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Otokiti AU, Craven CK, Shetreat-Klein A, Cohen S, Darrow B. 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. JMIR Res Protoc 2021; 10:e25148. [PMID: 33724202 PMCID: PMC8294464 DOI: 10.2196/25148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/29/2021] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ahmed Umar Otokiti
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Clinical Informatics Group, Information Technology Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Catherine K Craven
- Clinical Informatics Group, Information Technology Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Avniel Shetreat-Klein
- Clinical Informatics Group, Information Technology Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Stacey Cohen
- Clinical Informatics Group, Information Technology Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States.,Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, United States
| | - Bruce Darrow
- Department of Cardiology and Health Information Technology, Mount Sinai Health System, New York, NY, United States
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Alami H, Fortin JP, Gagnon MP, Lamothe L, Ghandour EK, Ag Ahmed MA, Roy D. [Strategic framework to Support the evaluation of complex and innovative digital health projects]. SANTE PUBLIQUE 2020; 32:221-228. [PMID: 32985838 DOI: 10.3917/spub.202.0221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Digital technologies play a central role in strategies to improve access, quality and efficiency of health care and services. However, many digital health projects have failed to become sustainable and spread across health organizations and systems. This situation is partly due to the fact that these projects are often developed and evaluated by reducing the issues linked mainly to the technological dimension. Such tradition has paid little attention to the fact that technology is introduced into pluralistic and complex sociotechnical systems such as health organizations and systems. The aim of this article is to propose practical and theorical, non-prescriptive, elements of reflection that can serve as a basis for evaluating complex and innovative digital health projects. This reflection builds on the lessons learned from the application of a strategic framework for evaluating three major complex and innovative digital health projects in Quebec over the last 15 years.
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Shiells K, Diaz Baquero AA, Štěpánková O, Holmerová I. Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study. BMC Med Inform Decis Mak 2020; 20:159. [PMID: 32660474 PMCID: PMC7359585 DOI: 10.1186/s12911-020-01160-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The electronic patient record (EPR) has been introduced into nursing homes in order to facilitate documentation practices such as assessment and care planning, which play an integral role in the provision of dementia care. However, little is known about how the EPR facilitates or hinders these practices from the end-user's perspective. Therefore, the objective of this qualitative study was to explore the usability issues associated with the EPR for assessment and care planning for people with dementia in nursing homes from a staff perspective. METHODS An exploratory, qualitative research design with a multiple case study approach was used. Contextual Inquiry was carried out with a variety of staff members (n = 21) who used the EPR in three nursing homes situated in Belgium, Czech Republic and Spain. Thematic analysis was used to code interview data, with codes then sorted into a priori components of the Health Information Technology Evaluation Framework: device, software functionality, organisational support. Two additional themes, structure and content, were also added. RESULTS Staff provided numerous examples of the ways in which EPR systems are facilitating and hindering assessment and care planning under each component, particularly for people with dementia, who may have more complex needs in comparison to other residents. The way in which EPR systems were not customisable was a common theme across all three homes. A comparison of organisational policies and practices revealed the importance of training, system support, and access, which may be linked with the successful adoption of the EPR system in nursing homes. CONCLUSIONS EPR systems introduced into the nursing home environment should be customisable and reflect best practice guidelines for dementia care, which may lead to improved outcomes and quality of life for people with dementia living in nursing homes. All levels of nursing home staff should be consulted during the development, implementation and evaluation of EPR systems as part of an iterative, user-centred design process.
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Affiliation(s)
- Kate Shiells
- Centre of Expertise in Longevity and Long-Term Care, Faculty of Humanities, Charles University, Prague, Czech Republic.
| | - Angie Alejandra Diaz Baquero
- Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
- Department of Research & Development, Iberian Research Psycho-sciences Institute, INTRAS Foundation, Zamora, Spain
| | - Olga Štěpánková
- Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Iva Holmerová
- Centre of Expertise in Longevity and Long-Term Care, Faculty of Humanities, Charles University, Prague, Czech Republic
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Oakey-Neate L, Schrader G, Strobel J, Bastiampillai T, van Kasteren Y, Bidargaddi N. Using algorithms to initiate needs-based interventions for people on antipsychotic medication: implementation protocol. BMJ Health Care Inform 2020; 27:bmjhci-2019-100084. [PMID: 32051177 PMCID: PMC7062355 DOI: 10.1136/bmjhci-2019-100084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/19/2019] [Accepted: 10/23/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Non-adherence to antipsychotic medications for individuals with serious mental illness increases risk of relapse and hospitalisation. Real time monitoring of adherence would allow for early intervention. AI2 is a both a personal nudging system and a clinical decision support tool that applies machine learning on Medicare prescription and benefits data to raise alerts when patients have discontinued antipsychotic medications without supervision, or when essential routine health checks have not been performed. Methods and analysis We outline two intervention models using AI2. In the first use-case, the personal nudging system, patients receive text messages when an alert of a missed medication or routine health check is detected by AI2. In the second use-case, as a clinical decision support tool, AI2 generated alerts are presented as flags through a dashboard to the community mental health professionals. Implementation protocols for different scenarios of AI2, along with a mixed-methods evaluation, are planned to identify pragmatic issues necessary to inform a larger randomised control trial, as well as improve the application. Ethics and dissemination This study protocol has been approved by The Southern Adelaide Clinical Human Research Ethics Committee. The dissemination of this trial will serve to inform further implementation of the AI2 into daily personal and clinical practice.
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Affiliation(s)
- Lydia Oakey-Neate
- Digital Psychiatry and Personal Health Informatics, Flinders University, Adelaide, South Australia, Australia
| | - Geoff Schrader
- Digital Psychiatry and Personal Health Informatics, Flinders University, Adelaide, South Australia, Australia.,Country Health SA Local Health Network, Adelaide, South Australia, Australia
| | - Jörg Strobel
- Digital Psychiatry and Personal Health Informatics, Flinders University, Adelaide, South Australia, Australia.,Country Health SA Local Health Network, Adelaide, South Australia, Australia
| | | | - Yasmin van Kasteren
- Digital Psychiatry and Personal Health Informatics, Flinders University, Adelaide, South Australia, Australia
| | - Niranjan Bidargaddi
- Digital Psychiatry and Personal Health Informatics, Flinders University, Adelaide, South Australia, Australia
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Gjestsen MT, Wiig S, Testad I. Health Care Personnel's Perspective on Potential Electronic Health Interventions to Prevent Hospitalizations for Older Persons Receiving Community Care: Qualitative Study. J Med Internet Res 2020; 22:e12797. [PMID: 31895045 PMCID: PMC6966552 DOI: 10.2196/12797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/30/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
Background The use of electronic health (eHealth) interventions is suggested to help monitor and treat degenerative and chronic diseases through the use of sensors, alarms, and reminders and can potentially prevent hospitalizations for home-dwelling older persons receiving community care. It is increasingly recognized that the health care personnel’s acceptance of a technological application remains a key challenge in adopting an intervention, thus interventions must be perceived to be useful and fit for purpose by the actual users. Objective The aim of this study was to identify and explore the perspectives of managers and health care personnel in community care regarding the use of eHealth interventions in terms of prevention of hospitalizations for home-dwelling older persons receiving community care. Methods A case study with a qualitative approach was carried out in community care in a Norwegian municipality, comprising individual interviews and focus group interviews. A total of 5 individual interviews and 2 focus group interviews (n=12) were undertaken to provide the health care personnel’s and managers’ perspective regarding the use of eHealth interventions, which could potentially prevent hospitalizations for home-dwelling older persons receiving community care. Data were analyzed by way of systematic text condensation, as described by Malterud. Results The data analysis of focus group interviews and individual interviews resulted in 2 categories: potential technological applications and potential patient groups. Discussions in the focus groups generated several suggestions and wishes related to technical applications that they could make use of in their day-to-day practice. The health care personnel warranted tools and measures to enhance and document their clinical observations in contact with patients. They also identified patient groups, such as patients with chronic obstructive pulmonary disease or dehydration or urinary tract infections, for whom hospitalizations could potentially have been prevented. Conclusions We have shown that the health care personnel in community care warrant various technological applications that have the potential to improve quality of care and resource utilization in the studied municipality. We have identified needs and important matters in practice, which are paramount for acceptance and adoption of an intervention in community care.
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Affiliation(s)
| | - Siri Wiig
- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Ingelin Testad
- Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway.,Exeter University Medical School, Exeter University, Exeter, United Kingdom
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Khalifa M, Magrabi F, Gallego B. Developing a framework for evidence-based grading and assessment of predictive tools for clinical decision support. BMC Med Inform Decis Mak 2019; 19:207. [PMID: 31664998 PMCID: PMC6820933 DOI: 10.1186/s12911-019-0940-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/16/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Clinical predictive tools quantify contributions of relevant patient characteristics to derive likelihood of diseases or predict clinical outcomes. When selecting predictive tools for implementation at clinical practice or for recommendation in clinical guidelines, clinicians are challenged with an overwhelming and ever-growing number of tools, most of which have never been implemented or assessed for comparative effectiveness. To overcome this challenge, we have developed a conceptual framework to Grade and Assess Predictive tools (GRASP) that can provide clinicians with a standardised, evidence-based system to support their search for and selection of efficient tools. METHODS A focused review of the literature was conducted to extract criteria along which tools should be evaluated. An initial framework was designed and applied to assess and grade five tools: LACE Index, Centor Score, Well's Criteria, Modified Early Warning Score, and Ottawa knee rule. After peer review, by six expert clinicians and healthcare researchers, the framework and the grading of the tools were updated. RESULTS GRASP framework grades predictive tools based on published evidence across three dimensions: 1) Phase of evaluation; 2) Level of evidence; and 3) Direction of evidence. The final grade of a tool is based on the highest phase of evaluation, supported by the highest level of positive evidence, or mixed evidence that supports a positive conclusion. Ottawa knee rule had the highest grade since it has demonstrated positive post-implementation impact on healthcare. LACE Index had the lowest grade, having demonstrated only pre-implementation positive predictive performance. CONCLUSION GRASP framework builds on widely accepted concepts to provide standardised assessment and evidence-based grading of predictive tools. Unlike other methods, GRASP is based on the critical appraisal of published evidence reporting the tools' predictive performance before implementation, potential effect and usability during implementation, and their post-implementation impact. Implementing the GRASP framework as an online platform can enable clinicians and guideline developers to access standardised and structured reported evidence of existing predictive tools. However, keeping GRASP reports up-to-date would require updating tools' assessments and grades when new evidence becomes available, which can only be done efficiently by employing semi-automated methods for searching and processing the incoming information.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Farah Magrabi
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Blanca Gallego
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Centre for Big Data Research in Health, Faculty of Medicine, Univerisity of New South Wales, Sydney, Australia
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Tawfik H, Anya O. Evaluating practice-centered awareness in cross-boundary telehealth decision support systems. TELEMATICS AND INFORMATICS 2015. [DOI: 10.1016/j.tele.2014.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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A sociotechnical perspective of health information technology. Int J Med Inform 2013; 82:1133-5. [PMID: 24216291 DOI: 10.1016/j.ijmedinf.2013.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 10/16/2013] [Indexed: 11/24/2022]
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Li J, Westbrook J, Callen J, Georgiou A, Braithwaite J. The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study. BMC Health Serv Res 2013; 13:356. [PMID: 24053508 PMCID: PMC3848906 DOI: 10.1186/1472-6963-13-356] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 09/17/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation. METHODS A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes. RESULTS The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance. CONCLUSIONS Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.
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Affiliation(s)
- Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Joanne Callen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Jeffrey Braithwaite
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
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Li J, Westbrook J, Callen J, Georgiou A. The role of ICT in supporting disruptive innovation: a multi-site qualitative study of nurse practitioners in emergency departments. BMC Med Inform Decis Mak 2012; 12:27. [PMID: 22462409 PMCID: PMC3359193 DOI: 10.1186/1472-6947-12-27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 04/02/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments. METHODS A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes. RESULTS The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care. CONCLUSIONS ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.
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Affiliation(s)
- Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Joanne Callen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, NSW 2052, Australia
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