Factors impacting clinical data and documentation quality in Australian aged care and disability services: a user-centred perspective

BACKGROUND

Research has highlighted a need to improve the quality of clinical documentation and data within aged care and disability services in Australia to support improved regulatory reporting and ensure quality and safety of services. However, the specific causes of data quality issues within aged care and disability services and solutions for optimisation are not well understood.

OBJECTIVES

This study explored aged care and disability workforce (referred to as 'data-users') experiences and perceived root causes of clinical data quality issues at a large aged care and disability services provider in Western Australia, to inform optimisation solutions.

METHODS

A purposive sample of n = 135 aged care and disability staff (including community-based and residential-based) in clinical, care, administrative and/or management roles participated in semi-structured interviews and web-based surveys. Data were analysed using an inductive thematic analysis method, where themes and subthemes were derived.

RESULTS

Eight overarching causes of data and documentation quality issues were identified: (1) staff-related challenges, (2) education and training, (3) external barriers, (4) operational guidelines and procedures, (5) organisational practices and culture, (6) technological infrastructure, (7) systems design limitations, and (8) systems configuration-related challenges.

CONCLUSION

The quality of clinical data and documentation within aged care and disability services is influenced by a complex interplay of internal and external factors. Coordinated and collaborative effort is required between service providers and the wider sector to identify behavioural and technical optimisation solutions to support safe and high-quality care and improved regulatory reporting.

Optimising the quality of clinical data in an Australian aged care and disability service to improve care delivery and clinical outcomes (OPTIMISE): Protocol for an Agile Lean Six Sigma study

BACKGROUND

In Australia, aged care and disability service providers are legally required to maintain comprehensive and accurate clinical documentation to meet regulatory and funding requirements and to support safe and high quality care provision. However, evidence suggests poor quality clinical data and documentation is widespread across the sector and can significantly affect clinical decision-making and care delivery and increase business costs.

OBJECTIVE

The OPTIMISE study uses an Agile Lean Six Sigma framework to: 1) identify opportunities for optimisation of clinical documentation processes and clinical information systems, 2) implement and test optimisation solutions, and 3) evaluate outcomes post-optimisation, in a large post-acute community-based health service providing aged care and disability services in Western Australia.

METHODS

A three-stage prospective optimisation study will be undertaken. Stage 1 (Baseline) will measure existing clinical data quality, identify root causes of data quality issues across services, and generate optimisation solutions. Stage 2 (Optimisation) will implement and test changes to clinical documentation processes and information systems using incremental Agile sprints, and Stage 3 (Evaluation) will evaluate change in primary and secondary outcomes from baseline to 12 months post-optimisation. The primary outcome is data quality measured in terms of Defects Per Unit (DPU), Defects Per Million Opportunities (DPMO) and Sigma level. Secondary outcomes are care delivery (direct care time), clinical incidents, business outcomes (cost of quality, workforce productivity), and user satisfaction. Case studies will be analysed to understand impacts of optimisation on clinical outcomes and business processes.

RESULTS

As of 1 June 2022, Stage 1 commenced with baseline data quality audits conducted to measure current data quality. Baseline data quality audits will be followed by user consultations to identify root causes of data quality issues. Optimisation solutions will be developed by January 2023 to inform optimisation (Stage 2) and evaluation (Stage 3).

CONCLUSIONS

Study findings will be of interest to individuals and organisations in the healthcare sector seeking novel solutions to improve the quality of clinical data and support high quality care delivery and reduce business costs.

CLINICALTRIAL

N/A.

The contribution of electronic health records to risk management through accreditation of residential aged care homes in Australia

Background

The Australian government has implemented a compulsory aged care accreditation system to guide and monitor the risk management approach in registered residential aged care (RAC) homes. This research assessed the contribution of electronic health records (EHR) to risk management in RAC homes in relation to the extent that aged care accreditation fulfils its role.

Methods

A convenience sample of 5560 aged care accreditation reports published from 2011 to 2018 was manually downloaded from the Accreditation Agency web site. A mixed-method approach of text data mining and manual content analysis was used to identify any significant differences in failure to meet accreditation outcomes among the RAC homes. This took account of whether EHR or paper records were used, year of accreditation, and size and location of the homes.

Results

It appears that aged care accreditation was focused on structure and process, with limited attention to outcome. There was a big variation between homes in their use of measurement indicators to assess accreditation outcomes. No difference was found in outcomes between RAC homes using EHR and those using paper records. Only 3% of the RAC homes were found to have failed some accreditation outcomes. Failure in monitoring mechanism was the key factor for failing many accreditation outcomes. The top five failed outcomes were Human Resource Management, Clinical Care, Information Systems, Medication Management and Behavioural Management.

Conclusions

Sub-optimal outcomes have limited the effectiveness of accreditation in driving and monitoring risk management for care recipient safety in RAC homes. Although EHR is an important structure and process component for RAC services, it made a limited contribution to risk management for accreditation in Australian RAC homes. Either EHR was not effective, or the accreditation process was not robust enough to recognize its influence. Aged care accreditation in Australia needs to develop further outcome-based measures that are supported by robust data infrastructure and clear guidance.

Advancing health information technology roadmaps in long term care

BACKGROUND

Our purpose is to provide evidence that health information technology should be a mainstay of all future health and social support services for older people globally, both within and across community and residential care services.

METHODS

This work was conducted in two phases. In phase I, the authors conducted a focused exploration by selecting a convenience sample of four long term care health information technology roadmaps, developed by members of four different long term care health information technology collaboratives in United States, Australia, United Kingdom, and New Zealand. During Phase II the research team carried out an extensive systematic review of existing literature sources (2000-2018) to support roadmap assumptions.

RESULTS

Using converging domains and content, we offer recommendations among five aged care roadmap domains: Strategy/Vision, Continuing Care Community, Services and Support Provided, External Clinical Support, and Administrative. Within these domains we provide recommendations in five content areas: Innovation, Policy, Evaluation, Delivery Systems and Human Resources. We recommend future strategies for LTC HIT roadmaps that include 61 emphasis areas in aged care in these content areas and domains.

CONCLUSIONS

The roadmap provides a navigation tool for LTC leaders to take a strategic and comprehensive approach as they harness the potential of health information technologies to address the challenges and opportunities of LTC in the future.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.

Impact of Electronic Health Records on Long-Term Care Facilities: Systematic Review

BACKGROUND

Long-term care (LTC) facilities are an important part of the health care industry, providing care to the fastest-growing group of the population. However, the adoption of electronic health records (EHRs) in LTC facilities lags behind other areas of the health care industry. One of the reasons for the lack of widespread adoption in the United States is that LTC facilities are not eligible for incentives under the Meaningful Use program. Implementation of an EHR system in an LTC facility can potentially enhance the quality of care, provided it is appropriately implemented, used, and maintained. Unfortunately, the lag in adoption of the EHR in LTC creates a paucity of literature on the benefits of EHR implementation in LTC facilities.

OBJECTIVE

The objective of this systematic review was to identify the potential benefits of implementing an EHR system in LTC facilities. The study also aims to identify the common conditions and EHR features that received favorable remarks from providers and the discrepancies that needed improvement to build up momentum across LTC settings in adopting this technology.

METHODS

The authors conducted a systematic search of PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and MEDLINE databases. Papers were analyzed by multiple referees to filter out studies not germane to our research objective. A final sample of 28 papers was selected to be included in the systematic review.

RESULTS

Results of this systematic review conclude that EHRs show significant improvement in the management of documentation in LTC facilities and enhanced quality outcomes. Approximately 43% (12/28) of the papers reported a mixed impact of EHRs on the management of documentation, and 33% (9/28) of papers reported positive quality outcomes using EHRs. Surprisingly, very few papers demonstrated an impact on patient satisfaction, physician satisfaction, the length of stay, and productivity using EHRs.

CONCLUSIONS

Overall, implementation of EHRs has been found to be effective in the few LTC facilities that have implemented them. Implementation of EHRs in LTC facilities caused improved management of clinical documentation that enabled better decision making.

Effect of an electronic medication administration record application on patient safety

RATIONALE, AIMS, AND OBJECTIVES

To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR).

METHODS

A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause. The two pharmacists independently classified the ME-MARs. In the case of disagreement, a research team examined the ME-MARs and categorized them by consensus. Three classifications were used: A classic medication error taxonomy and 2 technology-induced error taxonomies.

RESULTS

The pharmacists analysed 2835 (pre-) and 2621 (post-) medication administration records (MAR), respectively. Overall, the ME-MAR rate decreased from 48.0% (pre-) to 36.9% (post-) (P < .05). The same types of ME-MAR were observed in both phases except for "MAR with incomplete information," which was not observed in the postimplementation phase. In both phases, the most frequent ME-MAR was "MAR at the wrong time" (MAR before or after medication administration) (31.6% vs 30.2%). The main cause of ME-MARs in both phases was the failure to follow work procedures. The potential future risk of ME-MARs significantly decreased after the eMAR implementation (P < .05). All ME-MARs were "use errors" because of human factors. New ME-MARs (1.24%; n = 12) were observed in the postimplementation phase.

CONCLUSION

Use of the eMAR application significantly reduces the rate of ME-MAR and their potential risk. The main cause of ME-MAR was the failure to follow work procedures.

Measuring the operational impact of digitized hospital records: a mixed methods study

Background

Digitized (scanned) medical records have been seen as a means for hospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity.

Methods

Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which pre-defined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized.

Results

Four hundred six consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p = 0.016) and a significant difference in consultation times between specialties within hospitals (p = 0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p = 0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p > =0.285) or specialty level (p > =0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (p < =0.010, Δ = 01:50–07:10) and one specialty had a corresponding reduction in time spent searching paper records (p = 0.015, Δ = −00:28). Site B showed a notable increase in direct patient care (p < 0.001, Δ = 04:20–06:00) and time spent searching computer records (p < =0.043, Δ = 00:10–01:40) and reductions in the other time categories.

The focus group confirmed that the most recent clinical letter was a vital document in the patient record, often containing most of the required information. Concerns were expressed about consistency of scanning practice, causing uncertainty about what could be relied upon to exist in the digitized record. Benefits of digitized records included: access from multiple locations, better prepared ward rounds, improved inpatient handovers and an improved timeline of patient events. Limitations of digitized records included: increased complexity of creating a patient summary, display of specialised content such as hand-drawn diagrams, inability to quickly flick through the pages to find relevant content.

Conclusions

Digitized medical records can be implemented without detrimental operational impact. Inherent differences between specialties can outweigh the differences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

From bed to bench: bridging from informatics practice to theory: an exploratory analysis

BACKGROUND

In 2009, Applied Clinical Informatics (ACI)--focused on applications in clinical informatics--was launched as a companion journal to Methods of Information in Medicine (MIM). Both journals are official journals of the International Medical Informatics Association.

OBJECTIVES

To explore which congruencies and interdependencies exist in publications from theory to practice and from practice to theory and to determine existing gaps. Major topics discussed in ACI and MIM were analyzed. We explored if the intention of publishing companion journals to provide an information bridge from informatics theory to informatics practice and vice versa could be supported by this model. In this manuscript we will report on congruencies and interdependences from practice to theory and on major topics in MIM.

METHODS

Retrospective, prolective observational study on recent publications of ACI and MIM. All publications of the years 2012 and 2013 were indexed and analyzed.

RESULTS

Hundred and ninety-six publications were analyzed (ACI 87, MIM 109). In MIM publications, modelling aspects as well as methodological and evaluation approaches for the analysis of data, information, and knowledge in biomedicine and health care were frequently raised - and often discussed from an interdisciplinary point of view. Important themes were ambient-assisted living, anatomic spatial relations, biomedical informatics as scientific discipline, boosting, coding, computerized physician order entry, data analysis, grid and cloud computing, health care systems and services, health-enabling technologies, health information search, health information systems, imaging, knowledge-based decision support, patient records, signal analysis, and web science. Congruencies between journals could be found in themes, but with a different focus on content. Interdependencies from practice to theory, found in these publications, were only limited.

CONCLUSIONS

Bridging from informatics theory to practice and vice versa remains a major component of successful research and practice as well as a major challenge.

From bench to bed: bridging from informatics theory to practice. An exploratory analysis

BACKGROUND

In 2009, the journal Applied Clinical Informatics (ACI) commenced publication. Focused on applications in clinical informatics, ACI was intended to be a companion journal to METHODS of Information in Medicine (MIM). Both journals are official journals of IMIA, the International Medical Informatics Association.

OBJECTIVES

To explore, after five years, which congruencies and interdependencies exist in publications of these journals and to determine if gaps exist. To achieve this goal, major topics discussed in ACI and in MIM had to be analysed. Finally, we wanted to explore, whether the intention of publishing these companion journals to provide an information bridge from informatics theory to informatics practice and from practice to theory could be supported by this model. In this manuscript we will report on congruencies and interdependencies from practise to theory and on major topis in ACI. Further results will be reported in a second paper.

METHODS

Retrospective, prolective observational study on recent publications of ACI and MIM. All publications of the years 2012 and 2013 from these journals were indexed and analysed.

RESULTS

Hundred and ninety-six publications have been analysed (87 ACI, 109 MIM). In ACI publications addressed care coordination, shared decision support, and provider communication in its importance for complex patient care and safety and quality. Other major themes included improving clinical documentation quality and efficiency, effectiveness of clinical decision support and alerts, implementation of health information technology systems including discussion of failures and succeses. An emerging topic in the years analyzed was a focus on health information technology to predict and prevent hospital admissions and managing population health including the application of mobile health technology. Congruencies between journals could be found in themes, but with different focus in its contents. Interdependencies from practise to theory found in these publications, were only limited.

CONCLUSIONS

Bridging from informatics theory to practise and vice versa remains a major component of successful research and practise as well as a major challenge.