant noise. The study finds that incorporating the insights provided by nursing home staff may improve the acceptance of new and existing technology, which ultimately improves the delivery of care through greater usability.

Moderating Effects of Gender and Resistance to Change on the Adoption of Big Data Analytics in Healthcare

The big data analytics (BDA) has dragged tremendous attention in healthcare organizations. Healthcare organizations are investing substantial money and time in big data analytics and want to adopt it to get potential benefits. Thus, this study proposes a BDA adoption model in healthcare organizations to explore the critical factors that can influence its adoption process. The study extends the technology acceptance model (TAM) with the self-efficacy as an external factor and also includes gender and resistance to change (RTC) as moderators to strengthen the research model. The proposed research model has been tested on 283 valid responses which were collected through a structured survey, by applying structural equation modeling. Our results portray that self-efficacy is a strong predictor of intention to use BDA along with other TAM factors. Moreover, it is confirmed by the results that RTC dampens the positive relationship between intention to use and actual use of BDA in healthcare organizations. The outcomes revealed that male employees as compared to female employees are dominant towards the positive intention to use BDA. Furthermore, females create more RTC than males while adopting BDA in healthcare organizations. Theoretical and practical implications, limitations, and future research directions also underlined in this study.

Physician champions' perspectives and practices on electronic health records implementation: challenges and strategies

Objective

Physician champions are “boots on the ground” physician leaders who facilitate the implementation of, and transition to, new health information technology (HIT) systems within an organization. They are commonly cited as key personnel in HIT implementations, yet little research has focused on their practices and perspectives.

Materials and Methods

We addressed this research gap through a qualitative study of physician champions that aimed to capture their challenges and strategies during a large-scale HIT implementation. Email interviews were conducted with 45 physician champions from diverse clinical areas 5 months after a new electronic health record (EHR) system went live in a large academic medical center. We adopted a grounded theory approach to analyze the data.

Results

Our physician champion participants reported multiple challenges, including insufficient training, limited at-the-elbow support, unreliable communication with leadership and the EHR vendor, as well as flawed system design. To overcome these challenges, physician champions developed their own personalized training programs in a simulated context or in the live environment, sought and obtained more at-the-elbow support both internally and externally, and adapted their departmental sociotechnical context to make the system work better.

Discussion and Conclusions

This study identified the challenges physician champions faced and the strategies they developed to overcome these challenges. Our findings suggest factors that are crucial to the successful involvement of physician champions in HIT implementations, including the availability of instrumental (eg, reward for efforts), emotional (eg, mechanisms for expressing frustrations), and peer support; ongoing engagement with the champions; and appropriate training and customization planning.

Prescription digitization, online preservation, and retrieval on a smartphone

Background:

Medical records are important documents that should be stored for at least 3 years after the commencement of the treatment of an adult patient in India. In a health care facility, patients' data is saved in an online or offline retrieval system. However, in the case of the primary care physician, the data is not commonly kept in an easily retrievable system.

Aim:

To test the feasibility of using a set of free web-based services in digitization, preservation, and retrieval of prescription on a smartphone by primary care physicians.

Methods:

This study was conducted with 12 primary care physicians. They were provided hands-on guides on creating an online form for uploading a prescription and using an application for retrieval of the prescription on a smartphone. Their feedback on the training material was collected by a telephonic survey, which had a 10-point Likert-type response option. Then, an in-depth interview was conducted to ascertain their perception on the tutorial and the process of digitization and retrieval system.

Results:

All of the participants were able to create an online form on their smartphone. They uploaded their prescription and associated data and were able to retrieve it. The physicians opined positively on the “cost of the system,” “portability” on a smartphone and ease of the “tutorial”. They opined negatively on the “limited storage,” chances of “loss of data,” and “time constraints” for entry of the patients' data.

Conclusion:

Free web-based and smartphone applications can be used by a primary care physician for personal storage and retrieval of prescriptions. The simple tutorial presented in this article would help many primary care physicians in resource-limited settings.

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings

Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.

Factors influencing the selection of a picture archiving and communication system: A qualitative study

BACKGROUND

Picture Archiving and Communication System (PACS) is an evolving technology in health care domains that is used for storage, management, retrieval, transfer, and delivery of medical images. Some medical centers in Iran have installed the PACS in recent years but have not used it appropriately. One of the problems in implementing this system is inability to select appropriate PACS. Several factors are involved in the selection process. The objective of this study was to determine the factors that influence PACS selection.

METHODS

This qualitative study aimed to identify factors influencing the PACS selection. Data were collected through semistructured interviews with 10 experts in three educational hospitals and in the position to make decision for the purchase of PACS. Data were analyzed by the conventional qualitative content analysis method proposed by Lundman and Graneheim.

RESULTS

Analyses achieved 11 subcategories in two specific and general categories that influence PACS selection. The specific category of this study included six subcategories, and the general category included five subcategories.

CONCLUSION

The results of this study determined that usability was the most important factor from the perspective of participants. Since the main users of a system have a critical role in adoption or rejection of a system, ease of use (usability) is significant and must be considered in system selection as a significant factor.

Electronic medical record implementation for a healthcare system caring for homeless people

Objective

Electronic medical record (EMR) implementation at centers caring for homeless people is constrained by limited resources and the increased disease burden of the patient population. Few informatics articles address this issue. This report describes Boston Health Care for the Homeless Program’s migration to new EMR software without loss of unique care elements and processes.

Materials and methods

Workflows for clinical and operational functions were analyzed and modeled, focusing particularly on resource constraints and comorbidities. Workflows were optimized, standardized, and validated before go-live by user groups who provided design input. Software tools were configured to support optimized workflows. Customization was minimal. Training used the optimized configuration in a live training environment allowing users to learn and use the software before go-live.

Results

Implementation was rapidly accomplished over 6 months. Productivity was reduced at most minimally over the initial 3 months. During the first full year, quality indicator levels were maintained. Keys to success were completing before go-live workflow analysis, workflow mapping, building of documentation templates, creation of screen shot guides, role-based phased training, and standardization of processes. Change management strategies were valuable. The early availability of a configured training environment was essential. With this methodology, the software tools were chosen and workflows optimized that addressed the challenges unique to caring for homeless people.

Conclusions

Successful implementation of an EMR to care for homeless people was achieved through detailed workflow analysis, optimizing and standardizing workflows, configuring software, and initiating training all well before go-live. This approach was particularly suitable for a homeless population.

Taxonomic framework for factors influencing ERMS adoption in organisations of higher professional education

An electronic records management system (ERMS) is tightly linked with most of the daily activities of educational organisations and leads to enhance their performance and decision-making. The aim of this article is to identify the significant factors that could influence the ERMS adoption in higher professional education (HPE). The methodology of this article started with identifying the factors through theory analysis and literature and also recommended by experts. Technology–organisation–environment (TOE) theory was used for factor classification. Qualitative approach was used through the interview with experts to validate and verify the proposed framework. This article presents the results of a study which identifies the issues involved in the utilisation and adoption of ERMS. More than 100 previous works and six well-known theories were critically reviewed to identify the main factors for successful ERMS adoption in different areas with the aim of proposing a taxonomic framework that can depict and identify the main factors that have an impact on the success of ERMS adoption. The proposed framework includes 11 factors categorised into three dimensions. The framework is validated and verified by experts. The adoption factors identified here provide a sound theoretical basis for research to understand, support and facilitate the adoption of ERMS to HPE benefit. The proposed framework could help to improve educational outcomes and the successful implementation of ERMS.

The impact of financial incentives to improve quality indicators in patients with diabetes in Swiss primary care: a protocol for a cluster randomised controlled trial

INTRODUCTION

There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes.

METHODS AND ANALYSIS

This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups.

ETHICS AND DISSEMINATION

According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN13305645; Pre-results.

Exploring Factors Affecting Voluntary Adoption of Electronic Medical Records Among Physicians and Clinical Assistants of Small or Solo Private General Practice Clinics

The health care reform initiative led by the Hong Kong government's Food and Health Bureau has started the implementation of an electronic sharing platform to provide an information infrastructure that enables public hospitals and private clinics to share their electronic medical records (EMRs) for improved access to patients' health care information. However, previous attempts to convince the private clinics to adopt EMRs to document health information have faced challenges, as the EMR adoption has been voluntary. The lack of electronic data shared by private clinics carries direct impacts to the efficacy of electronic record sharing between public and private healthcare providers. To increase the likelihood of buy-in, it is essential to proactively identify the users' and organizations' needs and capabilities before large-scale implementation. As part of the reform initiative, this study examined factors affecting the adoption of EMRs in small or solo private general practice clinics, by analyzing the experiences and opinions of the physicians and clinical assistants during the pilot implementation of the technology, with the purpose to learn from it before full-scale rollout. In-depth, semistructured interviews were conducted with 23 physicians and clinical assistants from seven small or solo private general practice clinics to evaluate their experiences, expectations, and opinions regarding the deployment of EMRs. Interview transcripts were content analyzed to identify key factors. Factors affecting the adoption of EMRs to record and manage health care information were identified as follows: system interface design; system functions; stability and reliability of hardware, software, and computing networks; financial and time costs; task and outcome performance, work practice, and clinical workflow; physical space in clinics; trust in technology; users' information technology literacy; training and technical support; and social and organizational influences. The factors are interrelated with the others. The adoption factors identified are multifaceted, ranging from technological characteristics, clinician-technology interactions, skills and knowledge, and the user-workflow-technology fit. Other findings, which have been relatively underrepresented in previous studies, contribute unique insights about the influence of work and social environment on the adoption of EMRs, including limited clinic space and the effects of physicians' decision to use the technology on clinical staffs' adoption decisions. Potential strategies to address the concerns, overcome adoption barriers, and define relevant policies are discussed.

Digital disruption ‘syndromes’ in a hospital: important considerations for the quality and safety of patient care during rapid digital transformation

The digital transformation of hospitals in Australia is occurring rapidly in order to facilitate innovation and improve efficiency. Rapid transformation can cause temporary disruption of hospital workflows and staff as processes are adapted to the new digital workflows. The aim of this paper is to outline various types of digital disruption and some strategies for effective management. A large tertiary university hospital recently underwent a rapid, successful roll-out of an integrated electronic medical record (EMR). We observed this transformation and propose several digital disruption “syndromes” to assist with understanding and management during digital transformation: digital deceleration, digital transparency, digital hypervigilance, data discordance, digital churn and post-digital ‘depression’. These ‘syndromes’ are defined and discussed in detail. Successful management of this temporary digital disruption is important to ensure a successful transition to a digital platform. What is known about this topic? Digital disruption is defined as the changes facilitated by digital technologies that occur at a pace and magnitude that disrupt established ways of value creation, social interactions, doing business and more generally our thinking. Increasing numbers of Australian hospitals are implementing digital solutions to replace traditional paper-based systems for patient care in order to create opportunities for improved care and efficiencies. Such large scale change has the potential to create transient disruption to workflows and staff. Managing this temporary disruption effectively is an important factor in the successful implementation of an EMR. What does this paper add? A large tertiary university hospital recently underwent a successful rapid roll-out of an integrated electronic medical record (EMR) to become Australia’s largest digital hospital over a 3-week period. We observed and assisted with the management of several cultural, behavioural and operational forms of digital disruption which lead us to propose some digital disruption ‘syndromes’. The definition and management of these ‘syndromes’ are discussed in detail. What are the implications for practitioners? Minimising the temporary effects of digital disruption in hospitals requires an understanding that these digital ‘syndromes’ are to be expected and actively managed during large-scale transformation.

Best Practices in Clinical Decision Support: the Case of Preventive Care Reminders

BACKGROUND: Evidence demonstrates that clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety. However, implementing and maintaining effective decision support interventions presents multiple technical and organizational challenges. PURPOSE: To identify best practices for CDS, using the domain of preventive care reminders as an example. METHODS: We assembled a panel of experts in CDS and held a series of facilitated online and in-person discussions. We analyzed the results of these discussions using a grounded theory method to elicit themes and best practices. RESULTS: Eight best practice themes were identified as important: deliver CDS in the most appropriate ways, develop effective governance structures, consider use of incentives, be aware of workflow, keep content current, monitor and evaluate impact, maintain high quality data, and consider sharing content. Keys themes within each of these areas were also described. CONCLUSION: Successful implementation of CDS requires consideration of both technical and socio-technical factors. The themes identified in this study provide guidance on crucial factors that need consideration when CDS is implemented across healthcare settings. These best practice themes may be useful for developers, implementers, and users of decision support.

Bridging clinical researcher perceptions and health IT realities: A case study of stakeholder creep

PURPOSE

We present a case report detailing a challenge in health information technology (HIT) project implementations we term "stakeholder creep": not thoroughly identifying which stakeholders need to be involved and why before starting a project, consequently not understanding the true effort, skill sets, social capital, and time required to complete the project.

METHODS

A root cause analysis was performed post-implementation to understand what led to stakeholder creep. HIT project stakeholders were given a questionnaire to comment on these misconceptions and a proposed implementation tool to help mitigate stakeholder creep.

FINDINGS

Stakeholder creep contributed to an unexpected increase in time (3-month delayed go-live) and effort (68% over expected HIT work hours). Four main clinician/researcher misconceptions were identified that contributed to the development of stakeholder creep: 1) that EHR IT is a single group; 2) that all EHR IT members know the entire EHR functionality; 3) that changes to an EHR need the input of just a single EHR IT member; and 4) that the technological complexity of a project mirrors the clinical complexity. HIT project stakeholders similarly perceived clinicians/researchers to hold these misconceptions. The proposed stakeholder planning tool was perceived to be feasible and helpful.

CONCLUSIONS

Stakeholder creep can negatively affect HIT project implementations. Projects may be susceptible to stakeholder creep when clinicians/researchers hold misconceptions related to HIT organization and processes. Implementation tools, such as the proposed stakeholder checklist, could be helpful in preempting and mitigating the effect of stakeholder creep.

Causes of EHR projects stalling or failing: A study of EHR projects in Saudi Arabia

BACKGROUND

Electronic Medical Records (EMRs) are designed to automatically collect, store, and retrieve patients' information from healthcare providers within an organization. They assist clinicians in deciding the future course of treatment. The primary objective of this study is to investigate the practices of Electronic Health Record (EHR) project managers regarding the causes of EHR projects getting stalled or failing in Saudi Arabia.

METHODS

Three focus groups were identified across three main cities of Saudi Arabia, namely Riyadh, Jeddah, and Dammam during the years 2013 and 2014. Each group consisted of 10-15 experienced EHR project managers. Qualitative analysis consisted of immersion and crystallization to develop a coding scheme that included both preconceived and emergent themes.

RESULTS AND CONCLUSION

The findings of this study highlight the difficulties, which ensue between EHR and project management practice as well as the issues that can arise from the common use of these terms. It highlights how the aims of an EHR project and its management are transformed, and how the reputation of the project management is to achieve the exact and short-term objectives associated with the comprehensive aims of an EHR project.

Smart Homes for Elderly Healthcare-Recent Advances and Research Challenges

Advancements in medical science and technology, medicine and public health coupled with increased consciousness about nutrition and environmental and personal hygiene have paved the way for the dramatic increase in life expectancy globally in the past several decades. However, increased life expectancy has given rise to an increasing aging population, thus jeopardizing the socio-economic structure of many countries in terms of costs associated with elderly healthcare and wellbeing. In order to cope with the growing need for elderly healthcare services, it is essential to develop affordable, unobtrusive and easy-to-use healthcare solutions. Smart homes, which incorporate environmental and wearable medical sensors, actuators, and modern communication and information technologies, can enable continuous and remote monitoring of elderly health and wellbeing at a low cost. Smart homes may allow the elderly to stay in their comfortable home environments instead of expensive and limited healthcare facilities. Healthcare personnel can also keep track of the overall health condition of the elderly in real-time and provide feedback and support from distant facilities. In this paper, we have presented a comprehensive review on the state-of-the-art research and development in smart home based remote healthcare technologies.

Conversion of Provider EMR Training from Instructor-Led Training to eLearning at an Academic Medical Center

This case study overviews the conversion of provider training of the electronic medical record (EMR) from an instructor-led training (ILT) program to eLearning at an Academic Medical Center (AMC). This conversion provided us with both a useful training tool and the opportunity to maximize efficiency within both our training and optimization team and organization. eLearning Development Principles were created and served as a guide to assist us with designing an eLearning curriculum using a five step process. The result was a new training approach that allowed learners to complete training at their own pace, and even test out of sections based on demonstrated competency. The information we have leads us to believe that a substantial return on our investment can be obtained from the conversion with positive impacts that have served as the foundation for the future of end user EMR training at our AMC.

Differences in Sociocognitive Beliefs between Involved and Noninvolved Employees during the Implementation of an Electronic Health Record System

BACKGROUND

Electronic health records (EHRs) can improve quality and efficiency in patient care. However, the intention to work with such a new system is often relatively low among employees because the work processes of the healthcare organization may change. Involving employees in an EHR implementation may increase their beliefs and perceived capabilities concerning the new system. The current study aimed to assess the role of involvement and its effects on sociocognitive beliefs regarding the implementation of a new EHR system.

METHODS

The study was performed in June 2015 among all eligible employees of a hospital in the Netherlands. Both involved and noninvolved employees were invited to complete a paper-based questionnaire concerning their sociocognitive beliefs (i.e., attitude, social influence, self-efficacy, and intention) related to the EHR implementation. Independent sample t-tests were used to assess potential differences in sociocognitive beliefs between employees who were involved in the implementation process and those who were not. Effect sizes (Cohen's d) were calculated to indicate the standardized difference between the means.

RESULTS

A total of 359 participants completed the paper-based questionnaire and were included in the analyses. Involved employees (n = 94) reported significantly higher levels of attitude (p < .001, d = .62), perceived self-efficacy (p = .01, d = .31), social support (p < .001, d = .68), and a higher intention to work with the new EHR system (p < .001, d = .60), compared with the group of employees who were not involved in the implementation process (n = 265).

CONCLUSION

Involving employees during an EHR implementation appears to enhance employees' sociocognitive beliefs and increases their intention to work with the new system.

Mining Electronic Health Records Data: Domestic Violence and Adverse Health Effects

Intimate partner violence (IPV) often culminates in acute physical injury, sexual assault, and mental health issues. It is crucial to understand the healthcare habits of victims to develop interventions that can drastically improve a victim's quality of life and prevent future abuse. The objective of this study is to mine de-identified and aggregated Electronic Health Record data to identify women's health issues that are potentially associated with IPV. In this study we compared health issues of female domestic abuse victims to female non-domestic abuse victims. The Domestic abuse population contained 5870 patients, while the Non-Domestic Abuse population contained 14,315,140 patients. Explorys provides National Big Data from the entire USA. Statistical analysis identified 2429 terms as significantly more prevalent among victims of domestic abuse, compared to the general population. These terms were classified into broad categories, including acute injury, chronic conditions, substance abuse, mental health, disorders, gynecological and pregnancy related problems.

Clinical Decision Support: a 25 Year Retrospective and a 25 Year Vision

OBJECTIVE

The objective of this review is to summarize the state of the art of clinical decision support (CDS) circa 1990, review progress in the 25 year interval from that time, and provide a vision of what CDS might look like 25 years hence, or circa 2040.

METHOD

Informal review of the medical literature with iterative review and discussion among the authors to arrive at six axes (data, knowledge, inference, architecture and technology, implementation and integration, and users) to frame the review and discussion of selected barriers and facilitators to the effective use of CDS.

RESULT

In each of the six axes, significant progress has been made. Key advances in structuring and encoding standardized data with an increased availability of data, development of knowledge bases for CDS, and improvement of capabilities to share knowledge artifacts, explosion of methods analyzing and inferring from clinical data, evolution of information technologies and architectures to facilitate the broad application of CDS, improvement of methods to implement CDS and integrate CDS into the clinical workflow, and increasing sophistication of the end-user, all have played a role in improving the effective use of CDS in healthcare delivery.

CONCLUSION

CDS has evolved dramatically over the past 25 years and will likely evolve just as dramatically or more so over the next 25 years. Increasingly, the clinical encounter between a clinician and a patient will be supported by a wide variety of cognitive aides to support diagnosis, treatment, care-coordination, surveillance and prevention, and health maintenance or wellness.

Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use?

OBJECTIVE

This study assessed whether having an electronic health record (EHR) super-user, nurse champion for meaningful use (MU), and quality improvement (QI) team leading MU implementation is positively associated with MU Stage 1 demonstration.

METHODS

Data on MU demonstration of 596 providers in 37 ambulatory care clinics came from the clinical data warehouse and administrative systems of UNC Health Care. We surveyed the 37 clinics about champions, super-users, and QI teams. We used generalized estimating equation methods with an independence working correlation matrix to account for clustering within clinics and to weight contributions from each clinic according to clinic size.

RESULTS

Having a QI team lead MU implementation was significantly associated with MU demonstration (odds ratio, OR = 3.57, 95% CI, 1.83-6.96, P < .001, Table 2). Having neither a nurse champion nor an EHR super-user was significant.

CONCLUSION

Our findings support the alignment of MU with QI efforts by having the QI team lead MU implementation.

How Does Learnability of Primary Care Resident Physicians Increase After Seven Months of Using an Electronic Health Record? A Longitudinal Study

Background

Electronic health records (EHRs) with poor usability present steep learning curves for new resident physicians, who are already overwhelmed in learning a new specialty. This may lead to error-prone use of EHRs in medical practice by new resident physicians.

Objective

The study goal was to determine learnability gaps between expert and novice primary care resident physician groups by comparing performance measures when using EHRs.

Methods

We compared performance measures after two rounds of learnability tests (November 12, 2013 to December 19, 2013; February 12, 2014 to April 22, 2014). In Rounds 1 and 2, 10 novice and 6 expert physicians, and 8 novice and 4 expert physicians participated, respectively. Laboratory-based learnability tests using video analyses were conducted to analyze learnability gaps between novice and expert physicians. Physicians completed 19 tasks, using a think-aloud strategy, based on an artificial but typical patient visit note. We used quantitative performance measures (percent task success, time-on-task, mouse activities), a system usability scale (SUS), and qualitative narrative feedback during the participant debriefing session.

Results

There was a 6-percentage-point increase in novice physicians’ task success rate (Round 1: 92%, 95% CI 87-99; Round 2: 98%, 95% CI 95-100) and a 7-percentage-point increase in expert physicians’ task success rate (Round 1: 90%, 95% CI 83-97; Round 2: 97%, 95% CI 93-100); a 10% decrease in novice physicians’ time-on-task (Round 1: 44s, 95% CI 32-62; Round 2: 40s, 95% CI 27-59) and 21% decrease in expert physicians’ time-on-task (Round 1: 39s, 95% CI 29-51; Round 2: 31s, 95% CI 22-42); a 20% decrease in novice physicians mouse clicks (Round 1: 8 clicks, 95% CI 6-13; Round 2: 7 clicks, 95% CI 4-12) and 39% decrease in expert physicians’ mouse clicks (Round 1: 8 clicks, 95% CI 5-11; Round 2: 3 clicks, 95% CI 1-10); a 14% increase in novice mouse movements (Round 1: 9247 pixels, 95% CI 6404-13,353; Round 2: 7991 pixels, 95% CI 5350-11,936) and 14% decrease in expert physicians’ mouse movements (Round 1: 7325 pixels, 95% CI 5237-10,247; Round 2: 6329 pixels, 95% CI 4299-9317). The SUS measure of overall usability demonstrated only minimal change in the novice group (Round 1: 69, high marginal; Round 2: 68, high marginal) and no change in the expert group (74; high marginal for both rounds).

Conclusions

This study found differences in novice and expert physicians’ performance, demonstrating that physicians’ proficiency increased with EHR experience. Our study may serve as a guideline to improve current EHR training programs. Future directions include identifying usability issues faced by physicians when using EHRs, through a more granular task analysis to recognize subtle usability issues that would otherwise be overlooked.

Implementation of an Anesthesia Information Management System in an Ambulatory Surgery Center

Anesthesia information management systems (AIMS) are increasingly being implemented throughout the United States. However, little information exists on the implementation process for AIMS within ambulatory surgery centers (ASC). The objectives of this descriptive study are to document: 1) the phases of implementation of an AIMS at an ASC; and 2) lessons learnt from a socio-technical perspective. The ASC, within the Veterans Health Administration (VHA), has hosted an AIMS since 2008. As a quality improvement effort, we implemented a new version of the AIMS. This new version involved fundamental software changes to enhance clinical care such as real-time importing of laboratory data and total hardware exchange. The pre-implementation phase involved coordinated preparation over six months between multiple informatics teams along with local leadership. During this time, we conducted component, integration, and validation testing to ensure correct data flow from medical devices to AIMS and centralized databases. The implementation phase occurred in September 2014 over three days and was successful. Over the next several months, during post-implementation phase, we addressed residual items like latency of the application. Important lessons learnt from the implementation included the utility of partnering early with executive leadership; ensuring end user acceptance of new clinical workflow; continuous testing of data flow; use of a staged rollout; and providing additional personnel throughout implementation. Implementation of an AIMS at an ASC can utilize methods developed for large hospitals. However, issues unique to an ASC such as limited number of support personnel and distinctive workflows must be considered.

Establishing a binational student-run free-clinic in Tijuana, Mexico: a model for US-Mexico border states

In 2011, a bi-national student-run free clinic for the underserved, known as "Health Frontiers in Tijuana" (HFiT), was created in Tijuana, Mexico. Students and faculty from one Mexican and one US medical school staff the clinic and attend patients on Saturdays. Students from both medical schools enroll in a didactic course during the quarter/semester that they attend the free clinic. The course addresses clinical, ethical, cultural, population-specific issues and the structure, financing and delivery of medical care in Mexico. The clinic implements an electronic medical record and is developing telemedicine for consulting on complex cases. Despite challenges related to sustaining adequate funding, this program may be replicated in other border communities.

Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care

PURPOSE

This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation.

METHODS

This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews.

RESULTS

Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs.

CONCLUSION

Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators.

A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial

INTRODUCTION

The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS-providers-are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations.

METHODS

The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction rules (CPRs), could be efficiently integrated into workflow and result in changes in outcomes (e.g., antibiotic ordering) when embedded within a commercial electronic health record (EHR). We use the lessons learned from the iCPR project to illustrate a framework for constructing usable, useful, and effective actionable CDS while employing off-the-shelf functionality in a production system. Innovations that make up the framework combine the following: (1) active and actionable decision support, (2) multiple rounds of usability testing with iterative development for user acceptance, (3) numerous context sensitive triggers, (4) dedicated training and support for users of the CDS tool for user adoption, and (5) support from clinical and administrative leadership. We define "context sensitive triggers" as being workflow events (i.e., context) that result in a CDS intervention.

DISCUSSION

Success of the framework can be measured by CDS adoption (i.e., intervention is being used), acceptance (compliance with recommendations), and clinical outcomes (where appropriate). This framework may have broader implications for the deployment of Health Information Technology (HIT).

RESULTS AND CONCLUSION

iCPR was well adopted(57.4% of users) and accepted (42.7% of users). Usability testing identified and fixed many issues before the iCPR RCT. The level of leadership support and clinical guidance for iCPR was key in establishing a culture of acceptance for both the tool and its recommendations contributing to adoption and acceptance. The dedicated training and support lead to the majority of the residents reporting a high level of comfort with both iCPR tools strep pharyngitis (64.4 percent) and pneumonia (62.7 percent) as well as a high likelihood of using the tools in the future. A surprising framework addition resulted from usability testing: context sensitive triggers.

Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center

Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation.