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Michel J, Manns A, Boudersa S, Jaubert C, Dupic L, Vivien B, Burgun A, Campeotto F, Tsopra R. Clinical decision support system in emergency telephone triage: A scoping review of technical design, implementation and evaluation. Int J Med Inform 2024; 184:105347. [PMID: 38290244 DOI: 10.1016/j.ijmedinf.2024.105347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/09/2024] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Emergency department overcrowding could be improved by upstream telephone triage. Emergency telephone triage aims at managing and orientating adequately patients as early as possible and distributing limited supply of staff and materials. This complex task could be improved with the use of Clinical decision support systems (CDSS). The aim of this scoping review was to identify literature gaps for the future development and evaluation of CDSS for Emergency telephone triage. MATERIALS AND METHODS We present here a scoping review of CDSS designed for emergency telephone triage, and compared them in terms of functional characteristics, technical design, health care implementation and methodologies used for evaluation, following the PRISMA-ScR guidelines. RESULTS Regarding design, 19 CDSS were retrieved: 12 were knowledge based CDSS (decisional algorithms built according to guidelines or clinical expertise) and 7 were data driven (statistical, machine learning, or deep learning models). Most of them aimed at assisting nurses or non-medical staff by providing patient orientation and/or severity/priority assessment. Eleven were implemented in real life, and only three were connected to the Electronic Health Record. Regarding evaluation, CDSS were assessed through various aspects: intrinsic characteristics, impact on clinical practice or user apprehension. Only one pragmatic trial and one randomized controlled trial were conducted. CONCLUSION This review highlights the potential of a hybrid system, user tailored, flexible, connected to the electronic health record, which could work with oral, video and digital data; and the need to evaluate CDSS on intrinsic characteristics and impact on clinical practice, iteratively at each distinct stage of the IT lifecycle.
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Affiliation(s)
- Julie Michel
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, 125, rue de Stalingrad, 93009 Bobigny, France
| | - Aurélia Manns
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France.
| | - Sofia Boudersa
- Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Côme Jaubert
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Laurent Dupic
- Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France
| | - Benoit Vivien
- Digital Health Program of Université de Paris Cité, Paris, France; Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France
| | - Anita Burgun
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Florence Campeotto
- Digital Health Program of Université de Paris Cité, Paris, France; Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France; Faculté de Pharmacie, Université de Paris Cité, Inserm UMR S1139, Paris, France
| | - Rosy Tsopra
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
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2
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Procter S, Harrison D, Pearson P, Dickinson C. Theorising worker–client relations in front‐line service work: Understanding the experience of non‐professionally affiliated workers in UK mental health services. NEW TECHNOLOGY WORK AND EMPLOYMENT 2022. [DOI: 10.1111/ntwe.12212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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3
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Lewinski AA, Rushton S, Van Voorhees E, Boggan JC, Whited JD, Shoup JP, Tabriz AA, Adam S, Fulton J, Gordon AM, Ear B, Williams JW, Goldstein KM, Van Noord MG, Gierisch JM. Implementing remote triage in large health systems: A qualitative evidence synthesis. Res Nurs Health 2020; 44:138-154. [PMID: 33319411 DOI: 10.1002/nur.22093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/20/2020] [Accepted: 11/28/2020] [Indexed: 01/06/2023]
Abstract
Remote triage (RT) allows interprofessional teams (e.g., nurses and physicians) to assess patients and make clinical decisions remotely. RT use has developed widespread interest due to the COVID-19 pandemic, and has future potential to address the needs of a rapidly aging population, improve access to care, facilitate interprofessional team care, and ensure appropriate use of resources. However, despite rapid and increasing interest in implementation of RT, there is little research concerning practices for successful implementation. We conducted a systematic review and qualitative evidence synthesis of practices that impact the implementation of RT for adults seeking clinical care advice. We searched MEDLINE®, EMBASE, and CINAHL from inception through July 2018. We included 32 studies in this review. Our review identified four themes impacting the implementation of RT: characteristics of staff who use RT, influence of RT on staff, considerations in selecting RT tools, and environmental and contextual factors impacting RT. The findings of our systemic review underscore the need for a careful consideration of (a) organizational and stakeholder buy-in before launch, (b) physical and psychological workplace environment, (c) staff training and ongoing support, and (d) optimal metrics to assess the effectiveness and efficiency of implementation. Our findings indicate that preimplementation planning, as well as evaluating RT by collecting data during and after implementation, is essential to ensuring successful implementation and continued adoption of RT in a health care system.
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Affiliation(s)
- Allison A Lewinski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,School of Nursing, Duke University, Durham, North Carolina, USA
| | - Sharron Rushton
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Elizabeth Van Voorhees
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joel C Boggan
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John D Whited
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Amir A Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy University of North Carolina, Chapel Hill, North Carolina, USA
| | - Soheir Adam
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica Fulton
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adelaide M Gordon
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Belinda Ear
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - John W Williams
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen M Goldstein
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan G Van Noord
- Carlson Health Sciences Library, University of California, Davis, California, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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The recruitment, retention and development of an integrated urgent care telephone triage workforce: a small-scale study. JOURNAL OF INTEGRATED CARE 2020. [DOI: 10.1108/jica-06-2020-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeNHS 111 is a non-emergency telephone triage service that provides immediate access to urgent care 24 h a day. This study explored the recruitment, retention and development of one integrated urgent care (IUC) workforce in England, specifically the NHS 111 service and Clinical Hub.Design/methodology/approachAn online survey was distributed to the NHS 111 and Clinical Hub workforce. The data from 48 respondents were summarised and analysed thematically.FindingsThe survey respondents held a variety of clinical and non-clinical roles within NHS 111 and the Clinical Hub. The findings indicate that the IUC workforce is motivated to care for their patients and utilise a range of communication and cognitive skills to undertake their telephone triage roles. In total, 67% of respondents indicated that their work was stressful, particularly the volume and intensity of calls. Although the initial training prepared the majority of respondents for their current roles (73%), access to continuing professional development (CPD) varied across the workforce with only 40% being aware of the opportunities available. A total of 81% of respondents stated that their shifts were regularly understaffed which indicates that the retention of IUC staff is problematic; this can put additional pressure on the existing workforce, impact on staff morale and create logistical issues with managing annual leave entitlements or scheduling time for training.Originality/valueThis small-scale study highlights some of the complexities of telephone triage work and demonstrates the challenges for IUC service providers in retaining an appropriately skilled and motivated workforce.
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5
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Morgan JI, Muskett T. Interactional misalignment in the UK NHS 111 healthcare telephone triage service. Int J Med Inform 2019; 134:104030. [PMID: 31864097 DOI: 10.1016/j.ijmedinf.2019.104030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 10/02/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND A recent review of primary care serious incidents suggests that diagnosis and assessment problems, underpinned by communication failures, involving the UK telephone triage service, NHS 111, may contribute to patient harm. METHODS The present study utilised conversation analysis to address the lack of evaluative research examining the NHS 111 system and in particular interactions between system components (call handler, computerized decision support system, patients/caller). RESULTS Analysis of audio recorded call interactions revealed interactional misalignment across four mapped call phases (eliciting caller details, establishing reason for call, completing the Pathways assessment, and agreeing the outcome). This misalignment has the capacity to increase the risk of system failure, particularly in relation to assessment problems and issues related to the accurate transfer of care advice. Our analysis suggests that efforts to enhance the NHS 111 system, similar telehealth services, and patient safety management more generally, should shift their focus from a limited set of individual components towards a system-specific interactionist perspective encompassing all elements. CONCLUSIONS Further evaluative research is required in order to build a comprehensive evidence-base concerning the multiple interacting factors influencing patient safety in the NHS 111 system.
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Affiliation(s)
- James I Morgan
- Psychology Group, Leeds Beckett University, Leeds, United Kingdom.
| | - Thomas Muskett
- Psychology Group, Leeds Beckett University, Leeds, United Kingdom
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I, Greenhalgh T. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06210] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundThere is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.Objective(s)To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.DesignMultilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).SettingThree contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.Data collection and analysisMacro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.ResultsPolicy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.ConclusionsVirtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.LimitationsThe focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.Future researchFurther studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Remote clinical decision making: Evaluation of a new education module. Nurse Educ Pract 2018; 29:150-158. [PMID: 29367126 DOI: 10.1016/j.nepr.2018.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 11/10/2017] [Accepted: 01/02/2018] [Indexed: 11/22/2022]
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Pope C, Turnbull J. Using the concept of hubots to understand the work entailed in using digital technologies in healthcare. J Health Organ Manag 2017; 31:556-566. [PMID: 28933675 DOI: 10.1108/jhom-12-2016-0231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to explore the human work entailed in the deployment of digital health care technology. It draws on imagined configurations of computers and machines in fiction and social science to think about the relationship between technology and people, and why this makes implementation of digital technology so difficult. The term hubots is employed as a metaphorical device to examine how machines and humans come together to do the work of healthcare. Design/methodology/approach This paper uses the fictional depiction of hubots to reconceptualise the deployment of a particular technology - a computer decision support system (CDSS) used in emergency and urgent care services. Data from two ethnographic studies are reanalysed to explore the deployment of digital technologies in health services. These studies used comparative mixed-methods case study approaches to examine the use of the CDSS in eight different English NHS settings. The data include approximately 900 hours of observation, with 64 semi-structured interviews, 47 focus groups, and surveys of some 700 staff in call centres and urgent care centres. The paper reanalyses these data, deductively, using the metaphor of the hubot as an analytical device. Findings This paper focuses on the interconnected but paradoxical features of both the fictional hubots and the CDSS. Health care call handling using a CDSS has created a new occupation, and enabled the substitution of some clinical labour. However, at the same time, the introduction of the technology has created additional work. There are more tasks, both physical and emotional, and more training activity is required. Thus, the labour has been intensified. Practical implications This paper implies that if we want to realise the promise of digital health care technologies, we need to understand that these technologies substitute for and intensify labour. Originality/value This is a novel analysis using a metaphor drawn from fiction. This allows the authors to recognise the human effort required to implement digital technologies.
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Affiliation(s)
- Catherine Pope
- Faculty of Health Sciences, University of Southampton , Southampton, UK
| | - Joanne Turnbull
- Faculty of Health Sciences, University of Southampton , Southampton, UK
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10
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Turnbull J, Prichard J, Pope C, Brook S, Rowsell A. Risk work in NHS 111: the everyday work of managing risk in telephone assessment using a computer decision support system. HEALTH RISK & SOCIETY 2017. [DOI: 10.1080/13698575.2017.1324946] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Joanne Turnbull
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jane Prichard
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Catherine Pope
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Simon Brook
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Rowsell
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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11
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Greenhalgh T, Vijayaraghavan S, Wherton J, Shaw S, Byrne E, Campbell-Richards D, Bhattacharya S, Hanson P, Ramoutar S, Gutteridge C, Hodkinson I, Collard A, Morris J. Virtual online consultations: advantages and limitations (VOCAL) study. BMJ Open 2016; 6:e009388. [PMID: 26826147 PMCID: PMC4735312 DOI: 10.1136/bmjopen-2015-009388] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations. METHODS To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel--audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel--interviews, ethnographic observations and analysis of documents within the trust; macrolevel--key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory. ETHICS APPROVAL City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883. PLANNED OUTPUTS We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: 'what to expect in your virtual consultation'. DISCUSSION The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Joe Wherton
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Byrne
- Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
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Vessey JA, McCrave J, Curro-Harrington C, DiFazio RL. Enhancing Care Coordination Through Patient- and Family-Initiated Telephone Encounters: A Quality Improvement Project. J Pediatr Nurs 2015; 30:915-23. [PMID: 26048646 DOI: 10.1016/j.pedn.2015.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/22/2015] [Accepted: 05/23/2015] [Indexed: 11/17/2022]
Abstract
Telehealth activities are often conducted by ambulatory nurses to assist with care coordination; these activities are especially important for children with complex, chronic conditions. This quality-improvement project examines specific components of nursing care delivered to children on the neurology and gastroenterology services through patient-initiated telephone encounters. Metrics and nurse-sensitive indicators explored include the type of services requested, the nurses' ability to resolve patients' concerns while eliminating otherwise unnecessary care, and associated costs with providing this care. The usefulness of a standardized instrument, the care coordination management tool, used in this project is discussed.
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Affiliation(s)
- Judith A Vessey
- Medicine Patient Services, Boston Children's Hospital, Boston, MA; Boston College, William F. Connell School of Nursing, Chestnut Hill, MA.
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13
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Turner J, Coster J, Chambers D, Cantrell A, Phung VH, Knowles E, Bradbury D, Goyder E. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03430] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Viet-Hai Phung
- College of Social Science, University of Lincoln, Lincoln, UK
| | - Emma Knowles
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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14
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The impact of using computer decision-support software in primary care nurse-led telephone triage: Interactional dilemmas and conversational consequences. Soc Sci Med 2015; 126:36-47. [DOI: 10.1016/j.socscimed.2014.12.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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O'Cathain A, Knowles E, Turner J, Nicholl J. Acceptability of NHS 111 the telephone service for urgent health care: cross sectional postal survey of users' views. Fam Pract 2014; 31:193-200. [PMID: 24334420 PMCID: PMC3969523 DOI: 10.1093/fampra/cmt078] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2010, a new telephone service, NHS 111, was piloted to improve access to urgent care in England. A unique feature is the use of non-clinical call takers who triage calls with computerized decision support and have access to clinical advisors when necessary. Aim. To explore users' acceptability of NHS 111. DESIGN Cross-sectional postal survey. SETTING Four pilot sites in England. METHOD A postal survey of recent users of NHS 111. RESULTS The response rate was 41% (1769/4265), with 49% offering written comments (872/1769). Sixty-five percent indicated the advice given had been very helpful and 28% quite helpful. The majority of respondents (86%) indicated that they fully complied with advice. Seventy-three percent was very satisfied and 19% quite satisfied with the service overall. Users were less satisfied with the relevance of questions asked, and the accuracy and appropriateness of advice given, than with other aspects of the service. Users who were autorouted to NHS 111 from services such as GP out-of-hours services were less satisfied than direct callers. CONCLUSION In pilot services in the first year of operation, NHS 111 appeared to be acceptable to the majority of users. Acceptability could be improved by reassessing the necessity of triage questions used and auditing the accuracy and appropriateness of advice given. User acceptability should be viewed in the context of findings from the wider evaluation, which identified that the NHS 111 pilot services did not improve access to urgent care and indeed increased the use of emergency ambulance services.
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Affiliation(s)
- Alicia O'Cathain
- Medical Care Research Unit, The School of Health and Related Research, University of Sheffield, Sheffield UK
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16
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Turnbull J, Pope C, Rowsell A, Prichard J, Halford S, Jones J, May C, Lattimer V. The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundNHS 111 represents a fundamental change in the way that urgent care is delivered. It is underpinned by a computer decision support system (CDSS) and involves significant labour substitution, in particular the greater use of non-clinical staff to deliver services.ObjectiveTo investigate four core features of health-care innovation and change in relation to the new NHS 111 telephone-based service for 24/7 access to urgent care, namely the way in whichworkandworkforceare organised for this new service and how thetechnologyandorganisational contextshape the way in which services are delivered.DesignComparative mixed-methods case study of NHS 111 providers.SettingsFive NHS 111 sites, characterised by differences in organisational size, form and ethos and in the type of workforce employed and professional roles and skill mix.MethodsThe study combined ethnographic and survey methods. Non-participant observation was conducted at NHS 111 call centres and their linked urgent care centre(s) (UCCs; a total of 356 hours). Six focus groups were conducted with 47 call advisers, clinicians and organisational managers. An online survey was administered to call centre and UCC staff (n = 745) to ask their views about NHS 111; trust in NHS Pathways; and communication and information sharing (response rate: 41% for call centre staff, 35% for UCC staff).ResultsClinical assessment by call advisers is characterised by high levels of communication (including negotiation, communication and translation) and ‘emotion’ work, extending the work beyond simple operation of a CDSS. At most sites clinical advisers supported call advisers in clinical assessment but also played an important role in managing and sanctioning dispositions, notably emergency ambulance dispositions. Clinicians at UCCs have experienced a loss of control over their everyday work, which is now shaped by call centre workers. The Directory of Services, which provides information about locally available services, is key to delivering an integrated urgent care system. Trust in the CDSS is higher amongst call advisers than amongst clinical staff but there is widespread belief that the CDSS is risk averse. Staff often develop workarounds to ‘make the technology work’. There is considerable variation in how NHS 111 is organised and delivered, shaped by the organisational history and the professional culture of the organisations involved. Some sites were driven more by rationing and systemising, pursuing the NHS 111 vision of ‘right care, right place, right time’, whereas others were driven more by an ethos of what they perceived was a more patient-centred service.ConclusionsNHS 111 is primarily founded on a network of different organisations providing different aspects of the service. This network is primarily enabled through technological integration. Successful integration also requires understanding and trusting relationships between different providers, which were lacking in some sites. Underpinning NHS 111 with non-clinical workers offers significant opportunities for workforce reconfiguration, but this is not a simple substitution of labour (i.e. non-clinical staff replacing clinical staff). There is a significant organisational structure that is necessary to support and ‘keep in place’ both the CDSS itself and non-clinical workers using the CDSS.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne Turnbull
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Catherine Pope
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Rowsell
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jane Prichard
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Susan Halford
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jeremy Jones
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Valerie Lattimer
- School of Nursing Sciences, University of East Anglia, Norwich, UK
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Pope C, Halford S, Turnbull J, Prichard J, Calestani M, May C. Using computer decision support systems in NHS emergency and urgent care: ethnographic study using normalisation process theory. BMC Health Serv Res 2013; 13:111. [PMID: 23522021 PMCID: PMC3614561 DOI: 10.1186/1472-6963-13-111] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/11/2013] [Indexed: 12/03/2022] Open
Abstract
Background Information and communication technologies (ICTs) are often proposed as ‘technological fixes’ for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare. Methods We undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis. Results Our data comprise nearly 500 hours of observation, interviews with 64 call-handlers, and stakeholders and documents about the technology and settings. The technology has been implemented and is used distinctively in each setting reflecting important differences between work and contexts. Using Normalisation Process Theory we show how the work (collective action) of implementing the system and maintaining its routine use was enabled by a range of actors who established coherence for the technology, secured buy-in (cognitive participation) and engaged in on-going appraisal and adjustment (reflexive monitoring). Conclusions Huge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be ‘made to work’ in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place – it requires new resources and considerable effort, perhaps on an on-going basis.
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Affiliation(s)
- Catherine Pope
- Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK.
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