Unintended consequences of information technologies in health care--an interactive sociotechnical analysis

Re-visioning of a Nursing Informatics Course With Translational Pedagogy

For nurse leaders to excel in leadership roles in the clinical world of informatics, a comprehensive understanding of nursing informatics as translated within the broader scope of health informatics including clinical informatics and business intelligence is necessary. The translation of nursing informatics in the comprehensive scope of health informatics is not consistently taught in graduate nursing leadership curricula. Collaboratively, from an interprofessional education stance, a graduate nurse informatics course was re-visioned using translational pedagogy: the idea of teaching related concepts by translating each and vice versa. Specifically, we translated nursing informatics amid health informatics concepts including business intelligence. Leadership students in the re-visioned course experienced the ability to visualize, conceptualize, and understand how work in information systems impacts broader aspects of clinical and business decision-making. Looking at nursing informatics through the lens of health informatics will develop students' ability to visualize, conceptualize, and understand how work in information systems has an impact on the broader aspects of clinical decision-making and support. Further, this paradigm shift will enhance students' ability to utilize information systems in leadership decision-making as future knowledge workers.

AI implementation: Radiologists' perspectives on AI-enabled opportunistic CT screening

OBJECTIVE

AI adoption requires perceived value by end-users. AI-enabled opportunistic CT screening (OS) detects incidental clinically meaningful imaging risk markers on CT for potential preventative health benefit. This investigation assesses radiologists' perspectives on AI and OS.

METHODS

An online survey was distributed to 7500 practicing radiologists among ACR membership of which 4619 opened the emails. Familiarity with and views of AI applications were queried and tabulated, as well as knowledge of OS and inducements and impediments to use.

RESULTS

Respondent (n = 211) demographics: mean age 55 years, 73 % male, 91 % diagnostic radiologists, 46 % in private practice. 68 % reported using AI in practice, while 52 % were only somewhat familiar with AI. 70 % viewed AI positively though only 46 % reported AI's overall accuracy met expectations. 57 % were unfamiliar with OS, with 52 % of those familiar having a positive opinion. Patient perceptions were the most commonly reported (25 %) inducement for OS use. Provider (44 %) and patient (40 %) costs were the most common impediments. Respondents reported that osteoporosis/osteopenia (81 %), fatty liver (78 %), and atherosclerotic cardiovascular disease risk (76 %) could be well assessed by OS. Most indicated OS output requires radiologist oversight/signoff and should be included in a separate "screening" section in the Radiology report. 28 % indicated willingness to spend 1-3 min reviewing AI-generated output while 18 % would not spend any time. Society guidelines/recommendations were most likely to impact OS implementation.

DISCUSSION

Radiologists' perspectives on AI and OS provide practical insights on AI implementation. Increasing end-user familiarity with AI-enabled applications and development of society guidelines/recommendations are likely essential prerequisites for Radiology AI adoption.

A Systematic Review of Online Medical Consultation Research

Online medical consultation is a form of medical service that facilitates interactions between patients and doctors online, offering significant utility and value. This review aims to retrieve, screen, and analyze articles related to online medical consultations, formulating a theoretical framework and proposing future research directions. According to PRISMA guidelines, a systematic search was conducted in Web of Science, EBSCO, ScienceDirect, PubMed, and Scopus, retrieving a total of 4072 English records on 16 December 2023. After rigorous screening, 75 articles were included in this review. Among these, 8 articles focused on patients utilizing online medical consultation platforms, 5 on doctors participating in online medical platforms, 18 on patients' choice of doctors, 12 on doctors providing services, 7 on online reviews of patients, 14 on service quality for patients, 8 on rewards to doctors, and 11 on the spillover effect between online and offline services. These themes comprise the theoretical framework of the starting point, process, and outcomes of the online medical consultation system, providing a comprehensive understanding of the field and a foundation for future research.

Evaluating EHR-Integrated Digital Technologies for Medication-Related Outcomes and Health Equity in Hospitalised Adults: A Scoping Review

The purpose of this scoping review is to identify and evaluate studies that examine the effectiveness and implementation strategies of Electronic Health Record (EHR)-integrated digital technologies aimed at improving medication-related outcomes and promoting health equity among hospitalised adults. Using the Consolidated Framework for Implementation Research (CFIR), the implementation methods and outcomes of the studies were evaluated, as was the assessment of methodological quality and risk of bias. Searches through Medline, Embase, Web of Science, and CINAHL Plus yielded 23 relevant studies from 1,232 abstracts, spanning 11 countries and from 2008 to 2022, with varied research designs. Integrated digital tools such as alert systems, clinical decision support systems, predictive analytics, risk assessment, and real-time screening and surveillance within EHRs demonstrated potential in reducing medication errors, adverse events, and inappropriate medication use, particularly in older patients. Challenges include alert fatigue, clinician acceptance, workflow integration, cost, data integrity, interoperability, and the potential for algorithmic bias, with a call for long-term and ongoing monitoring of patient safety and health equity outcomes. This review, guided by the CFIR framework, highlights the importance of designing health technology based on evidence and user-centred practices. Quality assessments identified eligibility and representativeness issues that affected the reliability and generalisability of the findings. This review also highlights a critical research gap on whether EHR-integrated digital tools can address or worsen health inequities among hospitalised patients. Recognising the growing role of Artificial Intelligence (AI) and Machine Learning (ML), this review calls for further research on its influence on medication management and health equity through integration of EHR and digital technology.

Primary care provider perspectives on the value of opportunistic CT screening

BACKGROUND

Clinical adoption of AI applications requires stakeholders see value in their use. AI-enabled opportunistic-CT-screening (OS) capitalizes on incidentally-detected findings within CTs for potential health benefit. This study evaluates primary care providers' (PCP) perspectives on OS.

METHODS

A survey was distributed to US Internal and Family Medicine residencies. Assessed were familiarity with AI and OS, perspectives on potential value/costs, communication of results, and technology implementation.

RESULTS

62 % of respondents (n = 71) were in Family Medicine, 64.8 % practiced in community hospitals. Although 74.6 % of respondents had heard of AI/machine learning, 95.8 % had little-to-no familiarity with OS. The majority reported little-to-no trust in AI. Reported concerns included AI accuracy (74.6 %) and unknown liability (73.2 %). 78.9 % of respondents reported that OS applications would require radiologist oversight. 53.5 % preferred OS results be included in a separate "screening" section within the Radiology report, accompanied by condition risks and management recommendations. The majority of respondents reported results would likely affect clinical management for all queried applications, and that atherosclerotic cardiovascular disease risk, abdominal aortic aneurysm, and liver fibrosis should be included within every CT report regardless of reason for examination. 70.5 % felt that PCP practices are unlikely to pay for OS. Added costs to the patient (91.5 %), the healthcare provider (77.5 %), and unknown liability (74.6 %) were the most frequently reported concerns.

CONCLUSION

PCP preferences and concerns around AI-enabled OS offer insights into clinical value and costs. As AI applications grow, feedback from end-users should be considered in the development of such technology to optimize implementation and adoption. Increasing stakeholder familiarity with AI may be a critical prerequisite first step before stakeholders consider implementation.

Estimating and Rewarding the Value of Healthcare Interventions Beyond the Healthcare Sector: A Conceptual Framework

BACKGROUND

Evaluating healthcare interventions for their impacts beyond health outcomes may result in recognition of changes in human capital, income level, tax revenue, and government spending, which could affect economic growth and population health. In this paper, we document instances where current health technology assessment (HTA) practices fail to account for the impacts of healthcare interventions on broader society beyond the healthcare sector.

METHODS

We propose a novel conceptual framework, highlighting its three components (distributional cost-effectiveness analysis [DCEA], input-output model, and voting scheme) and their contributions to capturing the economic and societal ripple effects of healthcare interventions. This manuscript also outlines a case study in which the framework is applied to the reassessment of a previously evaluated digital health therapeutic for the treatment of opioid use disorder (OUD) compared with standard of care, demonstrating its practical application.

RESULTS

The DCEA health value metric indicates that digital therapeutic is more equitable, favoring socioeconomically disadvantaged groups, while standard of care exacerbates health inequality by benefiting the already advantaged. Additionally, digital therapeutic shows potential for boosting productivity, raising income, and creating jobs, supporting its consideration by employer-sponsored health plans to optimize resource allocation for treating OUD.

CONCLUSION

The conceptual framework provides insights for enhancing HTAs to incorporate the broader economic and societal impacts of healthcare interventions. By integrating DCEA, extended HTA analysis with input-output modeling, and a voting scheme, decision makers can make informed choices aligned with societal priorities, although further research and validation are necessary for practical implementation across diverse healthcare contexts.

Understanding Barriers and Facilitators to Living Kidney Donation Within a Sociotechnical Systems Framework

The objective of this study was to investigate factors influencing one's decision to become a live kidney donor under the framework of sociotechnical systems, by expanding the focus to include larger organizational influences and technological considerations. Semi-structured interviews were conducted with live kidney donors who donated through University of Louisville Health, Trager Transplant Center, a mid-scale transplant program, in the years 2017 through 2019. The interview transcripts were analyzed for barriers and facilitators to live kidney donation within a sociotechnical system. The most salient facilitators included: having an informative, caring, and available care team; the absence of any negative external pressure toward donating; donating to a family or friend; and the ability to take extra time off work for recovery. The most recurrent barriers included: short/medium-term (<1 year) negative health impacts because of donation; the need to make minor lifestyle changes (e.g., less alcohol consumption) after donation; and mental health deterioration stemming from the donation process. The sociotechnical systems framework promotes a balanced system comprised of social, technical, and environmental subsystems. Assessing the facilitators and barriers from the sociotechnical system perspective revealed the importance of and opportunities for developing strategies to promote integration of technical subsystem, such as social media apps and interactive AI platforms, with social and environmental subsystems to enable facilitators and reduce barriers effectively.

Human factors engineering simulated analysis in administrative, operational and maintenance loops of nuclear reactor control unit using artificial intelligence and machine learning techniques

The nuclear reactor control unit employs human factor engineering to ensure efficient operations and prevent any catastrophic incidents. This sector is of utmost importance for public safety. This study focuses on simulated analysis of specific areas of nuclear reactor control, specifically administration, operation, and maintenance, using artificial intelligence software. The investigation yields effective artificial intelligence algorithms that capture the essential and non-essential components of numerous parameters to be monitored in nuclear reactor control. The investigation further examines the interdependencies between various parameters and validates the statistical outputs of the model through attribution analysis. Furthermore, a Multivariant ANOVA analysis is conducted to identify the interactive plots and mean plots of crucial parameters interactions. The artificial intelligence algorithms demonstrate the correlation between the number of vacant staff jobs and both the frequency of license event reports each year and the ratio of contract employees to regular employees in the administrative domain. An AI method uncovers the relationships between the operator failing rate (OFR), operator processed errors (OEE), and operations at limited time frames (OLC). The AI algorithm reveals the interdependence between equipment in the out of service (EOS), progressive maintenance schedule (PRMR), and preventive maintenance schedules (PMRC). Effective machine learning neural network models are derived from generative adversarial network (GAN) algorithms and proposed for administrative, operational and maintenance loops of nuclear reactor control unit.

New Tools for Data Harmonization and Their Potential Applications in Organ Transplantation

In organ transplantation, accurate analysis of clinical outcomes requires large, high-quality data sets. Not only are outcomes influenced by a multitude of factors such as donor, recipient, and transplant characteristics and posttransplant events but they may also change over time. Although large data sets already exist and are continually expanding in transplant registries and health institutions, these data are rarely combined for analysis because of a lack of harmonization. Promoted by the digitalization of the healthcare sector, effective data harmonization tools became available, with potential applications also for organ transplantation. We discuss herein the present problems in the harmonization of organ transplant data and offer solutions to enhance its accuracy through the use of emerging new tools. To overcome the problem of inadequate representation of transplantation-specific terms, ontologies and common data models particular to this field could be created and supported by a consortium of related stakeholders to ensure their broad acceptance. Adopting clear data-sharing policies can diminish administrative barriers that impede collaboration between organizations. Secure multiparty computation frameworks and the artificial intelligence (AI) approach federated learning can facilitate decentralized and harmonized analysis of data sets, without sharing sensitive data and compromising patient privacy. A common image data model built upon a standardized format would be beneficial to AI-based analysis of pathology images. Implementation of these promising new tools and measures, ideally with the involvement and support of transplant societies, is expected to produce improved integration and harmonization of transplant data and greater accuracy in clinical decision-making, enabling improved patient outcomes.

When rules turn into tools: An activity theory-based perspective on implementation processes and unintended consequences

The idea that actions of people, organizations or governments may lead to Unintended Consequences (UICs) is not new. In health, UICs have been reported as a result of various interventions including quality improvement initiatives, health information technology implementation, and knowledge translation, especially those involving translation of broad policies (evidence-based medicine and patient-centred care) or system level improvement into actionable items or tools. While some unintended consequences cannot be anticipated, others may be predictable. In this article, we present a model based on cultural historical activity theory, which may help policy-makers, health leaders, and researchers better anticipate UICs resulting from implementation of new programs or technologies and take action to address them or mitigate their risk of occurrence. We support this model using examples of UICs of implementing family centred care principles, electronic health records, and computerized templates for quality improvement in chronic disease management.

Implementation of a Continuous Patient Monitoring System in the Hospital Setting: A Qualitative Study

BACKGROUND

Technology can improve care delivery, patient outcomes, and staff satisfaction, but integration into the clinical workflow remains challenging. To contribute to this knowledge area, this study examined the implementation continuum of a contact-free, continuous monitoring system (CFCM) in an inpatient setting. CFCM monitors vital signs and uses the information to alert clinicians of important changes, enabling early detection of patient deterioration.

METHODS

Data were collected throughout the entire implementation continuum at a community teaching hospital. Throughout the study, 3 group and 24 individual interviews and five process observations were conducted. Postimplementation alarm response data were collected. Analysis was conducted using triangulation of information sources and two-coder consensus.

RESULTS

Preimplementation perceived barriers were alarm fatigue, questions about accuracy and trust, impact on patient experience, and challenges to the status quo. Stakeholders identified the value of CFCM as preventing deterioration and benefitting patients who are not good candidates for telemetry. Educational materials addressed each barrier and emphasized the shared CFCM values. Mean alarm response times were below the desired target of two minutes. Postimplementation interview analysis themes revealed lessened concerns of alarm fatigue and improved trust in CFCM than anticipated. Postimplementation challenges included insufficient training for secondary users and impact on patient experience.

CONCLUSION

In addition to understanding the preimplementation anticipated barriers to implementation and establishing shared value before implementation, future recommendations include studying strategies for optimal tailoring of education to each user group, identifying and reinforcing positive process changes after implementation, and including patient experience as the overarching element in frameworks for digital tool implementation.

Systems archetypes to investigate the unintended consequences of telehealth in rural Australia: A systems thinking approach to telehealth evaluation and policymaking

As an alternative model of delivery to standard care, telehealth offers a promising solution to health access issues faced by rural and remote communities in Australia and worldwide. However, research typically focuses on its expected benefits and pitfalls, with little to no consideration of its unintended consequences and factors influencing its better utilisation. Drawing on systems thinking and informed by complexity science, we propose using systems archetypes-systems thinking tools - as a magnifying lens to investigate potential telehealth unintended consequences or outcomes. We conceptualise telehealth implementation in rural and remote Australia as a sociotechnical system whereby the interactions between its various agents shape telehealth implementation and, in turn, are shaped by it. When introducing new policies or interventions to any system, these interactions often lead to outcomes other than those initially planned or intended. Although systems archetypes cannot necessarily predict these outcomes, they are valuable for helping anticipate unintended, unforeseen outcomes and facilitating discussions about them to mitigate their negative impact and maximise their benefits. Outcomes are not necessarily adverse; they can also be positive. So, investigating such outcomes will minimise their negative impact and maximise their benefit. Our method was to review existing research and a selection of complexity and systems informed frameworks. Then, we assessed systems archetypes. And how they can be utilised to investigate unintended consequences. A worked example of what an unintended consequence in the implementation of telehealth in rural and remote Australia is presented.

Interactions in Sociotechnical Systems: Achieving Balance in the Use of an Augmented Reality Mobile Application

OBJECTIVE

We explore relationships between barriers and facilitators experienced by users to understand dynamic interactions in sociotechnical systems and improve a mobile phone-based augmented reality application that teaches users about the contents of a standardized pediatric code cart.

BACKGROUND

Understanding interactions between performance obstacles and facilitators can provide guidance to (re)designing sociotechnical systems to improve system outcomes. Clinicians should know about contents and organization of code carts, and an augmented reality mobile application may improve that knowledge but changes the sociotechnical system in which they learn. Prior work identified barriers and facilitators impacting the use of this application-participants described dimensions together, indicating interactions that are explored in the current study.

METHOD

We conducted four focus groups (number of clinicians = 18) and two interviews with clinicians who used the application. We performed a secondary analysis of focus group data exploring interactions between previously identified barriers and facilitators to application use. We used epistemic network analysis to visualize these interactions.

RESULTS

Work system barriers interacted with barriers and facilitators interacted with facilitators to amplify cumulative negative or positive impact, respectively. Facilitators balanced barriers, mitigating negative impact. Facilitators also exacerbated barriers, worsening negative impact.

CONCLUSION

Barriers and facilitators interact and can amplify, balance, and exacerbate each other-notably, positives are not always positive. To obtain desired outcomes, interactions must be further considered in sociotechnical system design, for example, the potential improvements to the application we identified.

CancelRx case study: implications for clinic and community pharmacy work systems

BACKGROUND

Medication prescribing and discontinuation processes are complex and involve the patient, numerous health care professionals, organizations, health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017. The health system also operates 15 outpatient community pharmacies.

OBJECTIVE

The goal of this qualitative study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations, before and after CancelRx implantation.

APPROACH

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n = 3), employed by the health system were interviewed across 3-time periods between 2017 and 2018- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and conducted a hybrid analysis with deductive content analysis following the Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductive analysis to capture additional codes and themes.

KEY RESULTS

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

CONCLUSIONS

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain

Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Software is Policy: Electronic Health Record Governance and the Implications of Clinical Standardization

BACKGROUND

Electronic health record (EHR) implementations, whether replacing paper or electronic systems, are major social and organizational transformations. Yet studies of EHR-to-EHR transitions have largely neglected to elucidate accompanying social and organizational changes. One such underexplored change is the standardization of clinical practice in the context of EHR transitions. The Department of Veterans Affairs (VA) has begun a decade-long process of replacing the approximately 130 separate versions of its homegrown EHR with a single commercial EHR system. This provides an opportunity to explore the standardization of clinical practice amidst an EHR transition.

OBJECTIVE

To identify, in the context of a large-scale EHR transition, (1) the scope and content of clinical standardization and (2) the anticipated implications of such standardization.

DESIGN

Qualitative study.

PARTICIPANTS

Twenty-nine members of VA councils established for the EHR transition.

APPROACH

We conducted semi-structured interviews, which were professionally transcribed, and analyzed first using rapid analysis methods, followed by coding and content analysis.

KEY RESULTS

Clinical standardization across facilities was a central goal of the EHR transition, encompassing computerized recommendations, order sets, professional roles/permissions, and clinical documentation. The anticipated implications of this standardization include (i) potential efficiency gains, with less duplicated effort across facilities; (ii) expanded bureaucracy; and (iii) increased uniformity, reducing both wanted and unwanted variation in care.

CONCLUSIONS

EHR systems shape a wide range of clinical processes, particularly in a large organization like VA with a long history of EHR use. This makes standardization of EHR content a powerful mechanism for standardizing clinical practice itself, which can bring dramatic collateral consequences. Organizations undergoing EHR transitions need to recognize the important role that clinical standardization plays by treating EHR transitions as major organizational transformations in the governance of clinical practice.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

How Digital Systems Are Used in Swedish Home Care Nursing Practice: A Qualitative Interview Study to Identify Challenges and Opportunities

This study investigates how digital technology is used (or not used) in home care nursing, to identify challenges and opportunities that can move the digitalization of home care nursing forward. The use of digital technology in daily practices of home care nursing was analyzed based on semistructured interviews in four Swedish home care organizations. The results correspond to the two initial stages of a design thinking process: (1) knowledge about users and the use context , presented as an up-to-date description of how digital technology has affected home care nursing practice, and (2) definition of areas for improvement , presented as challenges and opportunities. We identified the following areas to proceed with in the subsequent stages of designing home care nursing digitalization: (1) nurses' ability to access information and conduct documentation in the field, particularly how new digital systems are integrated with existing routines and systems; (2) the multitude of communication processes that nurses must manage, including communication channels that are used and the level of synchronicity; (3) an increasingly complex digital working environment, where evaluating existing systems and routines is one way to learn where improvements can be most efficient.

Examining Pediatric Resident Electronic Health Records Use During Prerounding: Mixed Methods Observational Study

BACKGROUND

Electronic health records (EHRs) play a substantial role in modern health care, especially during prerounding, when residents gather patient information to inform daily care decisions of the care team. The effective use of the EHR system is crucial for efficient and frustration-free prerounding. Ideally, the system should be designed to support efficient user interactions by presenting data effectively and providing easy navigation between different pages. Additionally, training on the system should aim to make user interactions more efficient by familiarizing the users with best practices that minimize interaction time while using the full potential of the system's capabilities. However, formal training on EHR systems often falls short of providing residents with all the necessary EHR-related skills, leading to the adoption of inefficient practices and the underuse of the system's full range of capabilities.

OBJECTIVE

This study aims to examine the efficiency of EHR use during prerounding among pediatric residents, assess the effect of experience level on EHR use, and identify areas for improvement in EHR design and training.

METHODS

A mixed methods approach was used, involving a self-reported survey and video analysis of prerounding practices of the entire population of pediatric residents from a large teaching hospital in the South Atlantic Region. The residents were stratified by experience level by postgraduate year. Data were collected on the number of pages accessed, duration of prerounding, task completion rates, and effective use of data sources. Observational and qualitative data complemented the quantitative analysis. Our study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines, ensuring completeness and transparency of reporting.

RESULTS

Of the 30 pediatric residents, 20 were included in the analyses; of these, 16 (80%) missed at least 1 step during prerounding. Although more experienced residents on average omitted fewer steps, 4 (57%) of the 7 most experienced residents still omitted at least 1 step. On average, residents took 6.5 minutes to round each patient and accessed 21 pages within the EHR during prerounding; no statistically significant differences were observed between experience levels for prerounding times (P=.48) or number of pages accessed (P=.92). The use of aggregated data pages within the EHR system neither seem to improve prerounding times nor decrease the number of pages accessed.

CONCLUSIONS

The findings suggest that EHR design should be improved to better support user needs, and hospitals should adopt more effective training programs to familiarize residents with the system's capabilities. We recommend implementing prerounding checklists and providing ongoing EHR training programs for health care practitioners. Despite the generalizability of limitations of our study in terms of sample size and specialization, it offers valuable insights for future research to investigate the impact of EHR use on patient outcomes and satisfaction, as well as identify factors that contribute to efficient and effective EHR usage.

CancelRx Case Study: Implications for Clinic and Community Pharmacy Work Systems

Background

The medication prescribing, and de-prescribing process is complex with numerous actors, organizations, and health information technology (IT). CancelRx is a health IT that automatically communicates medication discontinuations from the clinic electronic health record to the community pharmacy's dispensing platform, theoretically improving communication. CancelRx was implemented across a Midwest academic health system in October 2017.

Objective

The goal of this study was to describe how both the clinic and community pharmacy work systems change and interact over time regarding medication discontinuations.

Approach

Medical Assistants (n = 9), Community Pharmacists (n = 12), and Pharmacy Administrators (n =3), employed by the health system were interviewed across 3-time periods- 3-months prior to CancelRx implementation, 3-months after CancelRx implementation, and 9-months after CancelRx implementation. Interviews were audio recorded, transcribed, and analyzed via deductive content analysis.

Key Results

CancelRx changed the medication discontinuation process at both clinics and community pharmacies. In the clinics, the workflows and medication discontinuation tasks changed over time while MA roles and clinic staff communication practices remained variable. In the pharmacy, CancelRx automated and streamlined how medication discontinuation messages were received and processed, but also increased workload for the pharmacists and introduced new errors.

Conclusions

This study utilizes a systems approach to assess disparate systems within a patient network. Future studies may consider health IT implications for systems that are not in the same health system as well as assessing the role of implementation decisions on health IT use and dissemination.

Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation

RATIONALE

Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken.

AIM

To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective.

METHODS

Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling targeted key stakeholder groups. Online surveys (administered June-September 2019) and semistructured interviews (October-November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework.

RESULTS

Participants representing executive/program operations, MSU clinicians and hospital-based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships.

CONCLUSIONS

Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.

Interorganizational health information exchange-related patient safety incidents: A descriptive register-based qualitative study

PURPOSE

The current literature related to patient safety of interorganizational health information is fragmented. This study aims to identify interorganizational health information exchange-related patient safety incidents occurring in the emergency department, emergency medical services, and home care. The research also aimed to describe the causes and consequences of these incidents.

METHODS

A total of sixty (n = 60) interorganizational health information exchange-related patient safety incident free text reports were analyzed. The reports were reported in the emergency department, emergency medical services, or home care between January 2016 and December 2019 in one hospital district in Finland.

RESULTS

The identified interorganizational health information exchange-related incidents were grouped under two main categories: "Inadequate documentation"; and "Inadequate use of information". The causes of these incidents were grouped under the two main categories "Factors related to the healthcare professional " and "Organizational factors", while the consequences of these incidents fell under the two main categories "Adverse events" and "Additional actions to prevent, avoid, and correct adverse events".

CONCLUSION

This study shows that the inadequate documentation and use of information is mainly caused by factors related to the healthcare professional and organization, including technical problems. These incidents cause adverse events and additional actions to prevent, avoid, and correct the events. The sociotechnical perspective, including factors related to health care professionals, organization, and technology, should be emphasized in patient safety development of inter-organizational health information exchange and it will be the focus of our future research. Continuous research and development work is needed because the processes and information systems used in health care are constantly evolving.

Unintended consequences of pharmacy information systems: A case study

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of an Antimicrobial Stewardship Decision Support for Pediatric Infections

OBJECTIVES

Clinical decision support (CDS) has promise for the implementation of antimicrobial stewardship programs (ASPs) in the emergency department (ED). We sought to assess the usability of a newly developed automated CDS to improve guideline-adherent antibiotic prescribing for pediatric community-acquired pneumonia (CAP) and urinary tract infection (UTI).

METHODS

We conducted comparative usability testing between an automated, prototype CDS-enhanced discharge order set and standard order set, for pediatric CAP and UTI antibiotic prescribing. After an extensive user-centered design process, the prototype CDS was integrated into the electronic health record, used passive activation, and embedded locally adapted prescribing guidelines. Participants were randomized to interact with three simulated ED scenarios of children with CAP or UTI, across both systems. Measures included task completion, decision-making and usability errors, clinical actions (order set use and correct antibiotic selection), as well as objective measures of system usability, utility, and workload using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The prototype CDS was iteratively refined to optimize usability and workflow.

RESULTS

Usability testing in 21 ED clinical providers demonstrated that, compared to the standard order sets, providers preferred the prototype CDS, with improvements in domains such as explanations of suggested antibiotic choices (p < 0.001) and provision of additional resources on antibiotic prescription (p < 0.001). Simulated use of the CDS also led to overall improved guideline-adherent prescribing, with a 31% improvement for CAP. A trend was present toward absolute workload reduction. Using the NASA-TLX, workload scores for the current system were median 26, interquartile ranges (IQR): 11 to 41 versus median 25, and IQR: 10.5 to 39.5 for the CDS system (p = 0.117).

CONCLUSION

Our CDS-enhanced discharge order set for ED antibiotic prescribing was strongly preferred by users, improved the accuracy of antibiotic prescribing, and trended toward reduced provider workload. The CDS was optimized for impact on guideline-adherent antibiotic prescribing from the ED and end-user acceptability to support future evaluative trials of ED ASPs.

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.

Telemedicine in Southeast Asia: A Systematic Review

Introduction: Telemedicine is an effective means of delivering health care in Southeast Asian (SEA) countries. This systematic review explored the use of telemedicine systems for delivering health care services in SEA countries during the past 10 years. Methods: Literature searches were conducted in PubMed, Embase, Medline, Global Health, and CENTRAL (Cochrane Central Register of Controlled Trials). The inclusion criteria were as follows: (1) studies published between 2010 and 2021; (2) study settings located in SEA countries; (3) articles published in English; and (4) availability of a full-text version of the article. Information was extracted and evaluated for each study based on quality and risk of bias. Results: Thirty-seven of 6,554 records were eligible for inclusion. Studies included based on percentage were descriptive (29.73%), cost-effective (8.11%), randomized controlled trials (5.41%), and mixed methods (2.7%). Teleophthalmology and teleconsultation were the major reasons for using telemedicine, representing 21.62% of all studies. A hub-and-spoke and store-and-forward models were used. Free messenger applications supported communication modalities in or out of the systems. Discussion: The COVID-19 (coronavirus disease 2019) pandemic increased research studies on telemedicine, with most studies occurring in Singaporean hospitals (49%). Descriptive studies predominated, followed by retrospective and cross-sectional studies. Conclusions: Our findings demonstrated that telemedicine was a powerful tool. It is feasible, safe, effective, and less expensive than traditional methods. However, robust research is needed to fully investigate telemedicine systems in SEA countries.

Human-centered design of clinical decision support for management of hypertension with chronic kidney disease

Background

Primary care providers face challenges in recognizing and controlling hypertension in patients with chronic kidney disease (CKD). Clinical decision support (CDS) has the potential to aid clinicians in identifying patients who could benefit from medication changes. This study designed an alert to control hypertension in CKD patients using an iterative human-centered design process.

Methods

In this study, we present a human-centered design process employing multiple methods for gathering user requirements and feedback on design and usability. Initially, we conducted contextual inquiry sessions to gather user requirements for the CDS. This was followed by group design sessions and one-on-one formative think-aloud sessions to validate requirements, obtain feedback on the design and layout, uncover usability issues, and validate changes.

Results

This study included 20 participants. The contextual inquiry produced 10 user requirements which influenced the initial alert design. The group design sessions revealed issues related to several themes, including recommendations and clinical content that did not match providers' expectations and extraneous information on the alerts that did not provide value. Findings from the individual think-aloud sessions revealed that participants disagreed with some recommended clinical actions, requested additional information, and had concerns about the placement in their workflow. Following each step, iterative changes were made to the alert content and design.

Discussion

This study showed that participation from users throughout the design process can lead to a better understanding of user requirements and optimal design, even within the constraints of an EHR alerting system. While raising awareness of design needs, it also revealed concerns related to workflow, understandability, and relevance.

Conclusion

The human-centered design framework using multiple methods for CDS development informed the creation of an alert to assist in the treatment and recognition of hypertension in patients with CKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01962-y.

Mobile health technology as a solution to self-control problems: The behavioral impact of COVID-19 contact tracing apps in Japan

RATIONALE

Mobile technology has been widely utilized as an effective healthcare tool during the COVID-19 pandemic. Notably, over 50 countries have released contact-tracing apps to trace and contain infection chains. While earlier studies have examined obstacles to app uptake and usage, whether and how this uptake affects users' behavioral patterns is not well understood. This is crucial because uptake can theoretically increase or decrease behavior that carries infection risks.

OBJECTIVE

The goal of this study is to evaluate the impact of app uptake on the time spent out of home in Japan. It tests four potential underlying mechanisms that drive the uptake effect: compliance with stay-at-home requirements, learning about infection risk, reminders, and commitment device.

METHOD

We use unique nationwide survey data collected from 4,379 individuals aged between 20 and 69 in December 2020 and February 2021 in Japan. Japan has features suitable for this exercise. The Japanese government released a contact tracing app in June 2020, which sends a warning message to users who have been in close contact with an infected person. We conduct a difference-in-differences estimation strategy combined with the entropy balancing method.

RESULTS

App uptake reduces the time spent out of home. Sensitivity analysis shows that it cannot be explained by unobserved confounders. Importantly, the impact is large even among users who have not received a warning message from the app, and even larger for those with poor self-control ability. Furthermore, individuals' self-control ability is negatively associated with the uptake decision, supporting our hypothesis that the apps serve as a commitment device.

CONCLUSIONS

It may be beneficial to encourage citizens to uptake contact tracing apps and other forms of commitment devices. This study also contributes to the literature on mobile health (mHealth) by demonstrating its efficacy as a commitment device.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care

Background

The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process.

Methods

The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function.

Discussion

This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.

Trial registration

ClinicalTrials.gov, NCT05256394, Registered 25 February 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01217-4.

Determinants of the implementation of an artificial intelligence-supported device for the screening of diabetic retinopathy in primary care - a qualitative study

Diabetic retinopathy is a microvascular complication of diabetes mellitus that is usually asymptomatic in the early stages. Therefore, its timely detection and treatment are essential. First pilot projects exist to establish a smartphone-based and AI-supported screening of DR in primary care. This study explored health professionals' perceptions of potential barriers and enablers of using a screening such as this in primary care to understand the mechanisms that could influence implementation into routine clinical practice. Semi-structured telephone interviews were conducted and analysed with the help of qualitative analysis of Mayring. The following main influencing factors to implementation have been identified: personal attitude, organisation, time, financial factors, education, support, technical requirement, influence on profession and patient welfare. Most determinants could be relocated in the behaviour change wheel, a validated implementation model. Further research on the patients' perspective and a ranking of the determinants found is needed.

Systematic Process to Determine Clinical Harm From Delayed Communication Between Primary and Secondary Healthcare

Introduction: Timely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay. Methodology: Senior clinicians examined the letters following training to ensure a standardized consistent approach to the evaluation. They searched whether any actions that had been requested to be undertaken by primary care had been completed in a timely fashion. Thereafter, they indicated whether in their opinion there was any potential “predefined” harm. All letters that were identified as “potential” harm were reexamined by the leads to determine that the harm or inaction was truly accurate. The trust then contacted the patient to apologize and urgently expedite the outstanding action. Patients were not contacted in those situations where no actions were required or already undertaken (99.5%), as this could potentially cause unnecessary anxiety. If an actual harm was detected, it would then be declared as a serious incident and investigated appropriately, including a duty of candor (if the harm was moderate or severe). A “clinical harm review panel” convened regularly to monitor the quality of this process and thereby provide quality assurance. Governance of the process of review was assured by this panel being overseen by a regularly convened regionwide group. Results: 58,521 letters were evaluated over three months by 36 evaluators. No serious untoward incidents were identified, but 1,323 inactions were identified from these letters. These were then all cross-checked with information from EPR. Consequently, only 327 were deemed to be inactions that required further contact with the patient (of the 58,521 letters evaluated, this constituted 0.56%). Certain departments made more requests compared to others (e.g., cardiology, dermatology, and gastroenterology). Most surgical specialties did not generate any actions. Reassuringly, no letters related to cancer had any outstanding actions. The frequency of actions not enacted due to the delay was as follows: did not attend (n=3), medication change (n=173), blood tests (n=73), other investigations (n=31), onward referral (n=47). An audit trail of all outstanding actions has been maintained to allow monitoring in case there was any query in future. We also reviewed those patients who had died to investigate whether the death could be in any way linked to nonreceipt of the letter. There were 367 deaths, and an independent review revealed that no deaths were linked to the nonreceipt of the letter. Ten percent of the deaths (n=36) had a full structured clinical review to further validate the process. Discussion: This paper has described a systematic process of analyzing a large cohort of electronic correspondence to determine any potential harm to patients that may occur due to the delay in communication between primary and secondary care. The structured methodology, well supported by relevant community stakeholders and closely monitored by the clinical harm review panel, could serve as a template to other organizations that may face similar incidents in future.

Digital tools/eHealth to support CKD self-management: A qualitative study of perceptions, attitudes and needs of patients and health care professionals in China

BACKGROUND

A growing body of evidence supports the potential effectiveness of electronic health (eHealth) self-management interventions in improving disease self-management skills and health outcomes of patients suffering from chronic kidney disease (CKD). However, current research on CKD eHealth self-management interventions has almost exclusively focused on high-income, western countries.

OBJECTIVE

To inform the adaptation of a tailored eHealth self-management intervention for patients with CKD in China based on the Dutch Medical Dashboard (MD) intervention, we examined the perceptions, attitudes and needs of Chinese patients with CKD and health care professionals (HCPs) towards eHealth based (self-management) interventions in general and the Dutch MD intervention in specific.

METHODS

We conducted a basic interpretive, cross-sectional qualitative study comprising semi-structured interviews with 11 patients with CKD and 10 HCPs, and 2 focus group discussions with 9 patients with CKD. This study was conducted in the First Affiliated Hospital of Zhengzhou University in China. Data collection continued until data saturation was reached. All data were transcribed verbatim and analyzed using a framework approach.

RESULTS

Three themes emerged: (1) experience with eHealth in CKD (self-management), (2) needs for supporting CKD self-management with the use of eHealth, and (3) adaptation and implementation of the Dutch MD intervention in China. Both patients and HCPs had experience with and solely mentioned eHealth to 'inform, monitor and track' as potentially relevant interventions to support CKD self-management, not those to support 'interaction' and 'data utilization'. Factors reported to influence the implementation of CKD eHealth self-management interventions included information barriers (i.e. quality and consistency of the disease-related information obtained via eHealth), perceived trustworthiness and safety of eHealth sources, clinical compatibility and complexity of eHealth, time constraints and eHealth literacy. Moreover, patients and HCPs expressed that eHealth interventions should support CKD self-management by improving the access to reliable and relevant disease related knowledge and optimizing the timeliness and quality of patient and HCPs interactions. Finally, suggestions to adaptation and implementation of the Dutch MD intervention in China were mainly related to improving the intervention functionalities and content of MD such as addressing the complexity of the platform and compatibility with HCPs' workflows.

CONCLUSIONS

The identified perceptions, attitudes and needs towards eHealth self-management interventions in Chinese settings should be considered by researchers and intervention developers to adapt a tailored eHealth self-management intervention for patients with CKD in China. In more detail, future research needs to engage in co-creation processes with vulnerable groups during eHealth development and implementation, increase eHealth literacy and credibility of eHealth (information resource), ensure eHealth to be easy to use and well-integrated into HCPs' workflows.

Relationship between electronic health records strategy and user satisfaction: a longitudinal study using clinicians' online reviews

OBJECTIVE

We investigated how the electronic health records (EHRs) strategies concerning EHR sourcing and vendor switching impact user satisfaction over time.

MATERIALS AND METHODS

This study used a novel longitudinal dataset created by scraping clinicians' Glassdoor.com reviews on 109 US health systems from 2012 to 2017 and combining it with the Healthcare Information and Management Systems Society (HIMSS) database. We performed sentiment analysis of clinician reviews to construct our main dependent variable, user satisfaction. Our main independent variables, EHR single sourcing and vendor switching, were constructed using the HIMSS database.

RESULTS

Our fixed effects model showed that as health systems gain more experience with EHR, a single vendor sourcing strategy was associated with higher user satisfaction. Further, there was no significant impact of vendor switching on user satisfaction.

CONCLUSION

This work adds to the current understanding of EHR-driven clinician burnout using a novel longitudinal dataset. We show how organizational-level EHR strategy can impact user satisfaction and that providers and EHR vendors can mine clinician reviews online to understand their evolving needs and sentiments.

Measuring text similarity and its associated factors in electronic nursing progress notes: A retrospective review

AIMS AND OBJECTIVES

To measure text similarity in electronic nursing progress notes and determine factors associated with text similarity.

BACKGROUND

Electronic clinical notes with redundant information masks clinically relevant information, increases clinicians' cognitive burden and undermines patient safety.

DESIGN

Retrospective review of electronic medical record nursing progress notes.

METHODS

The study was conducted between November 2018 and February 2019 in two Australian Paediatric Intensive Care Units. De-identified, randomly selected inpatient data were extracted from the network's database. Manually classified shift summary progress notes for each admission were sequenced from admission to discharge. Text similarity was calculated for consecutive pairs of nursing progress notes. Linear regression was undertaken to determine the association between the similarity scores and variables of interest: note word count, total number of notes and unit. The STROBE checklist was used for reporting.

RESULTS

921 shift summary nursing progress notes were analysed. Similarity scores were widely distributed with a median of 10.37%. Only 17.2% (n = 144) of the notes have similarity scores above 20%. Of these, 5% (n = 47) were above 50% similar in comparison with a previously written note. Similarity above 50% was observed as early as the first note pair in the course of a patient's admission. A significant difference was found between the similarity scores of Unit 1 and Unit 2. Hospital unit was the only variable of interest significantly associated with similarity scores.

CONCLUSION

Text similarity among electronic nursing progress notes in Australian Paediatric ICUs is minimal; however, notes with >50% similarity have been identified. Text analytics provides measurable data and insights about electronic clinical documentation to inform future nursing practice, research and eMR design.

RELEVANCE TO CLINICAL PRACTICE

Findings have implications for nursing practice in the way that nursing staff are educated to maintain data quality, professional accountability and effective communication in electronic documentation and to avoid unnecessary repetition of text.

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review

BACKGROUND

Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice.

OBJECTIVES

The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting.

METHODS

Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork.

RESULTS

The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption.

CONCLUSION

There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

AI and Clinical Decision Making: The Limitations and Risks of Computational Reductionism in Bowel Cancer Screening

Advances in artificial intelligence in healthcare are frequently promoted as ‘solutions’ to improve the accuracy, safety, and quality of clinical decisions, treatments, and care. Despite some diagnostic success, however, AI systems rely on forms of reductive reasoning and computational determinism that embed problematic assumptions about clinical decision-making and clinical practice. Clinician autonomy, experience, and judgement are reduced to inputs and outputs framed as binary or multi-class classification problems benchmarked against a clinician’s capacity to identify or predict disease states. This paper examines this reductive reasoning in AI systems for colorectal cancer (CRC) to highlight their limitations and risks: (1) in AI systems themselves due to inherent biases in (a) retrospective training datasets and (b) embedded assumptions in underlying AI architectures and algorithms; (2) in the problematic and limited evaluations being conducted on AI systems prior to system integration in clinical practice; and (3) in marginalising socio-technical factors in the context-dependent interactions between clinicians, their patients, and the broader health system. The paper argues that to optimise benefits from AI systems and to avoid negative unintended consequences for clinical decision-making and patient care, there is a need for more nuanced and balanced approaches to AI system deployment and evaluation in CRC.

Clinical, Organizational and Regulatory, and Ethical and Social (CORES) Issues and Recommendations on Blockchain Deployment for Healthcare: Evidence from Experts

Objective

While existing research by our team has demonstrated the feasibility of building a decentralized identity management application ("MediLinker") for health information, there are implementation issues related to testing such blockchain-based health applications in real-world clinical settings. In this study, we identified clinical, organizational and regulatory, and ethical and social (CORES) issues, including recommendations, associated with deploying MediLinker, and blockchain in general, for clinical testing.

Methods

CORES issues and recommendations were identified through a focus group with 11 academic, industry, and government experts on March 26, 2021. They were grouped according to their expertise: clinical care (n = 4), organizational and regulatory concerns (n = 4), and ethical and social issues (n = 3). The focus group was conducted via Zoom in which experts were briefed about the study aims, formed into breakout groups to identify key issues based on their group's expertise, and reconvened to share identified issues with other groups and to discuss potential recommendations to address such issues. The focus group was video recorded and transcribed. The resulting transcriptions and meeting notes were imported to MAXQDA 2018 for thematic analysis.

Results

Clinical experts identified issues that concern the clinical system, clinical administrators, clinicians, and patients. Organizational and regulatory experts emphasized issues on accountability, compliance, and legal safeguards. Ethics and social-context experts raised issues on trust, transparency, digital divide, and health-related digital autonomy. Accordingly, experts proposed six recommendations that could address most of the identified issues: (1) design interfaces based on patient preferences, (2) ensure testing with diverse populations, (3) ensure compliance with existing policies, (4) present potential positive outcomes to top management, (5) maintain clinical workflow, and (6) increase the public's awareness of blockchain.

Conclusions

This study identified a myriad of CORES issues associated with deploying MediLinker in clinical settings. Moreover, the study also uncovered several recommendations that could address such issues. The findings raise awareness on CORES issues that should be considered when designing, developing, and deploying blockchain for healthcare. Further, the findings provide additional insights into the development of MediLinker from a prototype to a minimum viable product for clinical testing. Future studies can use CORES as a socio-technical model to identify issues and recommendations associated with deploying health information technologies in clinical settings.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Application of Natural Language Processing to Learn Insights on the Clinician's Lived Experience of Electronic Health Records

We interviewed six clinicians to learn about their lived experience using electronic health records (EHR, Allscripts users) using a semi-structured interview guide in an academic medical center in New York City from October to November 2016. Each participant interview lasted approximately one to two hours. We applied a clustering algorithm to the interview transcript to detect topics, applying natural language processing (NLP). We visualized eight themes using network diagrams (Louvain modularity 0.70). Novel findings include the need for a concise and organized display and data entry page, the user controlling functions for orders, medications, radiology reports, and missing signals of indentation or filtering functions in the order page and lab results. Application of topic modeling to qualitative interview data provides far-reaching research insights into the clinicians' lived experience of EHR and future optimal EHR design to address human-computer interaction issues in an acute care setting.

Advancing Patient Safety Through the Clinical Application of a Framework Focused on Communication

OBJECTIVES

The study of communication has evolved from diverse academic disciplines, yet those diverse fields are not well represented in theoretical frameworks that describe communication in health care, narrowing our ability to explain how communication affects patient safety. The purpose of this review article is to describe a conceptual framework of communication drawn from multiple academic disciplines and apply it to health care, specifically for examining communication between providers about the clinical care of their patients.

METHODS

A seminal article in the field of communication that attempted to map the entire field of communication theory inspired our conceptual framework. We adapted these concepts, largely from the social science literature, to find alternative ways of conceptualizing communication and ways to enhance communication in health care.

RESULTS

There are 8 theoretical traditions that informed our conceptual framework: rhetorical, phenomenological, semiotic, cybernetic, sociopsychological, sociocultural, critical, and pragmatic. We provide practical, clinical applications of our conceptual framework, encompassing the interpersonal nature of communication, relationship building and trust, hierarchical differences, and the role of technology in communication. In adopting our conceptual framework, we suggest that researchers and clinicians can choose from any combination of these 8 theoretical traditions to more fully describe and ultimately enhance communication-related phenomena.

CONCLUSIONS

Poor communication remains a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. Our conceptual framework suggests ways to build relationships and trust, addresses hierarchical differences between communicators, and illuminates the role of technology in communication. It also importantly expands the definition of the value of communication beyond simple information exchange to include creation of new knowledge during communication through the development of shared understanding.

Emergency Physician Perceptions of Electronic Health Record Usability and Safety

OBJECTIVES

Despite requirements for electronic health record (EHR) vendor usability testing, usability challenges persist, contributing to patient safety concerns. We sought to identify emergency physicians' perceived EHR usability and safety strengths and shortcomings across major EHR vendor products.

METHODS

Fifty-five emergency physicians from 4 different hospitals were interviewed. The interviews were qualitatively analyzed, and physician comments were aligned with a usability taxonomy to identify emerging themes by vendor and hospital.

RESULTS

Of the 194 comments about usability, the 3 most commonly discussed usability topics were Workflow Support (33.5% of comments), Visual Display (20.1%), and Data Entry (14.4%). Electronic health record usability strengths were centered on Visual Display, and the most common shortcoming was the lack of Workflow Support. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes were identified.

CONCLUSIONS

Usability shortcomings that spanned across hospitals and vendors may suggest a need for more applied research and improved design to resolve these issues. Shortcomings that are localized to a specific product or hospital may be due to customization and may be addressable by learning from other organizations.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Electronic Medication Management Systems: Analysis of Enhancements to Reduce Errors and Improve Workflow

BACKGROUND

Electronic medication management (eMM) has been shown to reduce medication errors; however, new safety risks have also been introduced that are associated with system use. No research has specifically examined the changes made to eMM systems to mitigate these risks.

OBJECTIVES

To (1) identify system-related medication errors or workflow blocks that were the target of eMM system updates, including the types of medications involved, and (2) describe and classify the system enhancements made to target these risks.

METHODS

In this retrospective qualitative study, documents detailing updates made from November 2014 to December 2019 to an eMM system were reviewed. Medication-related updates were classified according to "rationale for changes" and "changes made to the system."

RESULTS

One hundred and seventeen updates, totaling 147 individual changes, were made to the eMM system over the 4-year period. The most frequent reasons for changes being made to the eMM were to prevent medication errors (24% of reasons), optimize workflow (22%), and support "work as done" on paper (16%). The most frequent changes made to the eMM were options added to lists (14% of all changes), extra information made available on the screen (8%), and the wording or phrasing of text modified (8%). Approximately a third of the updates (37%) related to high-risk medications. The reasons for system changes appeared to vary over time, as eMM functionality and use expanded.

CONCLUSION

To our knowledge, this is the first study to systematically review and categorize system updates made to overcome new safety risks associated with eMM use. Optimization of eMM is an ongoing process, which changes over time as users become more familiar with the system and use is expanded to more sites. Continuous monitoring of the system is necessary to detect areas for improvement and capitalize on the benefits an electronic system can provide.

Power, paradox and pessimism: On the unintended consequences of digital health technologies in primary care

We consider what might be learned from the unintended, apparently unanticipated, consequences of the use of digital health (including alternatives to face to face consultations, electronic medical records, use of apps and online monitoring) in primary care. We chose a conceptual literature review method, to seek a higher order understanding of the nuanced patterning of unintended consequences of digital health technologies (for people, relationships, organisations and ways of working) which are rarely simply positive or negative. The approach is informed by realist review, which recognises that experiences and outcomes of interventions work (or fail) in different ways in particular contexts. We present three higher order themes to illuminate underpinning mechanisms for unintended consequences in digital health technologies in primary care. These themes are illustrated by case examples, with particular focus on those that have been little discussed in the literature. Following Merton's (1936) differentiation between consequences for the actor(s) and others, which are mediated through the culture and social structure, we discuss consequences that i) disrupt power relations between patients and health professionals or between different groups of health professions, ii) contribute to paradoxical outcomes and iii) result in a potentially corrosive sub-culture of pessimism about digital health. We conclude that when implementing or evaluating digital technologies in primary care, it is wise to consider the 'dark logic' of the intervention (Bonell et al., 2015). Attention to issues of power relations, the potential for paradoxical outcomes, and impacts on the expectations of staff in relation to digital innovation are particularly salient in relation to the dramatic changes in primary care delivery initiated during the Covid-19 pandemic. Fostering a sense of ownership and interest in monitoring the effects that matter to the organisation will likely help counter pessimism and renew interest in deploying those digital innovations that show promise.

Managing the tension between caring and charting: Labor and delivery nurses' experiences of the electronic health record

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.