On the importance of using a multidimensional sociotechnical model to study health information technology

Is primary health care ready for artificial intelligence? What do primary health care stakeholders say?

Background

Effective deployment of AI tools in primary health care requires the engagement of practitioners in the development and testing of these tools, and a match between the resulting AI tools and clinical/system needs in primary health care. To set the stage for these developments, we must gain a more in-depth understanding of the views of practitioners and decision-makers about the use of AI in primary health care. The objective of this study was to identify key issues regarding the use of AI tools in primary health care by exploring the views of primary health care and digital health stakeholders.

Methods

This study utilized a descriptive qualitative approach, including thematic data analysis. Fourteen in-depth interviews were conducted with primary health care and digital health stakeholders in Ontario. NVivo software was utilized in the coding of the interviews.

Results

Five main interconnected themes emerged: (1) Mismatch Between Envisioned Uses and Current Reality—denoting the importance of potential applications of AI in primary health care practice, with a recognition of the current reality characterized by a lack of available tools; (2) Mechanics of AI Don’t Matter: Just Another Tool in the Toolbox– reflecting an interest in what value AI tools could bring to practice, rather than concern with the mechanics of the AI tools themselves; (3) AI in Practice: A Double-Edged Sword—the possible benefits of AI use in primary health care contrasted with fundamental concern about the possible threats posed by AI in terms of clinical skills and capacity, mistakes, and loss of control; (4) The Non-Starters: A Guarded Stance Regarding AI Adoption in Primary Health Care—broader concerns centred on the ethical, legal, and social implications of AI use in primary health care; and (5) Necessary Elements: Facilitators of AI in Primary Health Care—elements required to support the uptake of AI tools, including co-creation, availability and use of high quality data, and the need for evaluation.

Conclusion

The use of AI in primary health care may have a positive impact, but many factors need to be considered regarding its implementation. This study may help to inform the development and deployment of AI tools in primary health care.

A Sociotechnical Approach to Analyze Pharmaceutical Policy and Services Management in Primary Health Care in a Brazilian Municipality

The decentralization of the Brazilian health system required that municipalities took responsibility for the local Pharmaceutical Policy and Services (PPS) system. This article presents and analyses an innovative experience of diagnosis of municipal PPS as a sociotechnical system. We adopted a multi-methods approach and various data sources. Sociotechnical theory was the framework of the methodology of evaluation and design of systems, analyzing the External System (health system, stakeholders, financing) and Internal System (goals, management, workforce, infrastructure, processes, technology and culture). The "objective" component of the PPS system was identified as the central element. The lack of a unified objective and of a central coordination and unmanaged pharmaceutical services prevented integrated internal planning and planning with other sectors. Stakeholders and documents referred only to technical elements of the system: Infrastructure, technical process, and technology. The social components of the workforce and culture were not mentioned. The organizational culture established was the culture of isolation: "Each one does his own". The pharmacists working in the municipal health system did not know each other. There was no integration strategy between pharmacists and their work processes. Consequently, the municipal PPS had limited scope as a public policy. It had constrained the characteristics of PPS as a complex and open system. Understanding the municipal PPS as a sociotechnical system can push the development of a new level of policy and practice to ensure the population's right to the access to and rational use of medicines.

Computerized provider order entry-related medication errors among hospitalized patients: An integrative review

The Institute of Medicine estimates that 7,000 lives are lost yearly as a result of medication errors. Computerized physician and/or provider order entry was one of the proposed solutions to overcome this tragic issue. Despite some promising data about its effectiveness, it has been found that computerized provider order entry may facilitate medication errors.The purpose of this review is to summarize current evidence of computerized provider order entry -related medication errors and address the sociotechnical factors impacting the safe use of computerized provider order entry. By using PubMed and Google Scholar databases, a systematic search was conducted for articles published in English between 2007 and 2019 regarding the unintended consequences of computerized provider order entry and its related medication errors. A total of 288 articles were screened and categorized based on their use within the review. One hundred six articles met our pre-defined inclusion criteria and were read in full, in addition to another 27 articles obtained from references. All included articles were classified into the following categories: rates and statistics on computerized provider order entry -related medication errors, types of computerized provider order entry -related unintended consequences, factors contributing to computerized provider order entry failure, and recommendations based on addressing sociotechnical factors. Identifying major types of computerized provider order entry -related unintended consequences and addressing their causes can help in developing appropriate strategies for safe and effective computerized provider order entry. The interplay between social and technical factors can largely affect its safe implementation and use. This review discusses several factors associated with the unintended consequences of this technology in healthcare settings and presents recommendations for enhancing its effectiveness and safety within the context of sociotechnical factors.

Joint Design with Providers of Clinical Decision Support for Value-Based Advanced Shoulder Imaging

BACKGROUND

Provider orders for inappropriate advanced imaging, while rarely altering patient management, contribute enough to the strain on available health care resources, and therefore the United States Congress established the Appropriate Use Criteria Program.

OBJECTIVES

To examine whether co-designing clinical decision support (CDS) with referring providers will reduce barriers to adoption and facilitate more appropriate shoulder ultrasound (US) over magnetic resonance imaging (MRI) in diagnosing Veteran shoulder pain, given similar efficacies and only 5% MRI follow-up rate after shoulder US.

METHODS

We used a theory-driven, convergent parallel mixed-methods approach to prospectively (1) determine medical providers' reasons for selecting MRI over US in diagnosing shoulder pain and identify barriers to ordering US, (2) co-design CDS, informed by provider interviews, to prompt appropriate US use, and (3) assess CDS impact on shoulder imaging use. CDS effectiveness in guiding appropriate shoulder imaging was evaluated through monthly monitoring of ordering data at our quaternary care Veterans Hospital. Key outcome measures were appropriate MRI/US use rates and transition to ordering US by both musculoskeletal specialist and generalist providers. We assessed differences in ordering using a generalized estimating equations logistic regression model. We compared continuous measures using mixed effects analysis of variance with log-transformed data.

RESULTS

During December 2016 to March 2018, 569 (395 MRI, 174 US) shoulder advanced imaging examinations were ordered by 111 providers. CDS "co-designed" in collaboration with providers increased US from 17% (58/335) to 50% (116/234) of all orders (p < 0.001), with concomitant decrease in MRI. Ordering appropriateness more than doubled from 31% (105/335) to 67% (157/234) following CDS (p < 0.001). Interviews confirmed that generalist providers want help in appropriately ordering advanced imaging.

CONCLUSION

Partnering with medical providers to co-design CDS reduced barriers and prompted appropriate transition to US from MRI for shoulder pain diagnosis, promoting evidence-based practice. This approach can inform the development and implementation of other forms of CDS.

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices

BACKGROUND

Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention.

METHODS

A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS.

DISCUSSION

This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.

Theoretical frameworks in telemedicine research

The purposive use of theory is a foundational component of research, which underpins the design, methodology, measures, interventions, and interpretation of the research project. This should be considered from the time the nascent idea of the research is born, until the final interpretation of results and write up of the discussion. Several theories relevant to telemedicine are described, discussed, and linked to typical research questions in the field.

Assessing organizational capacity for achieving meaningful use of electronic health records

BACKGROUND

Health care institutions are scrambling to manage the complex organizational change required for achieving meaningful use (MU) of electronic health records (EHR). Assessing baseline organizational capacity for the change can be a useful step toward effective planning and resource allocation.

PURPOSE

The aim of this article is to describe an adaptable method and tool for assessing organizational capacity for achieving MU of EHR. Data on organizational capacity (people, processes, and technology resources) and barriers are presented from outpatient clinics within one integrated health care delivery system; thus, the focus is on MU requirements for eligible professionals, not eligible hospitals.

METHODS

We conducted 109 interviews with representatives from 46 outpatient clinics.

FINDINGS

Most clinics had core elements of the people domain of capacity in place. However, the process domain was problematic for many clinics, specifically, capturing problem lists as structured data and having standard processes for maintaining the problem list in the EHR. Also, nearly half of all clinics did not have methods for tracking compliance with their existing processes. Finally, most clinics maintained clinical information in multiple systems, not just the EHR. The most common perceived barriers to MU for eligible professionals included EHR functionality, changes to workflows, increased workload, and resistance to change.

PRACTICE IMPLICATIONS

Organizational capacity assessments provide a broad institutional perspective and an in-depth clinic-level perspective useful for making resource decisions and tailoring strategies to support the MU change effort for eligible professionals.

The relationship between telehealth and information technology ranges from that of uneasy bedfellows to creative partnerships

The relationship between the clinical and technical aspects of a telehealth operation is frequently problematic, and technically-driven projects often fail to achieve sustainability. Qualitative data from a study of 37 Australian telehealth services were analysed to understand how the relationship between telehealth providers and information technology (IT) departments helps or hinders the development of telehealth. The most frequent difficulties reported were between telehealth services and the internal IT departments of health services, rather than with external vendors. The difficulties included barriers to installing telehealth over IT networks, a lack of priority given to telehealth services, and IT departments insisting on standardised approach. Alternatively, when IT staff were assigned to supporting clinical staff and had a close working relationship with them, they were major enablers of telehealth services. Authorising dedicated IT support and encouraging joint problem solving should provide a strong foundation for a healthy relationship which contributes to the growth and sustainability of telehealth.

Clinician acceptance is the key factor for sustainable telehealth services

Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.