Health IT success and failure: recommendations from literature and an AMIA workshop

System interoperability and data linkage in the era of health information management: A bibliometric analysis

Background: Across the world, health data generation is growing exponentially. The continuous rise of new and diversified technology to obtain and handle health data places health information management and governance under pressure. Lack of data linkage and interoperability between systems undermines best efforts to optimise integrated health information technology solutions. Objective: This research aimed to provide a bibliometric overview of the role of interoperability and linkage in health data management and governance. Method: Data were acquired by entering selected search queries into Google Scholar, PubMed, and Web of Science databases and bibliometric data obtained were then imported to Endnote and checked for duplicates. The refined data were exported to Excel, where several levels of filtration were applied to obtain the final sample. These sample data were analysed using Microsoft Excel (Microsoft Corporation, Washington, USA), WORDSTAT (Provalis Research, Montreal, Canada) and VOSviewer software (Leiden University, Leiden, Netherlands). Results: The literature sample was retrieved from 3799 unique results and consisted of 63 articles, present in 45 different publications, both evaluated by two specific in-house global impact rankings. Through VOSviewer, three main clusters were identified: (i) e-health information stakeholder needs; (ii) e-health information quality assessment; and (iii) e-health information technological governance trends. A residual correlation between interoperability and linkage studies in the sample was also found. Conclusion: Assessing stakeholders' needs is crucial for establishing an efficient and effective health information system. Further and diversified research is needed to assess the integrated placement of interoperability and linkage in health information management and governance. Implications: This research has provided valuable managerial and theoretical contributions to optimise system interoperability and data linkage within health information research and information technology solutions.

Factors Influencing Integration and Usability of Model-Informed Precision Dosing Software in the Intensive Care Unit

BACKGROUND

 Antimicrobial dosing in critically ill patients is challenging and model-informed precision dosing (MIPD) software may be used to optimize dosing in these patients. However, few intensive care units (ICU) currently adopt MIPD software use.

OBJECTIVES

 To determine the usability of MIPD software perceived by ICU clinicians and identify implementation barriers and enablers of software in the ICU.

METHODS

 Clinicians (pharmacists and medical staff) who participated in a wider multicenter study using MIPD software were invited to participate in this mixed-method study. Participants scored the industry validated Post-study System Usability Questionnaire (PSSUQ, assessing software usability) and Technology Acceptance Model 2 (TAM2, assessing factors impacting software acceptance) survey. Semistructured interviews were used to explore survey responses. The framework approach was used to identify factors influencing software usability and integration into the ICU from the survey and interview data.

RESULTS

 Seven of the eight eligible clinicians agreed to participate in the study. The PSSUQ usability scores ranked poorer than the reference norms (2.95 vs. 2.62). The TAM2 survey favorably ranked acceptance in all domains, except image. Qualitatively, key enablers to workflow integration included clear and accessible data entry, visual representation of recommendations, involvement of specialist clinicians, and local governance of software use. Barriers included rigid data entry systems and nonconformity of recommendations to local practices.

CONCLUSION

 Participants scored the MIPD software below the threshold that implies good usability. Factors such as availability of software support by specialist clinicians was important to participants while rigid data entry was found to be a deterrent.

Workarounds in the Shadow System: An Ethnographic Study of Requirements for Documentation and Cooperation in a Clinical Advisory Center

OBJECTIVE

Hospital information systems (HIS) are meant to manage complex work processes across healthcare organizations. We describe limitations of HIS to address local information requirements and how they are circumvented at different organizational levels. Results can be used to better support collaboration in socio-technical systems.

BACKGROUND

Workarounds describe a mismatch between a technology's purpose and its actual use, whereas shadow systems are unofficial IT systems circumventing limitations of official systems to support workflows. Boundary infrastructures are conceptualized as the entirety of all (in)formal digital and analog systems connecting different communities of practice in a socio-technical system.

METHODS

An ethnographic study with observations and semi-structured interviews was conducted and analyzed through categorization and iterative coding.

RESULTS

Several digital-analog workarounds are employed for documentation and a shared server functions as a shadow system to support workflows in ways the HIS cannot. For collaborative documentation, all (official and informal) information sources were used simultaneously as part of an interconnected boundary infrastructure.

CONCLUSION

Formal and informal IT systems are interconnected across different organizational levels and provide insights into unmet information requirements, effective and problematic work practices, and how to address them to improve system functioning. An integrated perspective on boundary infrastructures, workarounds, and shadow systems may advance system analysis, providing a more comprehensive picture of IT requirements than any concept alone.

APPLICATION

Workarounds and shadow systems highlight that HIS should support systemic and local needs. Customized interfaces in HIS to support search, access, and exchange of relevant data might help to mitigate current shortcomings.

Exploring the perceptions of former ICU patients and clinical staff on barriers and facilitators to the implementation of virtual reality exposure therapy: A qualitative study

BACKGROUND

Virtual reality (VR) as a digital technology has developed rapidly, becoming more realistic, portable, sensory and easier to navigate. Although studies have found VR to be effective for many clinical applications, patients and clinicians have described several barriers to the successful implementation of this technology. To remove barriers for implementation of VR in health care, a greater understanding is needed of how VR can integrate into clinical environments, particularly complex settings such as an intensive care unit.

AIM

This study aimed to explore the perceived barriers and facilitators for the implementation of VR exposure therapy for intensive care patients and clinical staff.

STUDY DESIGN

A qualitative study using an Interpretative Description approach was undertaken. Semi-structured focus groups were conducted with 13 participants: nine patients and four health care professionals. Focus groups explored barriers and facilitators of using virtual reality (VR) exposure therapy in intensive care. Thematic analysis was employed to produce codes and themes.

RESULTS

In total, eight themes describing the perceived barriers and facilitators to implementing VR exposure therapy were identified. Four themes related to the perceived barriers of implementing VR exposure therapy in intensive care were identified: psychological, sensory, environmental and staff competency and confidence. There were a further four themes related to the perceived facilitators to the implementation of VR exposure therapy: staff training, patient capacity, orientation to technology and support during the intervention.

CONCLUSIONS

This study identified novel barriers and facilitators that could be expected when implementing VR exposure therapy for patients' post-intensive care unit stay. The findings suggest that psychological barriers of fear and apprehension were expected to provoke patient avoidance of exposure therapy. Perceived barriers for staff focused on preparedness to deliver the VR exposure therapy and a lack of technological competence. Both patients and staff stated that a comprehensive induction, orientation and training could facilitate VR exposure therapy, improving engagement.

RELEVANCE TO CLINICAL PRACTICE

This study has identified that with appropriate staff training, resources, and integration into current patient care pathways, VR exposure therapy may be a valuable intervention to support patient recovery following critical illness. Prior to undertaking VR exposure therapy, patients often need reassurance that side-effects can be managed, and that they can easily control their virtual exposure experience.

Providing a framework for evaluation disease registry and health outcomes Software: Updating the CIPROS checklist

BACKGROUND AND AIMS

Properly designed and implemented registry systems play an important role in improving health outcomes and reducing care costs, and can provide a true representation of clinical practice, disease outcomes, safety, and efficacy. Therefore, the aim of this study was to redesign and develop a checklist with items for a patient registry software system (CIPROS) Checklist.

METHOD

The study is descriptive-cross-sectional. The extraction of the data elements of the checklist was first done through a comprehensive review of the texts in PubMed, Science Direct and Scopus databases and receiving articles related to the evaluation of registry systems. Based on the extracted data, a five-point Likert scale questionnaire was created and 30 experts in this field were asked for their opinions using the two-step Delphi method.

RESULTS

A total of 100 information items were determined as a registry software evaluation checklist. This checklist included 12 groups of software architecture factors, development, interfaces and interactivity, semantics and standardization, internationality, data management, data quality and usability, data analysis, security, privacy, organizational, education and public factors.

CONCLUSION

By using the results of this research, it is possible to identify the defects and possible strengths of the registry software and put it at the disposal of the relevant officials to make a decision in this field. In this way, among the designers and developers of these softwares, the best and most appropriate ones are selected with the needs of the registry programs.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

“It’s all about time and timing”: nursing staffs’ experiences with an agile development process, from its initial requirements to the deployment of its outcome of ICT solutions to support discharge planning

Background

Agile projects are statistically more likely to succeed then waterfall projects. The overall aim of this study was to explore the nursing staffs’ experiences with an agile development process, from its initial requirements to the deployment of its outcome of ICT solutions aimed at supporting discharge planning.

Methods

An explorative design with quantitative and qualitative methods was used. Qualitative data was collected through seven focus group interviews. Quantitative data was collected via an ICT-system, and with an evaluation form submitted by fourteen registered nurses and nine district nurses.

Results

Qualitative result of the experiences with the agile development process and its outcome resulted in one theme, four categories, and ten subcategories. The theme was found to be about time and timing, namely the amount of time for the different activities and the timing of activities within and between organisations. The agile development process increased the participants’ readiness for change by offering time to learn, practice, engage and reflect, and then adopt the ICT as a support to daily practice. Quantitative results showed a variated adoption of the ICT.

Conclusion

There is a need for time to prepare, understand and adopt new tools, services and procedures and a need for additional time to prepare, understand and adopt the new among individuals, collectives, organizations, and sometimes even between different collectives or organizations. The agile development process offered the end-users involvement through the development process, which gave them time to change it both individually and collectively. However, there is a need for close collaboration between the development project team and management to reach an organizational change that is timely for both the individual and the collective change. When time or timing fails in the development or implementation process, there is a huge risk of non-adoption of new tools, services, or procedures or among the end-users.

Total Quality and Innovation Management in Healthcare (TQIM-H) for an Effective Innovation Development: A Conceptual Framework and Exploratory Study

To thrive, an organization must adapt to the fast and constant change in the economic environment caused by an aging society, technological changes, and the pandemic crisis. Innovation becomes important for the adaptation of industries. Healthcare is one of them. Innovation development in hospitals is effective and acceptable when its management is effective and aligns with the healthcare quality context since quality is a philosophy of work in life-related settings. To the best of our knowledge, quality management and innovation management in healthcare have never been integrated. Therefore, this research aimed to create an integrated framework of quality and innovation management in healthcare (TQIM-H). To establish the effectiveness of applying TQIM-H for the development of effective healthcare innovation, this study developed a TQIM-H conceptual framework using multiple methodologies including a literature review, multiple case studies analysis, Delphi study with healthcare experts, Technology Acceptance Model (TAM), and triangulation with an external dataset. We constructed a TQIM-H conceptual framework, consisting of seven dimensions, that can be used in developing innovation projects in hospitals and which agrees with safety and quality principles in hospitals.

A Review on The Theories of Adoption Telemedicine in Middle Ease : Toward Building Iraqi Telemedicine

Telemedicine is the use of modern telecommunications and information technologies for the provision of clinical care to individuals at a distance, and transmission of information to provide that care. Recent advances in information technology and biomedicine increased significantly the technical feasibility, clinical feasibility and affordability enabled collaborative of telemedicine and medical service delivery. Health organizations around the world are becoming more interested in the acquisition and implementation the telemedicine technology to improve or expand existing services and patient care. The ultimate success of telemedicine in an organization requires the adoption of adequate care both technological and managerial issues. This study examined theadoption theories,the key management problem facing many health care organizations which interested in or currently evaluating telemedicine . this research models targeted the technology adoption and empirically evaluated in a study of the investigation involving more public health agencies and criticize the theories.Several research and management implications that emerged from the study results are discussed.

Are we doing it right? We need to evaluate the current approaches for implementation of digital health systems

Successful implementation of digital health programs is imperative as it is becoming increasingly clear that digital solutions will underpin modern health care. These projects are often supported by large budgets and if not implemented successfully, the quality, safety, and efficiency of patient care may be compromised. Failure rates for the implementation of large, complex healthcare software platforms in digital health programs have been persistently high. Although several factors may contribute to the failure of such projects, the majority have been reported to fail largely due to poor project management. Nevertheless, little is known about the optimal project management approaches for digital health projects, with many health services reliant on external advisory companies and contractors for advice. Although publication bias makes it difficult to reliably study and understand global trends for the failure of digital health projects, examination of media reports and published literature indicates that this is a global phenomenon affecting digital health projects in North America, Europe and Australasia. In this article, our aim is to examine the literature for evidence underpinning current project management approaches used when implementing commercial, off-the-shelf healthcare information technology solutions, including complex healthcare software in large digital health programs in hospitals or across health systems, and evaluate the suitability of current project management approaches to deliver these projects. This starts to build an important evidence base for hospitals and health services considering digital transformation projects.

Distributed IT championing: A process theory

Championing is key to the success of an IT implementation. Recently, changes in the nature of technologies used in organizational contexts and changing organizational structures call for a renewed focus on IT championing to explain its distributed nature. Following an analytic induction approach and drawing from semi-structured interviews with 37 practitioners (physicians, residents, nurses, IT staff, and administrators) in three healthcare-related settings, the study conceptualizes distributed IT championing as a process constituted of multiple individuals’ behaviors, unfolding over time, that proactively go beyond formal job requirements in support of an IT implementation. While multiple individuals may enact similar championing behaviors, the data indicate that multiple individuals may also enact distinct, yet complementary, championing behaviors over the course of the IT implementation. Overall, distributed IT championing evolves through cycles of distinct stages of bridging-in, bonding, and bridging-out, with each stage being shaped by different dimensions of social capital. Also, IT artifacts that are particularly generative appear more conducive to distributed IT championing than closed ones. This article contributes to extant literature on IT championing by developing a process model of distributed IT championing in the context of an IT implementation.

Disentangling the clinical data chaos: User-centered interface system design for trauma centers

This paper presents a year-long study of our project, aiming at (1) understanding the work practices of clinical staff in trauma intensive care units (TICUs) at a trauma center, with respect to their usage of clinical data interface systems, and (2) developing and evaluating an intuitive and user-centered clinical data interface system for their TICU environments. Based on a long-term field study in an urban trauma center that involved observation-, interview-, and survey-based studies to understand our target users and their working environment, we designed and implemented MediSenseView as a working prototype. MediSenseView is a clinical-data interface system, which was developed through the identification of three core challenges of existing interface system use in a trauma care unit-device separation, usage inefficiency, and system immobility-from the perspectives of three staff groups in our target environment (i.e., doctors, clinical nurses and research nurses), and through an iterative design study. The results from our pilot deployment of MediSenseView and a user study performed with 28 trauma center staff members highlight their work efficiency and satisfaction with MediSenseView compared to existing clinical data interface systems in the hospital.

Defining Data Migration Across Multidisciplinary Ambulatory Clinics Using Participatory Design

OBJECTIVE

This study aimed to develop an institutional approach for defining data migration based on participatory design principles.

METHODS

We outline a collaborative approach to define data migration as part of an electronic health record (EHR) transition at an urban hospital with 20 ambulatory clinics, based on participatory design. We developed an institution-specific list of data for migration based on physician end-user feedback. In this paper, we review the project planning phases, multidisciplinary governance, and methods used.

RESULTS

Detailed data migration feedback was obtained from 90% of participants. Depending on the specialty, requests for historical laboratory values ranged from 2 to as many as 145 unique laboratory types. Lookback periods requested by physicians varied and were ultimately assigned to provide the most clinical data. This clinical information was then combined to synthesize an overall proposed data migration request on behalf of the institution.

CONCLUSION

Institutions undergoing an EHR transition should actively involve physician end-users and key stakeholders. Physician feedback is vital for developing a clinically relevant EHR environment but is often difficult to obtain. Challenges include physician time constraints and overall knowledge about health information technology. This study demonstrates how a participatory design can serve to improve the clinical end-user's understanding of the technical aspects of an EHR implementation, as well as enhance the outcomes of such projects.

Beyond Getting Rid of Stupid Stuff in the Electronic Health Record (Beyond-GROSS): Protocol for a User-Centered, Mixed-Method Intervention to Improve the Electronic Health Record System

BACKGROUND

Up to 60% of health care providers experience one or more symptoms of burnout. Perceived clinician burden resulting in burnout arises from factors such as electronic health record (EHR) usability or lack thereof, perceived loss of autonomy, and documentation burden leading to less clinical time with patients. Burnout can have detrimental effects on health care quality and contributes to increased medical errors, decreased patient satisfaction, substance use, workforce attrition, and suicide.

OBJECTIVE

This project aims to improve the user-centered design of the EHR by obtaining direct input from clinicians about deficiencies. Fixing identified deficiencies via user-centered design has the potential to improve usability, thereby increasing satisfaction by reducing EHR-induced burnout.

METHODS

Quantitative and qualitative data will be obtained from clinician EHR users. The input will be received through a form built in a REDCap database via a link embedded in the home page of the EHR. The REDCap data will be analyzed in 2 main dimensions, based on nature of the input, what section of the EHR is affected, and what is required to fix the issue(s). Identified issues will be escalated to relevant stakeholders responsible for rectifying the problems identified. Data analysis, project evaluation, and lessons learned from the evaluation will be incorporated in a Plan-Do-Study-Act (PDSA) manner every 4-6 weeks.

RESULTS

The pilot phase of the study began in October 2020 in the Gastroenterology Division at Mount Sinai Hospital, New York City, NY, which includes 39 physicians and 15 nurses. The pilot is expected to run over a 4-6-month period. The results of the REDCap data analysis will be reported within 1 month of completing the pilot phase. We will analyze the nature of requests received and the impact of rectified issues on the clinician EHR user. We expect that the results will reveal which sections of the EHR have the highest deficiencies while also highlighting issues about workflow difficulties. Perceived impact of the project on provider engagement, patient safety, and workflow efficiency will also be captured by evaluation survey and other qualitative methods where possible.

CONCLUSIONS

The project aims to improve user-centered design of the EHR by soliciting direct input from clinician EHR users. The ultimate goal is to improve efficiency, reduce EHR inefficiencies with the possibility of improving staff engagement, and lessen EHR-induced clinician burnout. Our project implementation includes using informatics expertise to achieve the desired state of a learning health system as recommended by the National Academy of Medicine as we facilitate feedback loops and rapid cycles of improvement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25148.

Technology-Enabled Solutions for Australian Mental Health Services Reform: Impact Evaluation

Background

Health information technologies (HITs) are becoming increasingly recognized for their potential to provide innovative solutions to improve the delivery of mental health services and drive system reforms for better outcomes.

Objective

This paper describes the baseline results of a study designed to systematically monitor and evaluate the impact of implementing an HIT, namely the InnoWell Platform, into Australian mental health services to facilitate the iterative refinement of the HIT and the service model in which it is embedded to meet the needs of consumers and their supportive others as well as health professionals and service providers.

Methods

Data were collected via web-based surveys, semistructured interviews, and a workshop with staff from the mental health services implementing the InnoWell Platform to systematically monitor and evaluate its impact. Descriptive statistics, Fisher exact tests, and a reliability analysis were used to characterize the findings from the web-based surveys, including variability in the results between the services. Semistructured interviews were coded using a thematic analysis, and workshop data were coded using a basic content analysis.

Results

Baseline data were collected from the staff of 3 primary youth mental health services (n=18), a counseling service for veterans and their families (n=23), and a helpline for consumers affected by eating disorders and negative body image issues (n=6). As reported via web-based surveys, staff members across the services consistently agreed or strongly agreed that there was benefit associated with using technology as part of their work (38/47, 81%) and that the InnoWell Platform had the potential to improve outcomes for consumers (27/45, 60%); however, there was less certainty as to whether their consumers’ capability to use technology aligned with how the InnoWell Platform would be used as part of their mental health care (11/45, 24% of the participants strongly disagreed or disagreed; 15/45, 33% were neutral; and 19/45, 42% strongly agreed or agreed). During the semistructured interviews (n=3) and workshop, participants consistently indicated that the InnoWell Platform was appropriate for their respective services; however, they questioned whether the services’ respective consumers had the digital literacy required to use the technology. Additional potential barriers to implementation included health professionals’ digital literacy and service readiness for change.

Conclusions

Despite agreement among participants that HITs have the potential to result in improved outcomes for consumers and services, service readiness for change (eg, existing technology infrastructure and the digital literacy of staff and consumers) was noted to potentially impact the success of implementation, with less than half (20/45, 44%) of the participants indicating that their service was ready to implement new technologies to enhance mental health care. Furthermore, participants reported mixed opinions as to whether it was their responsibility to recommend technology as part of standard care.

Validation of an e-health readiness assessment framework for developing countries

Background

Studies document e-health as having potential to improve quality of healthcare services, resulting in both developed and developing countries demonstrating continued interest in e-health uptake and use. e-Health implementations are not always successful as high failure rates have been reported in both developed and developing countries. These failures are often a result of lack of e-health readiness. e-Health readiness has been defined as the preparedness of healthcare institutions or communities for the anticipated change brought by programs related to information and communication technologies. As such it is critical to conduct an e-health readiness assessment prior to implementation of e-health innovations so as to reduce chances of project failure. Noting the absence of an adequate e-health readiness assessment framework (eHRAF) suitable for use in developing countries, the authors conceptualised, designed, and created a developing country specific eHRAF to aid in e-health policy planning. The aim of this study was to validate the developed eHRAF and to determine if it required further refinement before empirical testing.

Methods

Published options for a framework validation process were adopted, and fifteen globally located e-health experts engaged. Botswana experts were engaged using saturation sampling, while international experts were purposively selected. Responses were collated in an Excel spreadsheet, and NVivo 11 software used to aid thematic analysis of the open ended questions.

Results

Analysis of responses showed overall support for the content and format of the proposed eHRAF. Equivocal responses to some open ended questions were recorded, most of which suggested modifications to terms within the framework. One expert from the developed world had alternate views.

Conclusions

The proposed eHRAF provides guidance for e-health policy development and planning by identifying, in an evidence based manner, the major areas to be considered when preparing for an e-health readiness assessment in the context of developing countries.

Assessment of organizational readiness to implement an electronic health record system in a low-resource settings cancer hospital: A cross-sectional survey

BACKGROUND

Organizational readiness for change is a key factor in success or failure of electronic health record (EHR) system implementations. Readiness is a multifaceted and multilevel abstract construct encompassing individual and organizational aspects, which makes it difficult to assess. Available tools for assessing readiness need to be tested in different contexts.

OBJECTIVE

To identify and assess relevant variables that determine readiness to implement an EHR in oncology in a low-and-middle income setting.

METHODS

At the Uganda Cancer Institute (UCI), a 100-bed tertiary oncology center in Uganda,we conducted a cross-sectional survey using the Paré model. This model has 39 indicator variables (Likert-scale items) for measuring 9 latent variables that contribute to readiness. We analyzed data using partial least squares structural equation modeling (PLS-SEM). In addition, we collected comments that we analyzed by qualitative content analysis and sentiment analysis as a way of triangulating the Likert-scale survey responses.

RESULTS

One hundred and forty-six clinical and non-clinical staff completed the survey, and 116 responses were included in the model. The measurement model showed good indicator reliability, discriminant validity, and internal consistency. Path coefficients for 6 of the 9 latent variables (i.e. vision clarity, change appropriateness, change efficacy, presence of an effective champion, organizational flexibility, and collective self-efficacy) were statistically significant at p < 0.05. The R2 for the outcome variable (organizational readiness) was 0.67. The sentiments were generally positive and correlated well with the survey scores (Pearson's r = 0.73). Perceived benefits of an EHR included improved quality, security and accessibility of clinical data, improved care coordination, reduction of errors, and time and cost saving. Recommended considerations for successful implementation include sensitization, training, resolution of organizational conflicts and computer infrastructure.

CONCLUSION

Change management during EHR implementation in oncology in low- and middle- income setting should focus on attributes of the change and the change targets, including vision clarity, change appropriateness, change efficacy, presence of an effective champion, organizational flexibility, and collective self-efficacy. Particularly, issues of training, computer skills of staff, computer infrastructure, sensitization and strategic implementation need consideration.

Tracing the Decisions That Shaped the Development of MyChart, an Electronic Patient Portal in Alberta, Canada: Historical Research Study

Background

Understanding how health organizations decide on information technology (IT) investments is imperative to ensure successful implementation and adoption. There is a high rate of failure and a tendency to downplay the complexity of implementation progression. Alberta Health Services introduced a patient portal called MyChart. Although MyChart allows patients to view appointments and selected laboratory results and to communicate with their providers, its uptake varies.

Objective

The study aimed to examine the institutional decision-making processes that shaped the development and implementation of MyChart.

Methods

A historical study was conducted based on the 7-step framework, where one engages in a rigorous archival critical analysis (including internal and external criticism) of documents and analysis of interviews. We reviewed and analyzed 423 primary and secondary sources and interviewed 10 key decision makers.

Results

Supportive leadership, project management, focused scope, appropriate technology and vendor selection, and quick decision making were some of the facilitators that allowed for the growth of proof of concept. The planning and implementation stages did not depend much on the technology itself but on the various actors who influenced the implementation by exerting power. The main barriers were lack of awareness about the technology, proper training, buy-in from diverse system leaders, and centralized government decision making.

Conclusions

Organizational priorities and decision-making tactics influence IT investments, implementation, adoption, and outcomes. Future research could focus on improving the applicability of needs assessments and funding decisions to health care scenarios.

Role of Health Information Technology in Addressing Health Disparities: Patient, Clinician, and System Perspectives

Over the last decade, health information technology (IT) has dramatically transformed medical practice in the United States. On May 11-12, 2017, the National Institute on Minority Health and Health Disparities, in partnership with the National Science Foundation and the National Health IT Collaborative for the Underserved, convened a scientific workshop, "Addressing Health Disparities with Health Information Technology," with the goal of ensuring that future research guides potential health IT initiatives to address the needs of health disparities populations. The workshop examined patient, clinician, and system perspectives on the potential role of health IT in addressing health disparities. Attendees were asked to identify and discuss various health IT challenges that confront underserved communities and propose innovative strategies to address them, and to involve these communities in this process. Community engagement, cultural competency, and patient-centered care were highlighted as key to improving health equity, as well as to promoting scalable, sustainable, and effective health IT interventions. Participants noted the need for more research on how health IT can be used to evaluate and address the social determinants of health. Expanding public-private partnerships was emphasized, as was the importance of clinicians and IT developers partnering and using novel methods to learn how to improve health care decision-making. Finally, to advance health IT and promote health equity, it will be necessary to record and capture health disparity data using standardized terminology, and to continuously identify system-level deficiencies and biases.

Elicitation and prioritization of requirements for electronic health records for oncology in low resource settings: A concept mapping study

BACKGROUND

Understanding functional and non-functional requirements is essential to successfully implement electronic medical record (EMR) systems. Actual requirements will be different for different contexts.

OBJECTIVE

To elicit and prioritize requirements for implementing EMRs in oncology in low and middle income countries (LMICs), and to relate these to requirements from high-income countries.

PARTICIPANTS AND SETTING

Cancer care stakeholders including oncologists, general doctors, nurses, biostatisticians, information technologists, from different LMICs, were involved.

METHODS

Concept mapping was used. Statements of requirements were obtained during focus group discussions (FGDs) and interviews. Using surveys, the requirements were clustered and ranked on importance and feasibility. Data were analyzed in SPSS using agglomerative hierarchical clustering and multidimensional scaling, to create cluster maps and go-zone maps reflecting the relationships between the requirements and their prioritization.

RESULTS

Four FGD sessions, with twenty participants, were conducted. In addition, six participants were interviewed. Twenty-two participants clustered the requirements and sixty-three participants ranked them on importance and feasibility. One hundred and sixty requirement statements were generated which were reduced to sixty-four after de-duplication and merging. Nine clusters were obtained encompassing the following domains, in order of importance: Security, Conducive organization, Management/Governance, General EMR functionalities, Computer infrastructure, Data management, Usability, Oncology decision support, and Ancillary requirements. On ranking, the requirements scored between 3.74 and 4.80 on importance, and between 3.55 and 4.46 on feasibility, on a 5-point Likert scale. We generated concept maps for use when communicating with stakeholders.

CONCLUSION

For oncology EMRs in LMICs, requirements overlap those from high-income countries, but generic EMR functionalities, Infrastructural and organizational requirements are still considered priority in LMICs compared to oncology-specific requirements or advanced EMR features e.g. computerized decision support or interoperability. Concept mapping is a fast and cost-effective method for eliciting and prioritizing EMR requirements in a user-centered manner.

What is needed by staff to implement PROMs into routine oncology care? A qualitative study with the multi-disciplinary team

INTRODUCTION

The aim of this study was to identify strategies to implement patient-reported outcome measures (PROMs) into routine oncology outpatients' clinical care.

METHODS

Qualitative focus groups were conducted with staff from multiple disciplines using a semistructured interview guide, with supporting data collected in field notes. Data were analysed using a Directed Content Analysis guided by an implementation science framework. The synthesis of the extracted data aimed to identify key requirements which correspond to intrinsic enablers and barriers for implementation.

RESULTS

52 staff members from the multi-disciplinary team participated. Data extracted showed five key themes and three key requirements regarding implementation of PROMs. Staff would consider using PROMs if there was strong research evidence that demonstrates benefits for patient outcomes, if PROM data was relevant to current clinical practice, and if applied appropriately in the specific setting. These findings add pragmatic detail and new knowledge to the current evidence on pathways to PROM implementation. This data can be used to inform implementation of PROMs into health services.

CONCLUSION

Staff have valuable tacit knowledge of what works in practice that offers a unique opportunity to increase successful implementation of a PROM intervention for patient symptom reporting.

Designing and evaluating functional laboratory information system requirements integrated to hospital information systems

RATIONALE, AIMS, AND OBJECTIVES

Laboratory information sub-systems play an important role in diagnosis and treatment of patients. This study aimed to determine functional requirements of users and assess the existence of these requirements in the laboratory information system.

METHOD

This descriptive cross-sectional study was conducted in 2016 in two phases. The first phase was done through three stages. First, based on an unsystematic review of related literature, an outline of functional laboratory information system requirements was identified. In the second stage, these requirements were identified in group meetings in the form of a semi-structured questionnaire and given to experts. Then, modified Delphi technique was used to reach agreement on each item. Then, based on experts' comments, the final version of the questionnaire was presented including 61 closed-ended items using Likert scale and an open-ended item. It was surveyed by 50 experts using Delphi technique. Responses were scored, and the requirements whose mean final score was 3 and above were finally confirmed. In the second phase, based on the confirmed requirements, a checklist comprising 68 requirements was prepared and adopted hospital information systems were evaluated through researcher observation. Data were analysed using descriptive statistics.

RESULTS

The final list of functional laboratory information system requirements was prepared with 68 items. The results of the evaluation revealed that confirmed requirements existed in 58.8% of hospital information systems.

CONCLUSION

Laboratory information system requirements were designed with 68 items. Evaluation results showed that the systems were moderate in terms of compliance with the requirements.

Building Usability Knowledge for Health Information Technology: A Usability-Oriented Analysis of Incident Reports

BACKGROUND

The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety.

OBJECTIVES

This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues?

METHODS

A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents.

RESULTS

A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information.

CONCLUSION

Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

The Evidence Base for an Ideal Care Pathway for Frail Multimorbid Elderly: Combined Scoping and Systematic Intervention Review

Background

There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored.

Objective

This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes.

Methods

We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects.

Results

Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects.

Conclusions

Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

A Mobile Phone App for Bedside Nursing Care: Design and Development Using an Adapted Software Development Life Cycle Model

Background

Nurses are increasingly spending time on computers, and providing them with a tailored tool to access clinical information and perform documentation at the bedside could help to improve their efficiency. Designing an app to support nurses’ work at the bedside is a challenging task, given the complexity of the care process.

Objective

This study aimed to present the design, development, and testing of a smartphone app for nurses guided by an adapted software development life cycle model that takes into consideration the complexity and constraints of a health care setting.

Methods

The model drives us through an iterative development process intersected by 3 stages of formative evaluation of growing ecological validity.

Results

The initial requirements identification stage included 11 participants who helped us select the most important functionalities to integrate into the tool. Starting with a usability evaluation allowed for the identification of design issues that could have caused misuse. Then, making on-site evaluations under the supervision of an investigator helped to understand the adequacy of the tool with limited risks. Finally, the on-site evaluation allowed us to validate the acceptance of the app by caregivers.

Conclusions

The interpretation of the collected evaluation confirms the necessary involvement of end users early in the process to help address the heterogeneity of the nursing workflow processes in the different wards. We also highlight the delicate balance between high-security measures to protect access to patient data and maintaining ease of access for efficiency and usability. Although a close collaboration with clinicians throughout the entire project facilitated the development of a tailored solution, it was also important to involve all stakeholders, in particular, the information technology (IT) security officers.

Toward the Design of an Engagement Tool for Effective Electronic Health Record Adoption

As healthcare systems continue to expand their use of electronic health records (EHRs), barriers to robust and successful engagement with such systems by stakeholders remain tenacious. To this effect, this research presents the results of a survey tool utilizing both original and modified constructs from the Consolidated Framework for Implementation Research to assess key points of engagement barriers and potential points of intervention for stakeholders of EHRs in a large-scale healthcare organization (500-bed level II regional trauma center). Based on the extensive assessment, the paper presents recommendations for the utility of engagement process modeling and discusses how intervention opportunities can be used to mitigate engagement barriers.

An investigation into the effective factors on the acceptance and use of integrated health system in the primary health-care centers

BACKGROUND

The successful application of the information systems in the health-care domain requires a reasonable recognition of the factors affecting the acceptance and use of such systems. The study aimed to investigate the factors affecting the acceptance and use of an integrated health system (IHS) in Isfahan primary health centers.

MATERIALS AND METHODS

It was an applied and descriptive-analytical survey conducted in Isfahan, Iran. Research population included all IHS's users in the health centers no. 1 and 2 of Isfahan city from which a sample of 320 individuals were selected in total. Data were collected using a questionnaire developed based on the Unified Theory of Acceptance and Use of Technology model. Data were analyzed using partial least squares (PLS) method and SmartPLS software.

RESULTS

The users' behavioral intention to use the IHS system was influenced by performance expectancy, effort expectancy, and social influence, but it was not significantly related to facilitating conditions. Behavioral intention to use the IHS also had a significant relationship with the use of system. Furthermore, performance expectancy was the most important predictor.

CONCLUSIONS

According to the findings, if the system users perceive the positive role of system in performance improvement, its convenience to use, and positive attitude of others toward it, their willingness to accept and use system will increase. Furthermore, it was important for the users that the system helps them in resolving their daily work-related problems and making rational decisions.

Putting the pieces together: EHR communication and diabetes patient outcomes

OBJECTIVES

This study seeks to determine how changes in electronic health record (EHR) communication patterns in primary care teams relate to quality of care and costs for patients with diabetes.

STUDY DESIGN

EHR-extracted longitudinal observational study.

METHODS

A total of 83 health professionals in 19 care teams at 4 primary care clinics associated with a large Midwestern university participated in the study. Counts of messages routed between any 2 team members in the EHR in the past 18 months were extracted. Flow-betweenness, defined as the proportion of information passed indirectly within the team, was calculated. The analysis related changes in team flow-betweenness to changes in emergency department visits, hospital stays, and associated medical costs for the teams' patients with diabetes, while adjusting for team face-to-face communication, patient-level covariates, comorbidities, team size, and clinic fixed effects.

RESULTS

Patient hospital visits increased by 13% (standard error [SE] = 6%) for every increase of 1 percentage point in team EHR message forwarding (ie, higher team flow-betweenness). Medical costs increased by $223 (SE = $105) per patient with diabetes in the past 6 months for every increase of 1 percentage point in team flow-betweenness.

CONCLUSIONS

Primary care teams whose EHR communication reached more team members indirectly (ie, via message forwarding) had worse outcomes and higher medical costs for their patients with diabetes. EHR team communication flow patterns may be an important avenue to explore in raising quality of care and lowering costs for patients with diabetes in primary care.

Healthcare predictive analytics: An overview with a focus on Saudi Arabia

Despite a newfound wealth of data and information, the healthcare sector is lacking in actionable knowledge. This is largely because healthcare data, though plentiful, tends to be inherently complex and fragmented. Health data analytics, with an emphasis on predictive analytics, is emerging as a transformative tool that can enable more proactive and preventative treatment options. This review considers the ways in which predictive analytics has been applied in the for-profit business sector to generate well-timed and accurate predictions of key outcomes, with a focus on key features that may be applicable to healthcare-specific applications. Published medical research presenting assessments of predictive analytics technology in medical applications are reviewed, with particular emphasis on how hospitals have integrated predictive analytics into their day-to-day healthcare services to improve quality of care. This review also highlights the numerous challenges of implementing predictive analytics in healthcare settings and concludes with a discussion of current efforts to implement healthcare data analytics in the developing country, Saudi Arabia.

Success or failure of hospital information systems of public hospitals affiliated with Zahedan University of Medical Sciences: A cross sectional study in the Southeast of Iran

INTRODUCTION

After implementation, evaluation of hospital information systems (HISs) is critical to ensure the fulfillment of the system goals. This study aimed to assess the success or failure of HISs in public hospitals affiliated with Zahedan University of Medical Sciences.

MATERIALS AND METHODS

A cross-sectional descriptive and analytic study was performed in 2016. The study population comprised IT and HIS authorities and hospital information system users. The sample consisted of 468 participants. The data were collected using two questionnaires and analyzed with the SPSS software using descriptive and analytical statistics.

RESULTS

The mean score of functional, behavioral, ethical, organizational, cultural and educational factors from the users' perspective was 3.14±0.66, 2.97± 0.60, 3.39±0.70, 2.96±0.642, 3.09±0.63, and 2.95±0.74, respectively. The mean score of organizational, behavioral, cultural, technological, educational and legal factors from IT and HIS authorities' perspective was 3.51±0.54, 3.35±0.45, 2.75±0.61, 3.58±0.32, and 3.96±0.59, respectively.

CONCLUSIONS

The evaluated hospital information systems were considered relatively successful in terms of functional, ethical, and cultural factors but were considered as a relative failure in terms of behavioral, organizational, and educational factors form the users' perspective. Only the legal factor showed success, while organizational, behavioral, technical and educational factors showed relative success and the cultural factor showed relative failure from HIS and IT authorities' perspective. Therefore, assessing the users' needs before implementing the system, involving them in various stages of implementation, training them, and improving their computer skills seem to be necessary to achieve a better level of system success.

An Electronic Health Record Data-driven Model for Identifying Older Adults at Risk of Unintentional Falls

Screening for risk of unintentional falls remains low in the primary care setting because of the time constraints of brief office visits. National studies suggest that physicians caring for older adults provide recommended fall risk screening only 30 to 37 percent of the time. Given prior success in developing methods for repurposing electronic health record data for the identification of fall risk, this study involves building a model in which electronic health record data could be applied for use in clinical decision support to bolster screening by proactively identifying patients for whom screening would be beneficial and targeting efforts specifically to those patients. The final model, consisting of priority and extended measures, demonstrates moderate discriminatory power, indicating that it could prove useful in a clinical setting for identifying patients at risk of falls. Focus group discussions reveal important contextual issues involving the use of fall-related data and provide direction for the development of health systems-level innovations for the use of electronic health record data for fall risk identification.

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

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

Key success factors behind electronic medical record adoption in Thailand

Purpose The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems. Design/methodology/approach Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel. Findings The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication. Research limitations/implications Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel. Practical implications Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues. Originality/value Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood.

Critical Success Factors in Electronic Health Records (EHR) Implementation

Electronic Health Records (EHR) has been the subject of much academic discussion in recent times. The impact that a successful implementation of EHR can have on a hospital cannot be overstated. Factors which are crucial to successful implementation of an EHR system are commonly known as Critical Success Factors (hereinafter referred to as CSFs). Purpose: The present study investigates the role of CSFs in implementation process of EHR systems in north Indian multispecialty hospitals. Design: The questionnaire has been distributed to 12 hospitals which have been using EHR technology. Findings: It has been concluded that three out of the five CSFs included in the study, play a more important role than the other two factors. Research limitations: The factors have not been considered separately based upon pre-implementation scenario and post-implementation phase. Originality: The study attempts to outline the impact of EHR systems on successful operational performance of hospitals.

Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland

AIMS AND OBJECTIVES

To explore the impact of implementing an electronic health record system on staff at a Scottish hospice.

BACKGROUND

Electronic health records are broadly considered preferable to paper-based systems. However, changing from one system to the other is difficult. This study analysed the impact of this change in a Scottish hospice.

DESIGN

Naturalistic prospective repeated-measures mixed-methods approach.

METHODS

Data on the usability of the system, staff engagement and staff experience were obtained at four time points spanning 30 months from inception. Quantitative data were obtained from surveys, and qualitative from concurrent analysis of free-text comments and focus group. Participants were all 150 employees of a single hospice in Scotland.

RESULTS

Both system usability and staff engagement scores decreased for the first two years before recovering at 30 months. Staff experience data pointed to two main challenges: (1) Technical issues, with subthemes of accessibility and usability. (2) Cultural issues, with subthemes of time, teamwork, care provision and perception of change.

CONCLUSIONS

It took 30 months for system usability and staff engagement scores to rise, after falling significantly for the first two years. The unintended outcomes of implementation included challenges to the way the patient story was both recorded and communicated. Nevertheless, this process of change was found to be consistent with the 'J-curve' theory of organisational change, and as such, it is both predictable and manageable for other organisations.

RELEVANCE TO CLINICAL PRACTICE

It is known that implementing an electronic health record system is complex. This paper puts parameters on this complexity by defining both the nature of the complexity ('J' curve) and the time taken for the organisation to begin recovery from the challenges (two years). Understanding these parameters will help health organisations across the world plan more strategically.

PD-atricians: Leveraging Physicians and Participatory Design to Develop Novel Clinical Information Tools

Participatory design, a method by which system users and stakeholders meaningfully contribute to the development of a new process or technology, has great potential to revolutionize healthcare technology, yet has seen limited adoption. We conducted a design session with eleven physicians working to create a novel clinical information tool utilizing participatory design methods. During the two-hour session, the physicians quickly engaged in the process and generated a large quantity of information, informing the design of a future tool. By utilizing facilitators experienced in design methodology, with detailed domain expertise, and well integrated into the healthcare organization, the participatory design session engaged a group of users who are often disenfranchised with existing processes as well as health information technology in general. We provide insight into why participatory design works with clinicians and provide guiding principles for how to implement these methods in healthcare organizations interested in advancing health information technology.

Model Guided Design and Development Process for an Electronic Health Record Training Program

Effective user training is important to ensure electronic health record (EHR) implementation success. Though many previous studies report best practice principles and success and failure stories, current EHR training is largely empirically-based and often lacks theoretical guidance. In addition, the process of training development is underemphasized and underreported. A white paper by the American Medical Informatics Association called for models of user training for clinical information system implementation; existing instructional development models from learning theory provide a basis to meet this call. We describe in this paper our experiences and lessons learned as we adapted several instructional development models to guide our development of EHR user training. Specifically, we focus on two key aspects of this training development: training content and training process.

A Systematic Review of Nurses' Experiences With Unintended Consequences When Using the Electronic Health Record

In response to unprecedented financial government incentives, electronic health record (EHR) adoption has tripled since 2009. While EHR benefits are emphasized, research demonstrates that adoption may result in unintended consequences that nurse administrators can anticipate and mitigate. Unintended consequences are defined as unplanned effects, whether positive or negative. Little is known about nursing perceptions and experience of unintended consequences arising from EHR implementation, and nursing studies are minimal in comparison with research on experience among their interprofessional colleagues. The purpose of this article is to present the state of the science on nurses' experiences with unintended consequences of EHRs derived from a systematic review that includes 4 original studies. Findings demonstrate that nurses experience changes to workflow, must continually adapt to meet patient's needs in the context of imperfect EHR systems, and have difficulty accessing the information they need to make patient care decisions. Even so, most state they would not revert to paper records if given the choice. Implications for nurse administrators include the need for continual engagement with nurses along the continuum of EHR design, as well as the need to encourage nurses to speak up and acknowledge workflow changes that threaten patient safety or do not support work efficiency.

Impact of Information Technology-Based Interventions for Type 2 Diabetes Mellitus on Glycemic Control: A Systematic Review and Meta-Analysis

BACKGROUND

Information technology-based interventions are increasingly being used to manage health care. However, there is conflicting evidence regarding whether these interventions improve outcomes in people with type 2 diabetes.

OBJECTIVE

The objective of this study was to conduct a systematic review and meta-analysis of clinical trials, assessing the impact of information technology on changes in the levels of hemoglobin A_1c (HbA_1c) and mapping the interventions with chronic care model (CCM) elements.

METHODS

Electronic databases PubMed and EMBASE were searched to identify relevant studies that were published up until July 2016, a method that was supplemented by identifying articles from the references of the articles already selected using the electronic search tools. The study search and selection were performed by independent reviewers. Of the 1082 articles retrieved, 32 trials (focusing on a total of 40,454 patients) were included. A random-effects model was applied to estimate the pooled results.

RESULTS

Information technology-based interventions were associated with a statistically significant reduction in HbA_1c levels (mean difference -0.33%, 95% CI -0.40 to -0.26, P<.001). Studies focusing on electronic self-management systems demonstrated the largest reduction in HbA_1c (0.50%), followed by those with electronic medical records (0.17%), an electronic decision support system (0.15%), and a diabetes registry (0.05%). In addition, the more CCM-incorporated the information technology-based interventions were, the more improvements there were in HbA_1c levels.

CONCLUSIONS

Information technology strategies combined with the other elements of chronic care models are associated with improved glycemic control in people with diabetes. No clinically relevant impact was observed on low-density lipoprotein levels and blood pressure, but there was evidence that the cost of care was lower.

A literature review for large-scale health information system project planning, implementation and evaluation

Information technology is perceived as a potential panacea for healthcare organisations to manage pressure to improve services in the face of increased demand. However, the implementation and evaluation of health information systems (HIS) is plagued with problems and implementation shortcomings and failures are rife. HIS implementation is complex and relies on organisational, structural, technological, and human factors to be successful. It also requires reflective, nuanced, multidimensional evaluation to provide ongoing feedback to ensure success. This article provides a comprehensive review of the literature about evaluating and implementing HIS, detailing the challenges and recommendations for both evaluators and healthcare organisations. The factors that inhibit or promote successful HIS implementation are identified and effective evaluation strategies are described with the goal of informing teams evaluating complex HIS.