Implementing change in primary care practices using electronic medical records: a conceptual framework

Facing the Post-Pandemic Challenges: The Role of Leadership Effectiveness in Shaping the Affective Well-Being of Healthcare Providers Working in a Hybrid Work Mode

The COVID-19 pandemic has brought new challenges to the medical industry, including hybrid work, in which specialists can perform some of their duties remotely, in addition to physical contact with patients and their teams. Hybrid work provides opportunities, but also generates difficulties (e.g., accurate long-distance diagnosis); therefore, there is a need to ensure the well-being of healthcare workers, especially in the context of leadership strategies. As there is little research on leadership practices in remote and hybrid medical worker management, this study analyses the relationship between certain behavioural strategies and competencies of leaders and the affective well-being of hybrid employees. The research was conducted among a group of employees (N = 135) from seven countries who provide healthcare in a hybrid model. The correlations between the variables showed the statistical significance of all leadership strategies introduced into the model and focused on building involvement (employee empowerment and team orientation), creating a shared vision, defining clear goals and strategies, promoting adaptability (change management, promotion of organisational learning and patient focus), managing consistency through shared values, agreement and effective coordination, as well as competencies such as communicativeness, credibility, self-development and digital readiness. Despite the significance of all the relationships, the linear regression showed that the variability of affective well-being was explained mainly by the adaptability leadership strategy. The results of the study expand the knowledge on the competencies of healthcare leaders, and shed new light on the management of medical employees performing remote and hybrid work. Because such research into well-being has not been published to date, the analysis begins an important discussion on redefining leadership in the healthcare sector, taking into account the digital transformation.

Digital Leadership: Attributes of Modern Healthcare Leaders

Background

Living in the current digital era requires widespread adoption of information technology in the modern healthcare industry.

Objective

The current research aimed to study key attributes and behaviors related to successful leaders' need to achieve the vision and ensure successful health IT adoption.

Methods

A Delphi technique with three rounds was employed and guided by structured questions. Part of the study was conducted online due to COVID-19 guidelines on distancing norms and lockdown in some areas. The answers of the participants were evaluated on a five-point Likert scale.

Results

The findings showed that similar leadership qualities are required in the healthcare sector as well as other sectors. For digital innovations in the rapidly changing healthcare space, leaders need to play a more proactive role, be visionary and dynamic, and should lead by example to take the organization to the next level.

Conclusions

Leaders need to come out of their comfort zone, understand the fast-evolving scenario where outstanding leadership qualities are essential to prove their mettle, outshine others, and create a strong foundation for the adoption of modern, efficient, customized digital technology in the fast-growing healthcare sector.

Exploring healthcare professionals' perceptions of artificial intelligence: Piloting the Shinners Artificial Intelligence Perception tool

Objective

There is an urgent need to prepare the healthcare workforce for the implementation of artificial intelligence (AI) into the healthcare setting. Insights into workforce perception of AI could identify potential challenges that an organisation may face when implementing this new technology. The aim of this study was to psychometrically evaluate and pilot the Shinners Artificial Intelligence Perception (SHAIP) questionnaire that is designed to explore healthcare professionals’ perceptions of AI. Instrument validation was achieved through a cross-sectional study of healthcare professionals (n = 252) from a regional health district in Australia.

Methods and Results

Exploratory factor analysis was conducted and analysis yielded a two-factor solution consisting of 10 items and explained 51.7% of the total variance. Factor one represented perceptions of ‘Professional impact of AI’ (α = .832) and Factor two represented ‘Preparedness for AI’ (α = .632). An analysis of variance indicated that ‘use of AI’ had a significant effect on healthcare professionals’ perceptions of both factors. ‘Discipline’ had a significant effect on Allied Health professionals’ perception of Factor one and low mean scale score across all disciplines suggests that all disciplines perceive that they are not prepared for AI.

Conclusions

The results of this study provide preliminary support for the SHAIP tool and a two-factor solution that measures healthcare professionals’ perceptions of AI. Further testing is needed to establish the reliability or re-modelling of Factor 2 and the overall performance of the SHAIP tool as a global instrument.

How Do Patients Want Us to Use the Computer During Medical Encounters?-A Discrete Choice Experiment Study

BACKGROUND

Primary care physicians (PCPs) now widely use electronic health records (EHRs) during medical encounters. Experts in clinical communication issued recommendations for a patient-centered use of EHRs. However, they have never been validated by patients themselves.

OBJECTIVE

To explore patients' preferences regarding physicians' EHR-related behaviors.

DESIGN

Discrete choice experiment study.

PATIENTS

French-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland.

MAIN MEASURES

We invited patients to watch videos displaying 2 or 3 variations of four specific EHR-related behaviors and asked them to indicate which one they preferred. EHR-related behaviors were (1) typing: continuous/intermittent/handwriting in biomedical or psychosocial focused consultations; (2) maintaining contact while typing: visual/verbal/both; (3) signposting the use of EHR: with/without; (4) position of physicians' hands and bust: on the keyboard and towards the patient/away from the keyboard and towards the patient/on the keyboard and towards the screen.

KEY RESULTS

Three hundred thirty-six patients participated (response rate 61.4%). They preferred intermittent typing versus handwriting or continuous typing for biomedical issues (32.7%; 95% CI: 26.0-40.2% vs 31.6%; 95% CI: 24.9-39.0% or 14.9%; 95% CI: 10.2-21.1%) and psychosocial issues (38.7%; 95% CI: 31.6-46.3% vs 24.4% 95% CI: 18.4-31.5% or 17.9%; 95% CI; 12.7-24.4%). They favored visual and verbal contact (38.9%; 95% CI: 31.9-46.3%) over verbal (30.3%; 95% CI: 23.9-37.5%) or visual contact only (11.4%; 95% CI: 7.5-17.1%) while the doctor was typing. A majority preferred signposting the use of EHR versus no signposting (58.9%; 95% CI: 53.5-64.0% vs 34.8%; 95% CI: 29.9-40.1%). Finally, half of the patients (49.7%; 95% CI: 42.0-57.4%) favored the position with the physician's bust towards the patient and hands away from the keyboard.

CONCLUSIONS

Our study shows that patients' preferences regarding EHR-related behaviors are in line with most experts' recommendations. Such recommendations should be more consistently integrated into under- and postgraduate communication skills training.

Exploring healthcare professionals' perceptions of artificial intelligence: Validating a questionnaire using the e-Delphi method

Objective

The aim of this study was to draw upon the collective knowledge of experts in the fields of health and technology to develop a questionnaire that measured healthcare professionals' perceptions of Artificial Intelligence (AI).

Methods

The panel for this study were carefully selected participants who demonstrated an interest and/or involvement in AI from the fields of health or information technology. Recruitment was accomplished via email which invited the panel member to participate and included study and consent information. Data were collected from three rounds in the form of an online survey, an online group meeting and email communication. A 75% median threshold was used to define consensus.

Results

Between January and March 2019, five healthcare professionals and three IT experts participated in three rounds of study to reach consensus on the structure and content of the questionnaire. In Round 1 panel members identified issues about general understanding of AI and achieved consensus on nine draft questionnaire items. In Round 2 the panel achieved consensus on demographic questions and comprehensive group discussion resulted in the development of two further questionnaire items for inclusion. In a final e-Delphi round, a draft of the final questionnaire was distributed via email to the panel members for comment. No further amendments were put forward and 100% consensus was achieved.

Conclusion

A modified e-Delphi method was used to validate and develop a questionnaire to explore healthcare professionals' perceptions of AI. The e-Delphi method was successful in achieving consensus from an interdisciplinary panel of experts from health and IT. Further research is recommended to test the reliability of this questionnaire.

An evaluation of the clinical microsystems approach in general practice quality improvement

Background:

Changes to the general practice (GP) contract in England (April 2019) introduced a new quality improvement (QI) domain. The clinical microsystems programme is an approach to QI with limited evidence in primary care.

Aim:

To explore experiences of GP staff participating in a clinical microsystems programme.

Design and setting:

GPs within one clinical commissioning group (CCG) in South East England. Normalisation process theory informed qualitative approach.

Method:

Review of all CCG clinical microsystems projects using pre-existing data. The Diffusion of Innovation Cycle was used to inform the sampling frame and GPs were invited to participate in interviews or focus groups. Ten practices participated; 11 coaches and 16 staff were interviewed.

Results:

The majority of projects were process-driven activities related to administrative systems. Projects directly related to health outputs were fewer and related to externally imposed targets. Four key elements facilitated practices to engage: feeling in control; receiving enhanced service payment; having a senior staff member championing the approach; and good practice–coach relationship. There appeared to be three key benefits in addition to project-specific ones: improved working relationships between CCG and practice; more cohesive practice team; and time to reflect.

Conclusion:

Small projects with clear parameters were more successful than larger ones or those spanning organisations. However, there was little evidence suggesting the key benefits were unique attributes of the microsystems approach and sustainability was problematic. Future research should focus on cross-organisational approaches to QI and identify what, if any, added value the approach provides.

Physician Communication Practices as a Barrier to Risk-Based HPV Vaccine Uptake Among Men Who Have Sex with Men

The Advisory Committee on Immunization Practices recommends that men who have sex with men (MSM) 26 years of age or younger be routinely vaccinated against HPV. For men outside of this risk-based population, the recommendation is routine vaccination until age 21. Thus, in order for this risk-based recommendation for MSM to be implemented, two distinct actions need to be completed during the clinical visit: (1) discuss recommendations for HPV vaccination with men and (2) assess sexual orientation to determine if a risk-based recommendation should be made. We assessed the degree to which physicians routinely discussed issues of sexual orientation and HPV vaccination with male patients 22-26 years old. We used data from a statewide representative sample of 770 primary care physicians practicing in Florida who were randomly selected from the American Medical Association Physician Masterfile. The analytic sample consisted of physicians who provided care to men 22-26 years old (N = 220). Response rate was 51%. Data collection took place in 2014 and analyses in 2016. Only 13.6% of physicians were routinely discussing both sexual orientation and HPV vaccination with male patients 22-26 years old, and approximately a quarter (24.5%) were not discussing either. Differences in these behaviors were found based on gender, Hispanic ethnicity, availability of HPV vaccine in clinic, HPV-related knowledge, and specialty. A minority of physicians in this sample reported engaging with these patients in ways that are mostly likely to result in recommendations consistent with current Advisory Committee on Immunization Practices guidelines.

The Politics of Primary Care Expansion: Lessons From Cancer Survivorship and Substance Abuse

EXECUTIVE SUMMARY

The purpose of this study is to understand the perspectives of primary care innovators treating patient populations not traditionally considered to be within the purview of primary care. Data were obtained from the 2015 Working Conference for PCMH (Patient-Centered Medical Home) Innovation funded by the Agency for Healthcare Research and Quality. The conference convened representatives from 10 innovative primary care practices and content experts to discuss experiences with integrating care for two nontraditional populations: patients with substance abuse issues and cancer survivors. Transcripts of the conference, one-on-one interviews, and written summaries of practice innovations were coded in NVivo (QSR International) and analyzed by means of an immersion/crystallization approach to identifying thematic patterns. Our study findings suggest that the politics surrounding entrenched professional identities contributed to barriers faced by conference participants in their efforts to provide innovative care for these nontraditional populations. Specifically, obstacles surfaced in relation to sharing patients across disciplinary boundaries, which resulted in issues of possessiveness, a questioning of provider qualifications, and a lack of interprofessional trust. Though support is increasing for primary care expansion and care integration, policy change may precede the identity transformations necessary for medical practitioners to embrace new primary care-centered models. For this reason, it is important that the formation and entrenchment of professional identities be critically considered as part of future efforts to transform primary care practice.

A Literature Review of Electronic Health Records in Chiropractic Practice: Common Challenges and Solutions

OBJECTIVE

The purpose of this study was to review the literature on current challenges and propose solutions for the optimal utilization of the electronic health records (EHRs) in chiropractic practice.

METHODS

A search was performed in the PubMed, Index of Chiropractic Literature, and Current Index to Nursing and Allied Health Literature databases from November 2005 to February 2015. A combination of the following key words was used: electronic health records, electronic medical records, implementation, documentation, benefits, and challenges. Articles were categorized into common problems and solutions. These were filtered by application to chiropractic or educational institutions.

RESULTS

The search resulted in 45 papers, which included case reports of EHR implementation, governmental insurance reports, commentaries, controlled studies, narrative reviews of past experiences with conversion from paper systems, and the implementation of EHRs in small offices and chiropractic offices. Minimal literature was found that directly related to chiropractic EHRs. Improper utilization, incorrect use of the software, faulty implementation, workflow burdens, financial considerations, and insufficient training were found to negatively affect the quality of the record.

CONCLUSIONS

Documentation errors are often innate in the EHR software. Improper utilization, insufficient training, or difficulty in integration of the EHR into the clinical office setting results in poor implementation of the electronic version of the clinical record. Solutions that may decrease documentation errors include EHR training, continued financial incentives, and appropriate implementation process and utilization of available software features.

'It's a very complicated issue here': understanding the limited and declining use of manual vacuum aspiration for postabortion care in Malawi: a qualitative study

Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions are an important contributor to Malawi's maternal mortality and morbidity, where abortion is illegal except to save the woman's life. Postabortion care (PAC) aims to reduce adverse consequences of unsafe abortions, in part by treating incomplete abortions. Although global and national PAC policies recommend manual vacuum aspiration (MVA) for treatment of incomplete abortion, usage in Malawi is low and appears to be decreasing, with sharp curettage being used in preference. There is limited evidence regarding what influences rejection of recommended PAC innovations. Hence, drawing on Greenhalgh et al. 's (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) diffusion of healthcare innovation framework, this qualitative study aimed to investigate factors contributing to the limited and declining use of MVA in Malawi. Semi-structured interviews with 17 PAC providers in a central hospital and a district hospital indicate that a range of factors coalesce and influence PAC and MVA use in Malawi. Factors pertain to four main domains: the system (shortages of material and human resources; lack of training, supervision and feedback), relationships (power dynamics; expected job roles), the health workers (attitudes towards abortion and PAC; prioritization of PAC) and the innovation (perceived risks and benefits of MVA use). Effective and sustainable PAC policy must adopt a broader people-centred health systems approach which considers all these factors, their interactions and the wider socio-cultural, legal and political context of abortion and PAC. The study showed the value of using Greenhalgh et al. 's (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) framework to consider the complex interaction of factors surrounding innovation use (or lack of), but provided more insights into rejections of innovations and, particularly, a low- and middle-income country perspective.

Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents

Background

The Electronic Health Record (EHR) is now widely used in clinical encounters. Because its use can negatively impact the physician-patient relationship, several recommendations on the “patient-centered” use of the EHR have been published. However, the impact of training to improve EHR use during clinical encounters is not well known. The aim of this study was to assess the impact of training on residents’ EHR-related communication skills and explore whether they varied according to the content of the consultation.

Methods

We conducted a pre-post intervention study at the Primary Care Division of the Geneva University Hospitals, Switzerland. Residents were invited to attend a 3-month training course that included 2 large group sessions and 2–4 individualized coaching sessions based on videotaped encounters. Outcomes were: 1) residents’ perceptions regarding the use of EHR, measured through a self-administered questionnaire and 2) objective use of the EHR during the first 10 min of patient encounters. Changes in practice were measured pre and post intervention using the Roter interaction analysis system (RIAS) and EHR specific items.

Results

Seventeen out of 27 residents took part in the study. Participants used EHR in about 30% of consultations. After training, they were less likely to consider EHR to be a barrier to the physician-patient relationship, and felt more comfortable using the EHR. After training, participants increased the use of signposting when using the EHR (pre: 0.77, SD 1.69; post: 1.80, SD3.35; p 0.035) and decreased EHR use when psychosocial issues appeared (pre: 24.5% and post: 9.76%, p < 0.001).

Conclusions

This study suggests that training can improve residents’ EHR-related communication skills, especially in situations where patients bring up sensitive psychosocial issues. Future research should focus on patients’ perceptions of the relevance and usefulness of such skills.

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

Background

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps.

Methods and findings

An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals.

Conclusion

A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work.

Systematic review registration

International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

A Digital Feedback System to Support Implementation of Measurement-Based Care by School-Based Mental Health Clinicians

Evidence supports the utility of measurement-based care (MBC) to improve youth mental health outcomes, but clinicians rarely engage in MBC practices. Digital measurement feedback systems (MFS) may reflect a feasible strategy to support MBC adoption and sustainment. This pilot study was initiated to evaluate the impact of a MFS and brief consultation supports to facilitate MBC uptake and sustainment among mental health clinicians in the education sector, the most common mental health service delivery setting for youth. Following an initial training in MBC, 14 clinicians were randomized to either a digital MFS and brief consultation supports or control. Baseline ratings of MBC attitudes, skill, and use were collected. In addition, daily assessment ratings tracked 2 core MBC practices (i.e., assessment tool administration, provision of feedback) over a 6-month follow-up period. Clinicians in the MFS condition demonstrated rapid increases in both MBC practices, whereas the control group did not significantly change. For clinicians in the MFS group, consultation effects were significant for feedback and approached significance for administration. Over the follow-up period, average decreases in the current study were moderate with only 1 of the 2 outcome variables (administration) decreasing significantly. Inspection of individual clinician trajectories revealed substantial within-group trend variation. MFS may represent an effective MBC implementation strategy beyond initial training, although individual clinician response is variable. Identifying feasible and impactful implementation strategies is critical given the ability of MBC to support precision health care.

Use of electronic medical records and quality of patient data: different reaction patterns of doctors and nurses to the hospital organization

BACKGROUND

As the implementation of Electronic Medical Records (EMRs) in hospitals may be challenged by different responses of different user groups, this paper examines the differences between doctors and nurses in their response to the implementation and use of EMRs in their hospital and how this affects the perceived quality of the data in EMRs.

METHODS

Questionnaire data of 402 doctors and 512 nurses who had experience with the implementation and the use of EMRs in hospitals was analysed with Multi group Structural equation modelling (SEM). The models included measures of organisational factors, results of the implementation (ease of use and alignment of EMR with daily routine), perceived added value, timeliness of use and perceived quality of patient data.

RESULTS

Doctors and nurses differ in their response to the organisational factors (support of IT, HR and administrative departments) considering the success of the implementation. Nurses respond to culture while doctors do not. Doctors and nurses agree that an EMR that is easier to work with and better aligned with their work has more added value, but for the doctors this is more pronounced. The doctors and nurses perceive that the quality of the patient data is better when EMRs are easier to use and better aligned with their daily routine.

CONCLUSIONS

The result of the implementation, in terms of ease of use and alignment with work, seems to affect the perceived quality of patient data more strongly than timeliness of entering patient data. Doctors and nurses value bottom-up communication and support of the IT department for the result of the implementation, and nurses respond to an open and innovative organisational culture.

Obesity services planning framework for interprofessional primary care organizations

Aim

We report on a formative project to develop an organization-level planning framework for obesity prevention and management services.

Background

It is common when developing new services to first develop a logic model outlining expected outcomes and key processes. This can be onerous for single primary care organizations, especially for complex conditions like obesity.

Methods

The initial draft was developed by the research team, based on results from provider and patient focus groups in one large Family Health Team (FHT) in Ontario. This draft was reviewed and activities prioritized by 20 FHTs using a moderated electronic consensus process. A national panel then reviewed the draft.

Findings

Providers identified five main target groups: pregnancy to 2, 3–12, 13–18, 18+ years at health risk, and 18+ with complex care needs. Desired outcomes were identified and activities were prioritized under categories: raising awareness (eg, providing information and resources on weight-health), identification and initial management (eg, wellness care), follow-up management (eg, group programs), expanded services (eg, availability of team services), and practice initiatives (eg, interprofessional education). Overall, there was strong support for raising awareness by providing information on the weight-health connection and on community services. There was also strong support for growth assessment in pediatric care. In adults, there was strong support for wellness care/health check visits and episodic care to identify people for interventions, for group programs, and for additional provider education.

Conclusions

Joint development by different teams proved useful for consensus on outcomes and for ensuring relevancy across practices. While priorities will vary depending on local context, the basic descriptions of care processes were endorsed by reviewers. Key next steps are to trial the use of the framework and for further implementation studies to find optimally effective approaches for obesity prevention and management across the lifespan.

How organizational escalation prevention potential affects success of implementation of innovations: electronic medical records in hospitals

BACKGROUND

Escalation of commitment is the tendency that (innovation) projects continue, even if it is clear that they will not be successful and/or become extremely costly. Escalation prevention potential (EPP), the capability of an organization to stop or steer implementation processes that do not meet their expectations, may prevent an organization of losing time and money on unsuccessful projects. EPP consists of a set of checks and balances incorporated in managerial practices that safeguard management against irrational (but very human) decisions and may limit the escalation of implementation projects. We study whether successful implementation of electronic medical records (EMRs) relates to EPP and investigate the organizational factors accounting for this relationship.

METHODS

Structural equation modelling (SEM), using questionnaire data of 427 doctors and 631 nurses who had experience with implementation and use of EMRs in hospitals, was applied to study whether formal governance and organizational culture mediate the relationship between EPP and the perceived added value of EMRs.

RESULTS

Doctors and nurses in hospitals with more EPP report more successful implementation of EMR (in terms of perceived added value of the EMR). Formal governance mediates the relation between EPP and implementation success. We found no evidence that open or innovative culture explains the relationship between EPP and implementation success.

CONCLUSIONS

There is a positive relationship between the level of EPP and perceived added value of EMRs. This relationship is explained by formal governance mechanisms of organizations. This means that management has a set of tangible tools to positively affect the success of innovation processes. However, it also means that management needs to be able to critically reflect on its (previous) actions and decisions and is willing to change plans if elements of EPP signal that the implementation process is hampered.

Development and implementation of an integrated chronic disease model in South Africa: lessons in the management of change through improving the quality of clinical practice

Background

South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge.

Methods

The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model.

Results

The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes.

Conclusion

The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.

The impact of clinical leadership on health information technology adoption: systematic review

PURPOSE

To conduct a systematic review to examine evidence of associations between clinical leadership and successful information technology (IT) adoption in healthcare organisations.

METHODS

We searched Medline, Embase, Cinahl, and Business Source Premier for articles published between January 2000 to May 2013 with keywords and subject terms related to: (1) the setting--healthcare provider organisations; (2) the technology--health information technology; (3) the process--adoption; and (4) the intervention--leadership. We identified 3121 unique citations, of which 32 met our criteria and were included in the review. Data extracted from the included studies were assessed in light of two frameworks: Bassellier et al.'s IT competence framework; and Avgar et al.'s health IT adoption framework.

RESULTS

The results demonstrate important associations between the attributes of clinical leaders and IT adoption. Clinical leaders who have technical informatics skills and prior experience with IT project management are likely to develop a vision that comprises a long-term commitment to the use of IT. Leaders who possess such a vision believe in the value of IT, are motivated to adopt it, and can maintain confidence and stability through the adversities that IT adoptions often entail. This leads to proactive leadership behaviours and partnerships with IT professionals that are associated with successful organisational and clinical outcomes.

CONCLUSIONS

This review provides evidence that clinical leaders can positively contribute to successful IT adoption in healthcare organisations. Clinical leaders who aim for improvements in the processes and quality of care should cultivate the necessary IT competencies, establish mutual partnerships with IT professionals, and execute proactive IT behaviours to achieve successful IT adoption.

Organizational attributes and screening and brief intervention in primary care

Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening and brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that were included in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to the implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of the implementation of SBI and treatment.

Strategies to increase colorectal cancer screening

Colorectal cancer screening (CRCS) is the only way to detect colorectal cancer in its earlier stages when morbidity and mortality are low. The literature has shown provider-directed recommendations with office system-directed interventions are the best way to increase CRCS rates.

Improving medication safety in primary care using electronic health records

OBJECTIVES

Electronic health record (EHR) systems offer promising tools to assist clinicians and staff with improving medication safety, yet many of the decision support components within these information systems are not well used. The aim of this study was to identify the strategies planned by primary care practices participating in a 2-year medication safety quality improvement intervention within the Practice Partner Research Network.

METHODS

A theoretical model for primary care practice improvement was used to foster team-based approaches to prioritizing performance, system redesign, better use of EHR tools, and patient activation. The intervention included network meetings, site visits and performance reports. Improvement plans were qualitatively evaluated from field notes and organized to present a comprehensive approach to improving medication safety in primary care using EHRs.

RESULTS

A total of 32 distinct plans and 11 common strategies were developed by practices to improve adherence with prescribing and monitoring indicators. Common plans included enhancing medication reconciliation to improve the accuracy of medication lists, using Practice Partner Research Network reports to identify patients meeting criteria for preventable medication errors, and customizing and applying EHR decision support tools for medication dosing, drug-disease interactions, and monitoring.

CONCLUSIONS

Medication safety might be improved by implementing specific strategies within the primary care setting. Further evaluation is needed to provide an evidence base for improvement.

Colorectal cancer screening in primary care: theoretical model to improve prevalence in the practice partner research network

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Half of Americans older than age 50 are not current with recommended screening; research is needed to assess the impact of interventions designed to increase receipt of CRC screening. The Colorectal Cancer Screening in Primary Care (C-TRIP) study is a theoretically informed group randomized trial within 32 primary care practices. Baseline median proportion of active patients aged 50 years or older up-to-date with CRC screening among the 32 practices was 50.8% (N = 55,746). Men were more likely to have been screened than women (52.9% vs. 49.2%, respectively). Patients 50 to 59 years of age were less likely to be up-to-date with screening (45.4%) than those in the 60 to 69 years and 70 to 79 years groups (58.5% in both groups). Opportunities exist to increase the proportion of CRC screening received in adults aged 50 and older. C-TRIP evaluates the effectiveness of a model for improvement for increasing this proportion.

Gradual electronic health record implementation: new insights on physician and patient adaptation

PURPOSE

Although there is significant interest in implementation of electronic health records (EHRs), limited data have been published in the United States about how physicians, staff, and patients adapt to this implementation process. The purpose of this research was to examine the effects of EHR implementation, especially regarding physician-patient communication and behaviors and patients' responses.

METHODS

We undertook a 22-month, triangulation design, mixed methods study of gradual EHR implementation in a residency-based family medicine outpatient center. Data collection included participant observation and time measurements of 170 clinical encounters, patient exit interviews, focus groups with nurses, nurse's aides, and office staff, and unstructured observations and interviews with nursing staff and physicians. Analysis involved iterative immersion-crystallization discussion and searches for alternate hypotheses.

RESULTS

Patient trust in the physician and security in the physician-patient relationship appeared to override most patients' concerns about information technology. Overall, staff concerns about potential deleterious consequences of EHR implementation were dispelled, positive anticipated outcomes were realized, and unexpected benefits were found. Physicians appeared to become comfortable with the "third actor" in the room, and nursing and office staff resistance to EHR implementation was ameliorated with improved work efficiencies. Unexpected advantages included just-in-time improvements and decreased physician time out of the examination room.

CONCLUSIONS

Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.

Patient weight counseling choices and outcomes following a primary care and community collaborative intervention

OBJECTIVE

Obesity has become a public health epidemic in adults and children. Clinician practices need new models to effectively address overweight in patients, yet, practices lack time and resources. We tested a clinician-delivered intervention that utilized community resources for in-depth counseling for unhealthy behaviors including overweight.

METHODS

Eligible patients in nine primary care practices were identified using an electronic linkage system (eLinkS) which also automated patient referrals to group (Weight Watcher's), telephone counseling (TC), or usual care. Pre/post-survey data were used to assess factors related to counseling choices as well as changes in BMI (kg/m(2)) and weight-related behaviors using descriptive statistics, unadjusted, and adjusted statistical analyses.

RESULTS

Study sample (n=146) was 70% female with a mean age of 57 years. More patients (57%) selected WW, followed by usual care (27%) or TC (16%). Age, gender, clinician recommendation, and counseling program characteristics were influential in counseling selections. Weight Watcher's participants and those in TC, reported statistically significant weight loss, WW participants also reported significant increases in fruit/vegetable intake; after 4 months compared with usual care.

CONCLUSIONS

This practice-based intervention utilizing community counseling referrals was associated with positive health behavior change.

PRACTICE IMPLICATIONS

Identifying influential factors related to patient weight counseling choices may help guide referrals to community programs.

Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

CONTEXT

The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches.

METHODS

Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation.

FINDINGS

Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful").

CONCLUSIONS

The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.

An application of a modified constrained randomization process to a practice-based cluster randomized trial to improve colorectal cancer screening

BACKGROUND

When designing cluster randomized trials, it is important for researchers to be familiar with strategies to achieve valid study designs given limited resources. Constrained randomization is a technique to help ensure balance on pre-specified baseline covariates.

METHODS

The goal was to develop a randomization scheme that balanced 16 intervention and 16 control practices with respect to 7 factors that may influence improvement in study outcomes during a 4-year cluster randomized trial to improve colorectal cancer screening within a primary care practice-based research network. We used a novel approach that included simulating 30,000 randomization schemes, removing duplicates, identifying which schemes were sufficiently balanced, and randomly selecting one scheme for use in the trial. For a given factor, balance was considered achieved when the frequency of each factor's sub-classifications differed by no more than 1 between intervention and control groups. The population being studied includes approximately 32 primary care practices located in 19 states within the U.S. that care for approximately 56,000 patients at least 50 years old.

RESULTS

Of 29,782 unique simulated randomization schemes, 116 were determined to be balanced according to pre-specified criteria for all 7 baseline covariates. The final randomization scheme was randomly selected from these 116 acceptable schemes.

CONCLUSIONS

Using this technique, we were successfully able to find a randomization scheme that allocated 32 primary care practices into intervention and control groups in a way that preserved balance across 7 baseline covariates. This process may be a useful tool for ensuring covariate balance within moderately large cluster randomized trials.