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Harish V, Ackery A, Grant K, Jamieson T, Mehta S. Cyberattaques contre les systèmes d’information de santé au Canada. CMAJ 2024; 196:E198-E205. [PMID: 38378216 PMCID: PMC10890234 DOI: 10.1503/cmaj.230436-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Affiliation(s)
- Vinyas Harish
- Faculté de médecine Temerty) (Harish), Université de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Harish), École de santé publique Dalla Lana, Université de Toronto; Département de médecine d'urgence (Ackery, Mehta), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département de médecine d'urgence (Grant), Faculté de médecine, Université de la Colombie-Britannique, Vancouver, C.-B.; Département de médecine interne générale (Jamieson), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto; Institut pour des solutions dans les systèmes de santé et les soins virtuels (Jamieson), Hôpital Women's College; Département de médecine d'urgence (Mehta), Hôpital général de North York, Toronto, Ont.
| | - Alun Ackery
- Faculté de médecine Temerty) (Harish), Université de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Harish), École de santé publique Dalla Lana, Université de Toronto; Département de médecine d'urgence (Ackery, Mehta), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département de médecine d'urgence (Grant), Faculté de médecine, Université de la Colombie-Britannique, Vancouver, C.-B.; Département de médecine interne générale (Jamieson), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto; Institut pour des solutions dans les systèmes de santé et les soins virtuels (Jamieson), Hôpital Women's College; Département de médecine d'urgence (Mehta), Hôpital général de North York, Toronto, Ont
| | - Kiran Grant
- Faculté de médecine Temerty) (Harish), Université de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Harish), École de santé publique Dalla Lana, Université de Toronto; Département de médecine d'urgence (Ackery, Mehta), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département de médecine d'urgence (Grant), Faculté de médecine, Université de la Colombie-Britannique, Vancouver, C.-B.; Département de médecine interne générale (Jamieson), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto; Institut pour des solutions dans les systèmes de santé et les soins virtuels (Jamieson), Hôpital Women's College; Département de médecine d'urgence (Mehta), Hôpital général de North York, Toronto, Ont
| | - Trevor Jamieson
- Faculté de médecine Temerty) (Harish), Université de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Harish), École de santé publique Dalla Lana, Université de Toronto; Département de médecine d'urgence (Ackery, Mehta), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département de médecine d'urgence (Grant), Faculté de médecine, Université de la Colombie-Britannique, Vancouver, C.-B.; Département de médecine interne générale (Jamieson), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto; Institut pour des solutions dans les systèmes de santé et les soins virtuels (Jamieson), Hôpital Women's College; Département de médecine d'urgence (Mehta), Hôpital général de North York, Toronto, Ont
| | - Shaun Mehta
- Faculté de médecine Temerty) (Harish), Université de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Harish), École de santé publique Dalla Lana, Université de Toronto; Département de médecine d'urgence (Ackery, Mehta), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto, Toronto, Ont.; Département de médecine d'urgence (Grant), Faculté de médecine, Université de la Colombie-Britannique, Vancouver, C.-B.; Département de médecine interne générale (Jamieson), Hôpital St. Michael, Réseau catholique de soins de santé Unity Health de Toronto; Institut pour des solutions dans les systèmes de santé et les soins virtuels (Jamieson), Hôpital Women's College; Département de médecine d'urgence (Mehta), Hôpital général de North York, Toronto, Ont
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Affiliation(s)
- Vinyas Harish
- Temerty Faculty of Medicine (Harish), University of Toronto; Institute of Health Policy, Management, and Evaluation (Harish), Dalla Lana School of Public Health, University of Toronto; Department of Emergency Medicine (Ackery, Mehta), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Emergency Medicine (Grant), Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of General Internal Medicine (Jamieson), St. Michael's Hospital, Unity Health Toronto; Institute for Health System Solutions and Virtual Care (Jamieson), Women's College Hospital; Department of Emergency Medicine (Mehta), North York General Hospital, Toronto, Ont.
| | - Alun Ackery
- Temerty Faculty of Medicine (Harish), University of Toronto; Institute of Health Policy, Management, and Evaluation (Harish), Dalla Lana School of Public Health, University of Toronto; Department of Emergency Medicine (Ackery, Mehta), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Emergency Medicine (Grant), Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of General Internal Medicine (Jamieson), St. Michael's Hospital, Unity Health Toronto; Institute for Health System Solutions and Virtual Care (Jamieson), Women's College Hospital; Department of Emergency Medicine (Mehta), North York General Hospital, Toronto, Ont
| | - Kiran Grant
- Temerty Faculty of Medicine (Harish), University of Toronto; Institute of Health Policy, Management, and Evaluation (Harish), Dalla Lana School of Public Health, University of Toronto; Department of Emergency Medicine (Ackery, Mehta), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Emergency Medicine (Grant), Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of General Internal Medicine (Jamieson), St. Michael's Hospital, Unity Health Toronto; Institute for Health System Solutions and Virtual Care (Jamieson), Women's College Hospital; Department of Emergency Medicine (Mehta), North York General Hospital, Toronto, Ont
| | - Trevor Jamieson
- Temerty Faculty of Medicine (Harish), University of Toronto; Institute of Health Policy, Management, and Evaluation (Harish), Dalla Lana School of Public Health, University of Toronto; Department of Emergency Medicine (Ackery, Mehta), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Emergency Medicine (Grant), Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of General Internal Medicine (Jamieson), St. Michael's Hospital, Unity Health Toronto; Institute for Health System Solutions and Virtual Care (Jamieson), Women's College Hospital; Department of Emergency Medicine (Mehta), North York General Hospital, Toronto, Ont
| | - Shaun Mehta
- Temerty Faculty of Medicine (Harish), University of Toronto; Institute of Health Policy, Management, and Evaluation (Harish), Dalla Lana School of Public Health, University of Toronto; Department of Emergency Medicine (Ackery, Mehta), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Emergency Medicine (Grant), Faculty of Medicine, University of British Columbia, Vancouver, BC; Department of General Internal Medicine (Jamieson), St. Michael's Hospital, Unity Health Toronto; Institute for Health System Solutions and Virtual Care (Jamieson), Women's College Hospital; Department of Emergency Medicine (Mehta), North York General Hospital, Toronto, Ont
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Yip M, Ackery A, Jamieson T, Mehta S. The Priorities of End Users of Emergency Department Electronic Health Records: Modified Delphi Study. JMIR Hum Factors 2023; 10:e43103. [PMID: 36897633 DOI: 10.2196/43103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/16/2023] [Accepted: 02/11/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND The needs of the emergency department (ED) pose unique challenges to modern electronic health record (EHR) systems. A diverse case load of high-acuity, high-complexity presentations, and ambulatory patients, all requiring multiple transitions of care, creates a rich environment through which to critically examine EHRs. OBJECTIVE This investigation aims to capture and analyze the perspective of end users of EHR about the strengths, limitations, and future priorities for EHR in the setting of the ED. METHODS In the first phase of this investigation, a literature search was conducted to identify 5 key usage categories of ED EHRs. Using key usage categories in the first phase, a modified Delphi study was conducted with a group of 12 panelists with expertise in both emergency medicine and health informatics. Across 3 rounds of surveys, panelists generated and refined a list of strengths, limitations, and key priorities. RESULTS The findings from this investigation highlighted the preference of panelists for features maximizing functionality of basic clinical features relative to features of disruptive innovation. CONCLUSIONS By capturing the perspectives of end users in the ED, this investigation highlights areas for the improvement or development of future EHRs in acute care settings.
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Affiliation(s)
- Matthew Yip
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- The Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Alun Ackery
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
| | - Shaun Mehta
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, North York General Hospital, North York, ON, Canada
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Dainty KN, Seaton MB, Estacio A, Hicks LK, Jamieson T, Ward S, Yu CH, Mosko JD, Kassardjian CD. Virtual Specialist Care during the COVID-19 Pandemic: A Multi-Method Study of Patient Experience. JMIR Med Inform 2022; 10:e37196. [PMID: 35482950 PMCID: PMC9239568 DOI: 10.2196/37196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Transitioning nonemergency, ambulatory medical care to virtual visits in light of the COVID-19 global pandemic has been a massive shift in philosophy and practice that naturally came with a steep learning curve for patients, physicians, and clinic administrators. Objective We undertook a multimethod study to understand the key factors associated with successful and less successful experiences of virtual specialist care, particularly as they relate to the patient experience of care. Methods This study was designed as a multimethod patient experience study using survey methods, descriptive qualitative interview methodology, and administrative virtual care data collected by the hospital decision support team. Six specialty departments participated in the study (endoscopy, orthopedics, neurology, hematology, rheumatology, and gastroenterology). All patients who could speak and read English and attended a virtual specialist appointment in a participating clinic at St. Michael’s Hospital (Toronto, Ontario, Canada) between October 1, 2020, and January 30, 2021, were eligible to participate. Results During the study period, 51,702 virtual specialist visits were conducted in the departments that participated in the study. Of those, 96% were conducted by telephone and 4% by video. In both the survey and interview data, there was an overall consensus that virtual care is a satisfying alternative to in-person care, with benefits such as reduced travel, cost, time, and SARS-CoV-2 exposure, and increased convenience. Our analysis further revealed that the specific reason for the visit and the nature and status of the medical condition are important considerations in terms of guidance on where virtual care is most effective. Technology issues were not reported as a major challenge in our data, given that the majority of “virtual” visits reported by our participants were conducted by telephone, which is an important distinction. Despite the positive value of virtual care discussed by the majority of interview participants, 50% of the survey respondents still indicated they would prefer to see their physician in person. Conclusions Patient experience data collected in this study indicate a high level of satisfaction with virtual specialty care, but also signal that there are nuances to be considered to ensure it is an appropriate and sustainable part of the standard of care.
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Affiliation(s)
- Katie N Dainty
- North York General Hospital, 4001 Leslie StreetLE-140, Toronto, CA
| | - M Bianca Seaton
- North York General Hospital, 4001 Leslie StreetLE-140, Toronto, CA
| | | | - Lisa K Hicks
- Unity Health - St. Michael's Hospital, Toronto, CA
| | | | - Sarah Ward
- Unity Health - St. Michael's Hospital, Toronto, CA
| | | | - Jeff D Mosko
- Unity Health - St. Michael's Hospital, Toronto, CA
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Jamieson T, Zarn D. Interoperability: A National Person-Centred View. Healthc Pap 2022; 20:44-49. [PMID: 36433907 DOI: 10.12927/hcpap.2022.26962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We respond to Falk's (2022) recent recommendations around interoperability. Although we applaud the notion that the health data of Canadians be usable - that is, machine interpretable - and widely clinically available, Falk's (2022) recommendations must be extended. Specifically, interoperability must centre on the person and people's rights to hold and control a usable copy of their health information for their own purposes. Also, we must acknowledge that Canada is a small global market and avoid internal fragmentation with competing jurisdictional standards. Our national strategy must align with major trading partners. To do otherwise will disenfranchise Canadians and our digital health innovators.
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Affiliation(s)
- Trevor Jamieson
- Chief Medical Informatics Officer, Unity Health Toronto, Toronto, ON
| | - Denise Zarn
- Innovation Fellow, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
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Soobiah C, Phung M, Tadrous M, Jamieson T, Bhatia RS, Desveaux L. Understanding Engagement and the Potential Impact of an Electronic Drug Repository: Multi-Methods Study. JMIR Form Res 2022; 6:e27158. [PMID: 35353042 PMCID: PMC9008523 DOI: 10.2196/27158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 08/06/2021] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Centralized drug repositories can reduce adverse events and inappropriate prescriptions by enabling access to dispensed medication data at the point of care; however, how they achieve this goal is largely unknown. OBJECTIVE This study aims to understand the perceived clinical value; the barriers to and enablers of adoption; and the clinician groups for which a provincial, centralized drug repository may provide the most benefit. METHODS A mixed methods approach, including a web-based survey and semistructured interviews, was used. Participants were clinicians (eg, nurses, physicians, and pharmacists) in Ontario who were eligible to use the digital health drug repository (DHDR), irrespective of actual use. Survey data were ranked on a 7-point adjectival scale and analyzed using descriptive statistics, and interviews were analyzed using qualitative descriptions. RESULTS Of the 161 survey respondents, only 40 (24.8%) actively used the DHDR. Perceptions of the utility of the DHDR were neutral (mean scores ranged from 4.11 to 4.76). Of the 75.2% (121/161) who did not use the DHDR, 97.5% (118/121) rated access to medication information (eg, dose, strength, and frequency) as important. Reasons for not using the DHDR included the cumbersome access process and the perception that available data were incomplete or inaccurate. Of the 33 interviews completed, 26 (79%) were active DHDR users. The DHDR was a satisfactory source of secondary information; however, the absence of medication instructions and prescribed medications (which were not dispensed) limited its ability to provide a comprehensive profile to meaningfully support clinical decision-making. CONCLUSIONS Digital drug repositories must be adjusted to align with the clinician's needs to provide value. Ensuring integration with point-of-care systems, comprehensive clinical data, and streamlined onboarding processes would optimize clinically meaningful use. The electronic provision of accessible drug information to providers across health care settings has the potential to improve efficiency and reduce medication errors.
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Affiliation(s)
- Charlene Soobiah
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michelle Phung
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Mina Tadrous
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Unity Health Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Laura Desveaux
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
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Abstract
Current public health measures catalyzed a large shift to virtual care, resulting in a great uptake in telephone and video-enabled care. While pre-pandemic public healthcare funding rarely covered the telephone as a reimbursable care delivery model, it has proven a crucial offering for many populations. As the new standard of virtual service delivery is being solidified, simple technological solutions that provide access to care must continue to be supported. This paper explores an important consequence of relying on complex technologies as the new standard of virtual care: the risk of exacerbating health disparities by enabling a deeper digital divide for marginalized populations.
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Affiliation(s)
- Tyla Thomas-Jacques
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, University of Toronto, Toronto, Canada.
| | - Trevor Jamieson
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, University of Toronto, Toronto, Canada.,Department of Medicine, Unity Health Toronto, Toronto, Canada
| | - James Shaw
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, University of Toronto, Toronto, Canada.,Joint Centre for Bioethics, University of Toronto, Toronto, Canada
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Fujioka JK, Bickford J, Gritke J, Stamenova V, Jamieson T, Bhatia RS, Desveaux L. Implementation Strategies to Improve Engagement With a Multi-Institutional Patient Portal: Multimethod Study. J Med Internet Res 2021; 23:e28924. [PMID: 34709195 PMCID: PMC8587179 DOI: 10.2196/28924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Comprehensive multi-institutional patient portals that provide patients with web-based access to their data from across the health system have been shown to improve the provision of patient-centered and integrated care. However, several factors hinder the implementation of these portals. Although barriers and facilitators to patient portal adoption are well documented, there is a dearth of evidence examining how to effectively implement multi-institutional patient portals that transcend traditional boundaries and disparate systems. Objective This study aims to explore how the implementation approach of a multi-institutional patient portal impacted the adoption and use of the technology and to identify the lessons learned to guide the implementation of similar patient portal models. Methods This multimethod study included an analysis of quantitative and qualitative data collected during an evaluation of the multi-institutional MyChart patient portal that was deployed in Southwestern Ontario, Canada. Descriptive statistics were performed to understand the use patterns during the first 15 months of implementation (between August 2018 and October 2019). In addition, 42 qualitative semistructured interviews were conducted with 18 administrative stakeholders, 16 patients, 7 health care providers, and 1 informal caregiver to understand how the implementation approach influenced user experiences and to identify strategies for improvement. Qualitative data were analyzed using an inductive thematic analysis approach. Results Between August 2018 and October 2019, 15,271 registration emails were sent, with 67.01% (10,233/15,271) registered for an account across 38 health care sites. The median number of patients registered per site was 19, with considerable variation (range 1-2114). Of the total number of sites, 55% (21/38) had ≤30 registered patients, whereas only 2 sites had over 1000 registered patients. Interview participants perceived that the patient experience of the portal would have been improved by enhancing the data comprehensiveness of the technology. They also attributed the lack of enrollment to the absence of a broad rollout and marketing strategy across sites. Participants emphasized that provider engagement, change management support, and senior leadership endorsement were central to fostering uptake. Finally, many stated that regional alignment and policy support should have been sought to streamline implementation efforts across participating sites. Conclusions Without proper management and planning, multi-institutional portals can suffer from minimal adoption. Data comprehensiveness is the foundational component of these portals and requires aligned policies and a key base of technology infrastructure across all participating sites. It is important to look beyond the category of the technology (ie, patient portal) and consider its functionality (eg, data aggregation, appointment scheduling, messaging) to ensure that it aligns with the underlying strategic priorities of the deployment. It is also critical to establish a clear vision and ensure buy-ins from organizational leadership and health care providers to support a cultural shift that will enable a meaningful and widespread engagement.
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Affiliation(s)
- Jamie Keiko Fujioka
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | | | | | - Vess Stamenova
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Desveaux L, Kelley LT, Bhatia RS, Jamieson T. Catalyzing Digital Health Innovation in Ontario: The Role of an Academic Medical Centre. ACTA ACUST UNITED AC 2021; 16:55-68. [PMID: 33337314 DOI: 10.12927/hcpol.2020.26353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Overcoming barriers to health system innovation is an ongoing challenge in Canada. A total of 51 participants attended a digital health symposium in October 2017 to discuss the role of an academic medical centre (AMC) in advancing innovation. The conversation centred around (i) the current state of innovation in healthcare; (ii) the need for an innovation catalyst; and (iii) the roadmap for an AMC to drive change. AMCs can address the barriers to digital health innovation in Canada by providing a centralized network and infrastructure that supports innovation throughout its journey from "bench to bedside" as well as supporting educational reform.
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Affiliation(s)
- Laura Desveaux
- Scientist, Women's College Hospital, Institute for Health Systems Solutions and Virtual Care, Women's College Hospital; Assistant Professor, Institute for Health Policy Management & Evaluation, University of Toronto, Toronto, ON
| | - Leah T Kelley
- Research Coordinator, Women's College Hospital, Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON
| | - R Sacha Bhatia
- Director, Women's College Hospital, Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Cardiologist, Women's College Hospital, University Health Network, Toronto, ON
| | - Trevor Jamieson
- Chief Medical Informatics Officer, Unity Health Toronto, St. Michael's Hospital Site; Medical Director, Virtual Hospital, Women's College Hospital, Toronto, ON
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Bradley-Ridout G, Nekolaichuk E, Jamieson T, Jones C, Morson N, Chuang R, Springall E. UpToDate versus DynaMed: a cross-sectional study comparing the speed and accuracy of two point-of-care information tools. J Med Libr Assoc 2021; 109:382-387. [PMID: 34629966 PMCID: PMC8485969 DOI: 10.5195/jmla.2021.1176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To compare the accuracy, time to answer, user confidence, and user satisfaction between UpToDate and DynaMed (formerly DynaMed Plus), which are two popular point-of-care information tools. Methods: A crossover study was conducted with medical residents in obstetrics and gynecology and family medicine at the University of Toronto in order to compare the speed and accuracy with which they retrieved answers to clinical questions using UpToDate and DynaMed. Experiments took place between February 2017 and December 2019. Following a short tutorial on how to use each tool and completion of a background survey, participants attempted to find answers to two clinical questions in each tool. Time to answer each question, the chosen answer, confidence score, and satisfaction score were recorded for each clinical question. Results: A total of 57 residents took part in the experiment, including 32 from family medicine and 25 from obstetrics and gynecology. Accuracy in clinical answers was equal between UpToDate (average 1.35 out of 2) and DynaMed (average 1.36 out of 2). However, time to answer was 2.5 minutes faster in UpToDate compared to DynaMed. Participants were also more confident and satisfied with their answers in UpToDate compared to DynaMed. Conclusions: Despite a preference for UpToDate and a higher confidence in responses, the accuracy of clinical answers in UpToDate was equal to those in DynaMed. Previous exposure to UpToDate likely played a major role in participants' preferences. More research in this area is recommended.
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Affiliation(s)
- Glyneva Bradley-Ridout
- , Gerstein Science Information Center, University of Toronto Libraries, University of Toronto, Canada
| | - Erica Nekolaichuk
- , Gerstein Science Information Center, University of Toronto Libraries, University of Toronto, Canada
| | - Trevor Jamieson
- , Department of Medicine, University of Toronto, Division of General Internal Medicine, Unity Health Toronto, Canada
| | - Claire Jones
- , Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Fertility, Sinai Health System, Toronto, Canada
| | - Natalie Morson
- , Department of Family and Community Medicine, University of Toronto, Mount Sinai Academic Family Health Team, Sinai Health System, Toronto, Canada
| | - Rita Chuang
- , Department of Obstetrics and Gynaecology, University of Toronto, Canada
| | - Elena Springall
- , Gerstein Science Information Center, University of Toronto Libraries, University of Toronto, Canada
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Husain A, Cohen E, Dubrowski R, Jamieson T, Kurahashi AM, Lokuge B, Rapoport A, Saunders S, Stasiulis E, Stinson J, Subramaniam S, Wegier P, Barwick M. A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study. J Med Internet Res 2021; 23:e25505. [PMID: 33656445 PMCID: PMC8294640 DOI: 10.2196/25505] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/24/2020] [Accepted: 01/22/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record. OBJECTIVE The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. METHODS The study was a hybrid type II mixed methods design to simultaneously evaluate Loop's clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system. RESULTS We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop's potential value for engaging the patient and caregiver, and for improving communication within the patient's circle of care, Loop's relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. CONCLUSIONS Fundamental structural and implementation challenges persist toward realizing Loop's potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.
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Affiliation(s)
- Amna Husain
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada.,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Eyal Cohen
- Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Raluca Dubrowski
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Trevor Jamieson
- Department of Medicine, Unity Health Toronto, Toronto, ON, Canada
| | | | - Bhadra Lokuge
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada
| | - Adam Rapoport
- Pediatric Advanced Care Team, The Hospital for Sick Children, Toronto, ON, Canada.,Emily's House Children's Hospice, Toronto, ON, Canada
| | - Stephanie Saunders
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada.,School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Elaine Stasiulis
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jennifer Stinson
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Melanie Barwick
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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12
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Kelley LT, Fujioka J, Liang K, Cooper M, Jamieson T, Desveaux L. Barriers to Creating Scalable Business Models for Digital Health Innovation in Public Systems: Qualitative Case Study. JMIR Public Health Surveill 2020; 6:e20579. [PMID: 33300882 PMCID: PMC7759439 DOI: 10.2196/20579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/22/2020] [Accepted: 09/16/2020] [Indexed: 02/02/2023] Open
Abstract
Background Health systems are increasingly looking toward the private sector to provide digital solutions to address health care demands. Innovation in digital health is largely driven by small- and medium-sized enterprises (SMEs), yet these companies experience significant barriers to entry, especially in public health systems. Complex and fragmented care models, alongside a myriad of relevant stakeholders (eg, purchasers, providers, and producers of health care products), make developing value propositions for digital solutions highly challenging. Objective This study aims to identify areas for health system improvement to promote the integration of innovative digital health technologies developed by SMEs. Methods This paper qualitatively analyzes a series of case studies to identify health system barriers faced by SMEs developing digital health technologies in Canada and proposed solutions to encourage a more innovative ecosystem. The Women’s College Hospital Institute for Health System Solutions and Virtual Care established a consultation program for SMEs to help them increase their innovation capacity and take their ideas to market. The consultation involved the SME filling out an onboarding form and review of this information by an expert advisory committee using guided considerations, leading to a recommendation report provided to the SME. This paper reports on the characteristics of 25 SMEs who completed the program and qualitatively analyzed their recommendation reports to identify common barriers to digital health innovation. Results A total of 2 central themes were identified, each with 3 subthemes. First, a common barrier to system integration was the lack of formal evaluation, with SMEs having limited resources and opportunities to conduct such an evaluation. Second, the health system’s current structure does not create incentives for clinicians to use digital technologies, which threatens the sustainability of SMEs’ business models. SMEs faced significant challenges in engaging users and payers from the public system due to perverse economic incentives. Physicians are compensated by in-person visits, which actively works against the goals of many digital health solutions of keeping patients out of clinics and hospitals. Conclusions There is a significant disconnect between the economic incentives that drive clinical behaviors and the use of digital technologies that would benefit patients’ well-being. To encourage the use of digital health technologies, publicly funded health systems need to dedicate funding for the evaluation of digital solutions and streamlined pathways for clinical integration.
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Affiliation(s)
- Leah Taylor Kelley
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie Fujioka
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Kyle Liang
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Madeline Cooper
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | | | - Laura Desveaux
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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13
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Soobiah C, Phung M, Tadrous M, Bhatia S, Jamieson T, Desveaux L. Exploring the Impact of the Digital Health Drug Repository in Ontario. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- C. Soobiah
- Womens' College Hospital Institute for Health System Solutions and Virtual Care Toronto ON Canada
| | - M. Phung
- Women's College Hospital Toronto ON Canada
| | - M. Tadrous
- Women's College Hospital Toronto ON Canada
| | - S. Bhatia
- Women's College Hospital Toronto ON Canada
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14
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Wickerson L, Fujioka JK, Kishimoto V, Jamieson T, Fine B, Bhatia RS, Desveaux L. Utility and Perceived Value of a Provincial Digital Diagnostic Imaging Repository: Multimethod Study. JMIR Form Res 2020; 4:e17220. [PMID: 32459644 PMCID: PMC7418016 DOI: 10.2196/17220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/23/2020] [Accepted: 04/08/2020] [Indexed: 12/03/2022] Open
Abstract
Background Timely and comprehensive diagnostic image sharing across institutional and regional boundaries can produce multiple benefits while supporting integrated models of care. In Ontario, Canada, the Diagnostic Imaging Common Service (DICS) was created as a centralized imaging repository to enable the sharing and viewing of diagnostic images and associated reports across hospital-based and community-based clinicians throughout the province. Objective The aims of this study were as follows: (1) to explore real-world utilization and perceived clinical value of the DICS following the provision of system-wide access and (2) to identify strategies to optimize the technology platform functionality and encourage adoption. Methods This multimethod study included semistructured interviews with physicians and administrative stakeholders and descriptive analysis of the
current DICS usage data. Results In this study, 41 participants were interviewed, that is, 34 physicians and 7 administrative stakeholders. The following 4 key themes emerged: (1) utilization of the DICS depended on the awareness of the technology and the preferred channels for accessing images, which varied widely, (2) clinical responsibilities and available institutional resources were the drivers of utilization (or lack thereof), (3) centralized image repositories were perceived to offer value at the patient, clinician, and health care system levels, and (4) the enabling factors to realize value included aspects of technology infrastructure (ie, available functionality) alongside policy supports. High-volume DICS usage was not evenly distributed throughout the province. Conclusions Suboptimal adoption of the DICS was driven by poor awareness and variations in the clinical workflow. Alignment with physician workflow, policy supports, and investment in key technological features and infrastructure would improve functionality and data comprehensiveness, thereby optimizing health system performance, patient and provider experience, population health, and health care costs.
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Affiliation(s)
- Lisa Wickerson
- University Health Network, Toronto, ON, Canada.,Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie K Fujioka
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Vanessa Kishimoto
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ben Fine
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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15
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Mehta S, Jamieson T, Ackery AD. Helping clinicians and patients navigate electronic patient portals: ethical and legal principles. CMAJ 2020; 191:E1100-E1104. [PMID: 31591096 DOI: 10.1503/cmaj.190413] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- S Mehta
- Division of Emergency Medicine (Mehta, Ackery), Department of Medicine, University of Toronto; Division of General Internal Medicine (Jamieson), St. Michael's Hospital; Institute for Health System Solutions and Virtual Care (WIHV) (Jamieson), Women's College Hospital; Department of Emergency Medicine (Ackery), St. Michael's Hospital, Toronto, Ont
| | - T Jamieson
- Division of Emergency Medicine (Mehta, Ackery), Department of Medicine, University of Toronto; Division of General Internal Medicine (Jamieson), St. Michael's Hospital; Institute for Health System Solutions and Virtual Care (WIHV) (Jamieson), Women's College Hospital; Department of Emergency Medicine (Ackery), St. Michael's Hospital, Toronto, Ont
| | - A D Ackery
- Division of Emergency Medicine (Mehta, Ackery), Department of Medicine, University of Toronto; Division of General Internal Medicine (Jamieson), St. Michael's Hospital; Institute for Health System Solutions and Virtual Care (WIHV) (Jamieson), Women's College Hospital; Department of Emergency Medicine (Ackery), St. Michael's Hospital, Toronto, Ont.
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16
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Marani H, Halperin IJ, Jamieson T, Mukerji G. Quality Gaps of Electronic Health Records in Diabetes Care. Can J Diabetes 2020; 44:350-355. [DOI: 10.1016/j.jcjd.2019.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/24/2022]
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Abstract
Mobile health (mHealth) is the provision of health or medical services enabled by portable devices. This field is rapidly expanding as the global market for mobile devices grows. mHealth “apps” pose benefits and risks to their users that governments have attempted to address through regulation. There is substantial variability across regulatory bodies in the scope, specificity and robustness of mHealth regulations, with Canada's regulatory framework lacking in two major domains: (1) specificity of existing regulations for mHealth and (2) regulatory clarity for what apps require regulation. If Canada is to be a leader in digital health, it requires a new framework that encourages the growth of an mHealth market that can bring innovative solutions to contemporary healthcare challenges while maximizing user benefits and minimizing harms.
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Affiliation(s)
- Maria Jogova
- Department of MedicineUniversity of Toronto Toronto, ON
| | - James Shaw
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health University of Toronto, Toronto, ON
| | - Trevor Jamieson
- Women's College Hospital Institute for Health System Solutions and Virtual CareWomen's College HospitalDivision of General Internal Medicine, St. Michael's HospitalToronto, ON
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18
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Jamieson T, Mamdani MM, Etchells E. Linking Quality Improvement and Health Information Technology through the QI-HIT Figure 8. Appl Clin Inform 2019; 10:528-533. [PMID: 31340398 DOI: 10.1055/s-0039-1693456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The implementation of health information technology (HIT) is complex. A method for mitigating complexity is incrementalism. Incrementalism forms the foundation of both incremental software development models, like agile, and the Plan-Do-Study-Act cycles (PDSAs) of quality improvement (QI), yet we often fail to be incremental at the union of the disciplines. We propose a new model for HIT implementation that explicitly links incremental software development cycles with PDSAs, the QI-HIT Figure 8 (QIHIT-F8). We then detail a subsequent local HIT implementation where we demonstrated its use. The QIHIT-F8 requires a reprioritization of project management activities around tests of change, strong QI principles to detect these changes, and the presence of both baseline and prospective data about the chosen indicators. These conditions are most likely to be present when applied to indicators of high strategic importance to an organization.
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Affiliation(s)
- Trevor Jamieson
- General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Women's College Hospital Institute for Health Systems Solutions and Virtual Care (WIHV), Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training (LKS-CHART), St Michael's Hospital, Toronto, Ontario, Canada
| | - Edward Etchells
- Centre for Quality Improvement and Patient Safety, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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19
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Shaw J, Rudzicz F, Jamieson T, Goldfarb A. Artificial Intelligence and the Implementation Challenge. J Med Internet Res 2019; 21:e13659. [PMID: 31293245 PMCID: PMC6652121 DOI: 10.2196/13659] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/16/2019] [Accepted: 05/31/2019] [Indexed: 12/13/2022] Open
Abstract
Background Applications of artificial intelligence (AI) in health care have garnered much attention in recent years, but the implementation issues posed by AI have not been substantially addressed. Objective In this paper, we have focused on machine learning (ML) as a form of AI and have provided a framework for thinking about use cases of ML in health care. We have structured our discussion of challenges in the implementation of ML in comparison with other technologies using the framework of Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies (NASSS). Methods After providing an overview of AI technology, we describe use cases of ML as falling into the categories of decision support and automation. We suggest these use cases apply to clinical, operational, and epidemiological tasks and that the primary function of ML in health care in the near term will be decision support. We then outline unique implementation issues posed by ML initiatives in the categories addressed by the NASSS framework, specifically including meaningful decision support, explainability, privacy, consent, algorithmic bias, security, scalability, the role of corporations, and the changing nature of health care work. Results Ultimately, we suggest that the future of ML in health care remains positive but uncertain, as support from patients, the public, and a wide range of health care stakeholders is necessary to enable its meaningful implementation. Conclusions If the implementation science community is to facilitate the adoption of ML in ways that stand to generate widespread benefits, the issues raised in this paper will require substantial attention in the coming years.
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Affiliation(s)
- James Shaw
- Women's College Hospital, Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Frank Rudzicz
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Hospital, Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,St Michael's Hospital, Toronto, ON, Canada
| | - Avi Goldfarb
- Rotman School of Management, University of Toronto, Toronto, ON, Canada
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20
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Hensel JM, Shaw J, Ivers NM, Desveaux L, Vigod SN, Cohen A, Onabajo N, Agarwal P, Mukerji G, Yang R, Nguyen M, Bouck Z, Wong I, Jeffs L, Jamieson T, Bhatia RS. A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial. J Med Internet Res 2019; 21:e10838. [PMID: 31165710 PMCID: PMC6684216 DOI: 10.2196/10838] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support. OBJECTIVE The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. METHODS A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. RESULTS Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (-1.83 points, 95% CI -2.85 to -0.82) and GAD-7 score (-1.55 points, 95% CI -2.42 to -0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. CONCLUSIONS The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO).
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Affiliation(s)
- Jennifer M Hensel
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - James Shaw
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - Noah M Ivers
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Simone N Vigod
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ashley Cohen
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Nike Onabajo
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rebecca Yang
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Megan Nguyen
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Zachary Bouck
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Ivy Wong
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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21
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Jamieson T, Goldfarb A. Clinical considerations when applying machine learning to decision-support tasks versus automation. BMJ Qual Saf 2019; 28:778-781. [DOI: 10.1136/bmjqs-2019-009514] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/22/2023]
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22
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Jeffs L, Jamieson T, Saragosa M, Mukerji G, Jain AK, Man R, Desveaux L, Shaw J, Agarwal P, Hensel JM, Maione M, Onabajo N, Nguyen M, Bhatia R. Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study. JMIR Hum Factors 2019; 6:e9720. [PMID: 30990460 PMCID: PMC6488957 DOI: 10.2196/humanfactors.9720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 11/29/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. Methods This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study. Results The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. Conclusions Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.
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Affiliation(s)
- Lianne Jeffs
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- St. Michael's Hospital, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Marianne Saragosa
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Geetha Mukerji
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Arsh K Jain
- London Health Sciences Centre, London, ON, Canada
| | - Rachel Man
- London Health Sciences Centre, London, ON, Canada
| | - Laura Desveaux
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - James Shaw
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Payal Agarwal
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer M Hensel
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | | | - Nike Onabajo
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Megan Nguyen
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - R Bhatia
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
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Hensel JM, Shaw J, Ivers NM, Desveaux L, Vigod SN, Bouck Z, Onabajo N, Agarwal P, Mukerji G, Yang R, Nguyen M, Jeffs L, Jamieson T, Bhatia RS. Extending access to a web-based mental health intervention: who wants more, what happens to use over time, and is it helpful? Results of a concealed, randomized controlled extension study. BMC Psychiatry 2019; 19:39. [PMID: 30678676 PMCID: PMC6345062 DOI: 10.1186/s12888-019-2030-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/16/2019] [Indexed: 01/08/2023] Open
Abstract
Background Web-based mental health applications may be beneficial, but adoption is often low leaving optimal implementation and payment models unclear. This study examined which users were interested in extended access to a web-based application beyond an initial 3-month trial period and evaluated if an additional 3 months of access was beneficial. Methods This study was a concealed extension of a multi-center, pragmatic randomized controlled trial that assessed the benefit of 3 months of access to the Big White Wall (BWW), an anonymous web-based moderated, multi-component mental health application offering self-directed activities and peer support. Trial participants were 16 years of age or older, recruited from hospital-affiliated mental health programs. Participants who received access to the intervention in the main trial and completed 3-month outcome assessments were offered participation. We compared those who were and were not interested in an extension of the intervention, and re-randomized consenting participants 1:1 to receive extended access or not over the subsequent 3 months. Use of the intervention was monitored in the extension group and outcomes were measured at 3 months after re-randomization in both groups. The primary outcome was mental health recovery as assessed by total score on the Recovery Assessment Scale (RAS-r), as in the main trial. Linear mixed models were used to examine the time by group interaction to assess for differences in responses over the 3-month extension study. Results Of 233 main trial participants who responded, 119 (51.1%) indicated an interest in receiving extended BWW access. Those who were interested had significantly higher baseline anxiety symptoms compared to those who were not interested. Of the 119, 112 were re-randomized (55 to extended access, 57 to discontinuation). Only 21 of the 55 extended access participants (38.2%) used the intervention during the extension period. Change in RAS-r scores over time was not significantly different between groups (time by group, F(1,77) = 1.02; P = .31). Conclusions Only half of eligible participants were interested in extended access to the intervention with decreasing use over time, and no evidence of added benefit. These findings have implications for implementation and payment models for this type of web-based mental health intervention. Trial registration Clinicaltrials.govNCT02896894. Registered retrospectively on September 12, 2016.
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Affiliation(s)
- Jennifer M Hensel
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada. .,Department of Psychiatry, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada. .,Women's College Research Institute, Toronto, Ontario, Canada. .,Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - James Shaw
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada
| | - Noah M Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simone N Vigod
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Department of Psychiatry, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Nike Onabajo
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Yang
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Megan Nguyen
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Agarwal P, Mukerji G, Desveaux L, Ivers NM, Bhattacharyya O, Hensel JM, Shaw J, Bouck Z, Jamieson T, Onabajo N, Cooper M, Marani H, Jeffs L, Bhatia RS. Mobile App for Improved Self-Management of Type 2 Diabetes: Multicenter Pragmatic Randomized Controlled Trial. JMIR Mhealth Uhealth 2019; 7:e10321. [PMID: 30632972 PMCID: PMC6329896 DOI: 10.2196/10321] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/08/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
Background As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A1c (HbA1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear. Objective The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA1c levels compared with controls. Methods The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app. Results The results of an analysis of covariance controlling for baseline HbA1c levels did not show evidence of intervention impact on HbA1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51). Conclusions The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed. Trial Registration Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)
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Affiliation(s)
- Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Noah M Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Jennifer M Hensel
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - James Shaw
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Nike Onabajo
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Madeline Cooper
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Husayn Marani
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
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25
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Jeffs L, Jamieson T, Saragosa M, Mukerji G, Jain AK, Man R, Desveaux L, Shaw J, Agarwal P, Hensel JM, Maione M, Nguyen M, Onabajo N, Bhatia RS. Improving safety and efficiency in care: multi-stakeholders' perceptions associated with a peritoneal dialysis virtual care solution. Patient Prefer Adherence 2018; 12:2623-2629. [PMID: 30587934 PMCID: PMC6294168 DOI: 10.2147/ppa.s181604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home. METHODS A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach. RESULTS The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies. DISCUSSION Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers. CONCLUSION The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management.
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Affiliation(s)
- Lianne Jeffs
- Sinai Health System, Toronto, ON M5G 1X5, Canada,
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON M5G 1WB, Canada,
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
| | - Trevor Jamieson
- Department of Medicine, University of Toronto, Division of General Internal Medicine, St Michael's Hospital, Women's College Hospital, Toronto, ON M5G 1WB, Canada
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Marianne Saragosa
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Arsh K Jain
- London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Rachel Man
- London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - James Shaw
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Payal Agarwal
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, ON M5S 1B2, Canada
| | - Jennifer M Hensel
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Department of Psychiatry, University of Toronto, Women's College Hospital, Women's College Research Institute, Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Maria Maione
- St Michael's Hospital, Toronto, ON M5G 1WB, Canada
| | - Megan Nguyen
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Nike Onabajo
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - R Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- University Health Network, Toronto, ON M5S 1B2, Canada
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26
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Kurahashi AM, Stinson JN, van Wyk M, Luca S, Jamieson T, Weinstein P, Cafazzo JA, Lokuge B, Cohen E, Rapoport A, Husain A. The Perceived Ease of Use and Usefulness of Loop: Evaluation and Content Analysis of a Web-Based Clinical Collaboration System. JMIR Hum Factors 2018; 5:e2. [PMID: 29317386 PMCID: PMC5780614 DOI: 10.2196/humanfactors.7882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/27/2017] [Accepted: 11/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with complex health care needs require the expertise of many health care providers. Communication, collaboration, and patient-centered care positively impact care quality and patient outcomes. Few technologies exist that facilitate collaboration between providers across settings of care and also engage the patient. We developed a Web-based clinical collaboration system, Loop, to address this gap. The likelihood of a technological system's uptake is associated with its perceived ease of use and perceived usefulness. We engaged stakeholders in the conceptualization and development of Loop in an effort to maximize its intuitiveness and utility. OBJECTIVE This study aimed to report end users' perceptions about the ease of use and usefulness of Loop captured during usability tests of Loop. METHODS Participants represented three user types (patients, caregivers, and health care providers) recruited from three populations (adults with cancer, adolescents and young adults with cancer, and children with medical complexity). We conducted usability testing over three iterative cycles of testing and development in both laboratory-based and off-site environments. We performed a content analysis of usability testing transcripts to summarize and describe participant perceptions about the ease of use and usefulness of Loop. RESULTS Participants enjoyed testing Loop and were able to use the core functions-composing, posting, and reading messages-with little difficulty. They had difficulty interpreting certain visual cues and design elements or the purpose of some features. This difficulty negatively impacted perceived ease of use but was primarily limited to auxiliary features. Participants predicted that Loop could improve the efficiency and effectiveness of communication between care team members; however, this perceived usefulness could be compromised by disruptions to personal workflow such as additional time or task requirements. CONCLUSIONS Loop was perceived to have value as a collaboration system; however, usability testing findings indicate that some design and functional elements need to be addressed to improve ease of use. Additionally, participant concerns highlight the need to consider how a system can be implemented so as to minimize impact on workflow and optimize usefulness.
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Affiliation(s)
- Allison M Kurahashi
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Jennifer N Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Margaret van Wyk
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie Luca
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Trevor Jamieson
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Weinstein
- Healthcare Human Factors, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Healthcare Human Factors, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Bhadra Lokuge
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Adam Rapoport
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Emily's House Children's Hospice, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Amna Husain
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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27
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Desveaux L, Shaw J, Wallace R, Bhattacharyya O, Bhatia RS, Jamieson T. Examining Tensions That Affect the Evaluation of Technology in Health Care: Considerations for System Decision Makers From the Perspective of Industry and Evaluators. JMIR Med Inform 2017; 5:e50. [PMID: 29222075 PMCID: PMC5741827 DOI: 10.2196/medinform.8207] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/09/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022] Open
Abstract
Virtual technologies have the potential to mitigate a range of challenges for health care systems. Despite the widespread use of mobile devices in everyday life, they currently have a limited role in health service delivery and clinical care. Efforts to integrate the fast-paced consumer technology market with health care delivery exposes tensions among patients, providers, vendors, evaluators, and system decision makers. This paper explores the key tensions between the high bar for evidence prior to market approval that guides health care regulatory decisions and the “fail fast” reality of the technology industry. We examine three core tensions: balancing user needs versus system needs, rigor versus responsiveness, and the role of pre- versus postmarket evidence generation. We use these to elaborate on the structure and appropriateness of evaluation mechanisms for virtual care solutions. Virtual technologies provide a foundation for personalized, patient-centered medicine on the user side, coupled with a broader understanding of impact on the system side. However, mechanisms for stakeholder discussion are needed to clarify the nature of the health technology marketplace and the drivers of evaluation priorities.
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Affiliation(s)
- Laura Desveaux
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - James Shaw
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ross Wallace
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Santis Health, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
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Shaw J, Jamieson T, Agarwal P, Griffin B, Wong I, Bhatia RS. Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. J Telemed Telecare 2017; 24:608-615. [PMID: 28945161 DOI: 10.1177/1357633x17730444] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The development of new virtual care technologies (including telehealth and telemedicine) is growing rapidly, leading to a number of challenges related to health policy and planning for health systems around the world. Methods We brought together a diverse group of health system stakeholders, including patient representatives, to engage in policy dialogue to set health system priorities for the application of virtual care in the primary care sector in the Province of Ontario, Canada. We applied a nominal group technique (NGT) process to determine key priorities, and synthesized these priorities with group discussion to develop recommendations for virtual care policy. Methods included a structured priority ranking process, open-ended note-taking, and thematic analysis to identify priorities. Results Recommendations were summarized under the following themes: (a) identify clear health system leadership to embed virtual care strategies into all aspects of primary and community care; (b) make patients the focal point of health system decision-making; (c) leverage incentives to achieve meaningful health system improvements; and (d) building virtual care into streamlined workflows. Two key implications of our policy dialogue are especially relevant for an international audience. First, shifting the dialogue away from technology toward more meaningful patient engagement will enable policy planning for applications of technology that better meet patients' needs. Second, a strong conceptual framework on guiding the meaningful use of technology in health care settings is essential for intelligent planning of virtual care policy. Conclusions Policy planning for virtual care needs to shift toward a stronger focus on patient engagement to understand patients' needs.
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Affiliation(s)
- James Shaw
- 1 Scientist Institute for Health System Solutions and Virtual Care Women's College Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- 2 Institute for Health System Solutions and Virtual Care Women's College Hospital Toronto, ON, Canada
| | - Payal Agarwal
- 2 Institute for Health System Solutions and Virtual Care Women's College Hospital Toronto, ON, Canada
| | - Bailey Griffin
- 2 Institute for Health System Solutions and Virtual Care Women's College Hospital Toronto, ON, Canada
| | - Ivy Wong
- 2 Institute for Health System Solutions and Virtual Care Women's College Hospital Toronto, ON, Canada
| | - R Sacha Bhatia
- 2 Institute for Health System Solutions and Virtual Care Women's College Hospital Toronto, ON, Canada
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29
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Voruganti T, Grunfeld E, Jamieson T, Kurahashi AM, Lokuge B, Krzyzanowska MK, Mamdani M, Moineddin R, Husain A. My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer. J Med Internet Res 2017; 19:e219. [PMID: 28720558 PMCID: PMC5539387 DOI: 10.2196/jmir.7421] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/05/2017] [Accepted: 05/26/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The management of patients with complex care needs requires the expertise of health care providers from multiple settings and specialties. As such, there is a need for cross-setting, cross-disciplinary solutions that address deficits in communication and continuity of care. We have developed a Web-based tool for clinical collaboration, called Loop, which assembles the patient and care team in a virtual space for the purpose of facilitating communication around care management. OBJECTIVE The objectives of this pilot study were to evaluate the feasibility of integrating a tool like Loop into current care practices and to capture preliminary measures of the effect of Loop on continuity of care, quality of care, symptom distress, and health care utilization. METHODS We conducted an open-label pilot cluster randomized controlled trial allocating patients with advanced cancer (defined as stage III or IV disease) with ≥3 months prognosis, their participating health care team and caregivers to receive either the Loop intervention or usual care. Outcome data were collected from patients on a monthly basis for 3 months. Trial feasibility was measured with rate of uptake, as well as recruitment and system usage. The Picker Continuity of Care subscale, Palliative care Outcomes Scale, Edmonton Symptom Assessment Scale, and Ambulatory and Home Care Record were patient self-reported measures of continuity of care, quality of care, symptom distress, and health services utilization, respectively. We conducted a content analysis of messages posted on Loop to understand how the system was used. RESULTS Nineteen physicians (oncologists or palliative care physicians) were randomized to the intervention or control arms. One hundred twenty-seven of their patients with advanced cancer were approached and 48 patients enrolled. Of 24 patients in the intervention arm, 20 (83.3%) registered onto Loop. In the intervention and control arms, 12 and 11 patients completed three months of follow-up, respectively. A mean of 1.2 (range: 0 to 4) additional healthcare providers with an average total of 3 healthcare providers participated per team. An unadjusted between-arm increase of +11.4 was observed on the Picker scale in favor of the intervention arm. Other measures showed negligible changes. Loop was primarily used for medical care management, symptom reporting, and appointment coordination. CONCLUSIONS The results of this study show that implementation of Loop was feasible. It provides useful information for planning future studies further examining effectiveness and team collaboration. Numerically higher scores were observed for the Loop arm relative to the control arm with respect to continuity of care. Future work is required to understand the incentives and barriers to participation so that the implementation of tools like Loop can be optimized. TRIAL REGISTRATION ClinicalTrials.gov NCT02372994; https://clinicaltrials.gov/ct2/show/NCT02372994 (Archived by WebCite at http://www.webcitation.org/6r00L4Skb).
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Affiliation(s)
- Teja Voruganti
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Eva Grunfeld
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - Bhadra Lokuge
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - Monika K Krzyzanowska
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Muhammad Mamdani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael's Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute of Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Amna Husain
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, ON, Canada
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Jeffs L, Jain AK, Man RH, Onabajo N, Desveaux L, Shaw J, Hensel J, Agarwal P, Saragosa M, Jamieson T, Wong I, Maione M, Bhatia RS. Exploring the utility and scalability of a telehomecare intervention for patients with chronic kidney disease undergoing peritoneal dialysis-a study protocol. BMC Nephrol 2017; 18:155. [PMID: 28486991 PMCID: PMC5424340 DOI: 10.1186/s12882-017-0557-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/16/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a pressing global health concern that is placing increased strain on health care resources. CKD patients regularly receive peritoneal dialysis as a common CKD treatment. An emerging technological solution is telehomecare as way to support patients receiving PD in their homes. This study protocol outlines a mixed methods evaluation exploring a telehomecare developed to enhance CKD patients' outcomes and experiences. The study aims to assess the usability, acceptability and scalability of this virtual care application. METHODS A realist evaluation using an embedded case study design will be used to understand the usability, acceptability and scalability of a telehomecare application for patients with CKD undergoing PD. The realist evaluation that is further described in this paper is part of a larger evaluation of the eQ Connect™ intervention that includes a randomized, parallel-arm control trial aimed at determining if utilizing eQ Connect improves selected clinical outcomes for PD patients (CONNECT Trial). DISCUSSION Potential implications of this study include elucidating which components of the intervention are most effective and under what conditions with a focus on the contextual influences. Collectively, our multi-method design will yield knowledge around how best to implement, sustain and spread the telehomecare application that will be useful to guide the development, implementation and evaluation of future virtual care applications aimed at improving the quality of care outcomes and experiences of patients. TRIAL REGISTRATION NCT02670512 . Registered: January 18, 2016.
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Affiliation(s)
- Lianne Jeffs
- Keenan Research Centre, Li Ka Shing Knowledge Institute St Michaels Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada.
| | - Arsh Kumar Jain
- London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Rachel HiuTung Man
- London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Nike Onabajo
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Laura Desveaux
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - James Shaw
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Jennifer Hensel
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Payal Agarwal
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Marianne Saragosa
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Trevor Jamieson
- Keenan Research Centre, Li Ka Shing Knowledge Institute St Michaels Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada.,Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Ivy Wong
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Maria Maione
- Keenan Research Centre, Li Ka Shing Knowledge Institute St Michaels Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - R Sacha Bhatia
- Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
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Desveaux L, Agarwal P, Shaw J, Hensel JM, Mukerji G, Onabajo N, Marani H, Jamieson T, Bhattacharyya O, Martin D, Mamdani M, Jeffs L, Wodchis WP, Ivers NM, Bhatia RS. A randomized wait-list control trial to evaluate the impact of a mobile application to improve self-management of individuals with type 2 diabetes: a study protocol. BMC Med Inform Decis Mak 2016; 16:144. [PMID: 27842539 PMCID: PMC5109669 DOI: 10.1186/s12911-016-0381-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background Management of diabetes through improved glycemic control and risk factor modification can help prevent long-term complications. Much diabetes management is self-management, in which healthcare providers play a supporting role. Well-designed e-Health solutions targeting behavior change can improve a range of measures, including glycemic control, perceived health, and a reduction in hospitalizations. Methods The primary objective of this study is to evaluate if a mobile application designed to improve self-management among patients with type 2 diabetes (T2DM) improves glycemic control compared to usual care. The secondary objectives are to determine the effects on patient experience and health system costs; evaluate how and why the intervention worked as observed; and gain insight into considerations for system-wide scale-up. This pragmatic, randomized, wait-list-control trial will recruit adult participants from three Diabetes Education Programs in Ontario, Canada. The primary outcome is glycemic control (measured by HbA1c). Secondary outcomes include patient-reported outcomes and patient-reported experience measures, health system utilization, and intervention usability. The primary outcome will be analyzed using an ANCOVA, with continuous secondary outcomes analyzed using Poisson regression. Direct observations will be conducted of the implementation and application-specific training sessions provided to each site. Semi-structured interviews will be conducted with participants, healthcare providers, organizational leaders, and system stakeholders as part of the embedded process evaluation. Thematic analysis will be applied to the qualitative data in order to describe the relationships between (a) key contextual factors, (b) the mechanisms by which they effect the implementation of the intervention, and (c) the impact on the outcomes of the intervention, according to the principles of Realist Evaluation. Discussion The use of mobile health and virtual tools is on the rise in health care, but the evidence of their effectiveness is mixed and their evaluation is often lacking key contextual data. Results from this study will provide much needed information about the clinical and cost-effectiveness of a mobile application to improve diabetes self-management. The process evaluation will provide valuable insight into the contextual factors that influence the application effectiveness, which will inform the potential for adoption and scale. Trial registration Clinicaltrials.gov NCT02813343. Registered on 24 June 2016 (retrospectively registered). Trial Sponsor: Ontario Telemedicine Network
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Affiliation(s)
- Laura Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Women's College Research Institute, Women's College Hospital, 76 Grenville Ave, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada
| | - Jay Shaw
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Women's College Research Institute, Women's College Hospital, 76 Grenville Ave, Toronto, ON, Canada.,Insititue for Health Policy, Management, and Evaluation, University of Toronto, 155 College St, Toronto, ON, Canada
| | - Jennifer M Hensel
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Department of Psychiatry, Women's College Hospital and University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Insititue for Health Policy, Management, and Evaluation, University of Toronto, 155 College St, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nike Onabajo
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada
| | - Husayn Marani
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Division of General Internal Medicine, St. Michael's Hospital, 209 Victoria St, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Women's College Research Institute, Women's College Hospital, 76 Grenville Ave, Toronto, ON, Canada.,Department of Family and Community Medicine, Women's College Hospital and University of Toronto, 76 Grenville Ave, Toronto, ON, Canada
| | - Danielle Martin
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Department of Family and Community Medicine, Women's College Hospital and University of Toronto, 76 Grenville Ave, Toronto, ON, Canada
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael's Hospital, 209 Victoria St, Toronto, ON, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, Canada.,Insititue for Health Policy, Management, and Evaluation, University of Toronto, 155 College St, Toronto, ON, Canada.,Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON, Canada
| | - Noah M Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada.,Women's College Research Institute, Women's College Hospital, 76 Grenville Ave, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, Canada.,Insititue for Health Policy, Management, and Evaluation, University of Toronto, 155 College St, Toronto, ON, Canada.,Department of Family and Community Medicine, Women's College Hospital and University of Toronto, 76 Grenville Ave, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville Ave, Toronto, ON, M5S 1B2, Canada. .,Women's College Research Institute, Women's College Hospital, 76 Grenville Ave, Toronto, ON, Canada. .,Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Hensel JM, Shaw J, Jeffs L, Ivers NM, Desveaux L, Cohen A, Agarwal P, Wodchis WP, Tepper J, Larsen D, McGahan A, Cram P, Mukerji G, Mamdani M, Yang R, Wong I, Onabajo N, Jamieson T, Bhatia RS. A pragmatic randomized control trial and realist evaluation on the implementation and effectiveness of an internet application to support self-management among individuals seeking specialized mental health care: a study protocol. BMC Psychiatry 2016; 16:350. [PMID: 27756281 PMCID: PMC5069942 DOI: 10.1186/s12888-016-1057-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental illness is a substantial and rising contributor to the global burden of disease. Access to and utilization of mental health care, however, is limited by structural barriers such as specialist availability, time, out-of-pocket costs, and attitudinal barriers including stigma. Innovative solutions like virtual care are rapidly entering the health care domain. The advancement and adoption of virtual care for mental health, however, often occurs in the absence of rigorous evaluation and adequate planning for sustainability and spread. METHODS A pragmatic randomized controlled trial with a nested comparative effectiveness arm, and concurrent realist process evaluation to examine acceptability, effectiveness, and cost-effectiveness of the Big White Wall (BWW) online platform for mental health self-management and peer support among individuals aged 16 and older who are accessing mental health services in Ontario, Canada. Participants will be randomized to 3 months of BWW or treatment as usual. At the end of the 3 months, participants in the intervention group will have the opportunity to opt-in to an intervention extension arm. Those who opt-in will be randomized to receive an additional 3 months of BWW or no additional intervention. The primary outcome is recovery at 3 months as measured by the Recovery Assessment Scale-revised (RAS-r). Secondary outcomes include symptoms of depression and anxiety measured with the Personal Health Questionnaire-9 item (PHQ-9) and the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7) respectively, quality of life measured with the EQ-5D-5L, and community integration assessed with the Community Integration Questionnaire. Cost-effectiveness evaluations will account for the cost of the intervention and direct health care costs. Qualitative interviews with participants and stakeholders will be conducted throughout. DISCUSSION Understanding the impact of virtual strategies, such as BWW, on patient outcomes and experience, and health system costs is essential for informing whether and how health system decision-makers can support these strategies system-wide. This requires clear evidence of effectiveness and an understanding of how the intervention works, for whom, and under what circumstances. This study will produce such effectiveness data for BWW, while simultaneously exploring the characteristics and experiences of users for whom this and similar online interventions could be helpful. TRIAL REGISTRATION Clinicaltrials.gov NCT02896894 . Registered on 31 August 2016 (retrospectively registered).
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Affiliation(s)
- Jennifer M. Hensel
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Department of Psychiatry, Women’s College Hospital and University of Toronto, 76 Grenville St, Toronto, ON Canada ,Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Jay Shaw
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria St, Toronto, ON Canada
| | - Noah M. Ivers
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Department of Family and Community Medicine, Women’s College Hospital and University of Toronto, 76 Grenville St, Toronto, ON Canada ,Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON Canada
| | - Laura Desveaux
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Ashley Cohen
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria St, Toronto, ON Canada
| | - Payal Agarwal
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Walter P. Wodchis
- Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON Canada ,Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON Canada
| | - Joshua Tepper
- Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON Canada ,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON Canada
| | - Darren Larsen
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON Canada ,Women’s College Hospital Family Health Centre, 77 Grenville St, Toronto, ON Canada ,OntarioMD, 150 Bloor St, Toronto, ON Canada
| | - Anita McGahan
- Rotman School of Management, University of Toronto, 105 St. George St, Toronto, ON Canada
| | - Peter Cram
- Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, and University of Toronto, 600 University Ave, Toronto, ON Canada
| | - Geetha Mukerji
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON Canada ,Department of Medicine, University of Toronto, 1 King’s College Circle #3172, Toronto, ON Canada
| | - Muhammad Mamdani
- Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College St, Toronto, ON Canada ,Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael’s Hospital, 209 Victoria St, Toronto, ON Canada ,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON Canada
| | - Rebecca Yang
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Ivy Wong
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Nike Onabajo
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - Trevor Jamieson
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada
| | - R. Sacha Bhatia
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Toronto, ON Canada ,Department of Medicine, University of Toronto, 1 King’s College Circle #3172, Toronto, ON Canada
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Jamieson T, Ailon J, Chien V, Mourad O. An electronic documentation system improves the quality of admission notes: a randomized trial. J Am Med Inform Assoc 2016; 24:123-129. [PMID: 27274016 DOI: 10.1093/jamia/ocw064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE There are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit. METHODS This was a prospective randomized crossover study comparing handwritten paper notes to electronic notes on different patients by the same author, generated using a semistructured electronic admission documentation system over a 2-month period in 2014. The setting was a 4-team, 80-bed general internal medicine clinical teaching unit at a large urban academic hospital. The quality of clinical documentation was assessed using the QNOTE instrument (best possible score = 100), and word counts were assessed for free-text sections of notes. RESULTS Twenty-one electronic-paper note pairs (42 notes) written by 21 authors were randomly drawn from a pool of 303 eligible notes. Overall note quality was significantly higher in electronic vs paper notes (mean 90 vs 69, P < .0001). The quality of free-text subsections (History of Present Illness and Impression and Plan) was significantly higher in the electronic vs paper notes (mean 93 vs 78, P < .0001; and 89 vs 77, P = .001, respectively). The History of Present Illness subsection was significantly longer in electronic vs paper notes (mean 172.4 vs 92.4 words, P = .0001). CONCLUSIONS An electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions.
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Affiliation(s)
- Trevor Jamieson
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada .,Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Ailon
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Vince Chien
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Ophyr Mourad
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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Kurahashi AM, Weinstein PB, Jamieson T, Stinson JN, Cafazzo JA, Lokuge B, Morita PP, Cohen E, Rapoport A, Bezjak A, Husain A. In the Loop: The Organization of Team-Based Communication in a Patient-Centered Clinical Collaboration System. JMIR Hum Factors 2016; 3:e12. [PMID: 27025912 PMCID: PMC4811668 DOI: 10.2196/humanfactors.4996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/14/2015] [Accepted: 01/19/2016] [Indexed: 11/13/2022] Open
Abstract
Background We describe the development and evaluation of a secure Web-based system for the purpose of collaborative care called Loop. Loop assembles the team of care with the patient as an integral member of the team in a secure space. Objective The objectives of this paper are to present the iterative design of the separate views for health care providers (HCPs) within each patient’s secure space and examine patients’, caregivers’, and HCPs’ perspectives on this separate view for HCP-only communication. Methods The overall research program includes cycles of ethnography, prototyping, usability testing, and pilot testing. This paper describes the usability testing phase that directly informed development. A descriptive qualitative approach was used to analyze participant perspectives that emerged during usability testing. Results During usability testing, we sampled 89 participants from three user groups: 23 patients, 19 caregivers, and 47 HCPs. Almost all perspectives from the three user groups supported the need for an HCP-only communication view. In an earlier prototype, the visual presentation caused confusion among HCPs when reading and composing messages about whether a message was visible to the patient. Usability testing guided us to design a more deliberate distinction between posting in the Patient and Team view and the Health Care Provider Only view at the time of composing a message, which once posted is distinguished by an icon. Conclusions The team made a decision to incorporate an HCP-only communication view based on findings during earlier phases of work. During usability testing we tested the separate communication views, and all groups supported this partition. We spent considerable effort designing the partition; however, preliminary findings from the next phase of evaluation, pilot testing, show that the Patient and Team communication is predominantly being used. This demonstrates the importance of a subsequent phase of the clinical trial of Loop to validate the concept and design.
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Affiliation(s)
- Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, ON, Canada
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Abstract
We report a case of rectal angiosarcoma after prostatic radiotherapy, illustrating diagnostic difficulty. Awareness of this potential diagnosis is important with increasing use of radiotherapy in the treatment of pelvic cancers.
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Affiliation(s)
- A Ahmad
- Department of Surgery, Crosshouse Hospital, Kilmarnock, UK.
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Abstract
BACKGROUND A variety of local haemostatic agents is now available to stop troublesome bleeding. These agents are indicated for use during surgical interventions where conventional methods of haemostasis are not applicable because of the site of surgery or the degree of bleeding. METHOD A literature search using the PubMed and ISI Web of Knowledge databases identified relevant studies on topical haemostatic agents. Manufacturers' recommendations were also sought through commercial websites. RESULTS AND CONCLUSION A significant body of evidence now exists to support the use of topical haemostatic agents in a wide variety of clinical situations. The advantages and disadvantages of many of these agents are highlighted.
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Affiliation(s)
- H Seyednejad
- Division of Surgery and Interventional Science, University College London, UK
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McCluggage WG, Jamieson T, Dobbs SP, Grey A. Aggressive angiomyxoma of the vulva: Dramatic response to gonadotropin-releasing hormone agonist therapy. Gynecol Oncol 2006; 100:623-5. [PMID: 16246403 DOI: 10.1016/j.ygyno.2005.09.033] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Revised: 09/19/2005] [Accepted: 09/19/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aggressive angiomyxoma (AA) is a vulvovaginal mesenchymal neoplasm with a marked tendency to local recurrence but which usually does not metastasise. Most cases exhibit positive immunohistochemical staining with oestrogen receptor (ER) and, or, progesterone receptor (PR). CASE We report a case of AA which exhibited positive immunohistochemical staining with ER and in which radiological examination following resection showed extensive residual tumour. The patient was commenced on gonadotropin-releasing hormone (GnRH) agonist therapy which resulted in complete radiological remission with replacement by scar tissue. The patient is currently maintained on a GnRH agonist. CONCLUSION The present case, together with several others reported in the literature, suggests that GnRH agonists may be of value in managing cases of AA, either primary or recurrent, which are not amenable to surgical excision. These agents may also be used to effect a reduction in size, so that more conservative surgery can be undertaken.
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Affiliation(s)
- W G McCluggage
- Department of Pathology, Royal Group of Hospitals Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK.
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Jamieson T. ED Offload Study: The Subjective Impressions of Patients Awaiting Emergency Medical Services Offload in the Emergency Department. Acad Emerg Med 2005. [DOI: 10.1197/j.aem.2005.03.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Pantanowitz L, Jamieson T, Beavon I. Pathobiology of sacrococcygeal teratomas. S AFR J SURG 2001; 39:56-62. [PMID: 14601451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Sacrococcygeal teratomas are rare tumours, occurring in approximately 1 in 40,000 live births. The sacrococcygeal area is, however, the commonest site for teratomas that are present at birth. There are many conflicting theories as to the origin of sacrococcygeal teratomas. Recent studies have begun to shed light on some of the dilemmas posed by these enigmatic tumours and have revealed factors that impact on therapy and outcome. Advances contributing to the understanding of sacrococcygeal teratomas and their impact on prognosis and therapy are reviewed in this article.
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Affiliation(s)
- L Pantanowitz
- Department of Anatomical Pathology, South African Institute for Medical Research, University of the Witwatersrand, Johannesburg
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Hemmer PA, Jamieson T, Pangaro LN. Reliable, valid, and educational in-training medical student evaluation overlooked. J Gen Intern Med 2001; 16:72-3. [PMID: 11251755 PMCID: PMC1495155 DOI: 10.1111/j.1525-1497.2001.01109.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jarmin DI, Nibbs RJ, Jamieson T, de Bono JS, Graham GJ. Granulocyte macrophage colony-stimulating factor and interleukin-3 regulate chemokine and chemokine receptor expression in bone marrow macrophages. Exp Hematol 1999; 27:1735-45. [PMID: 10641591 DOI: 10.1016/s0301-472x(99)00115-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The beta-chemokine macrophage inflammatory protein-1 alpha (MIP-1alpha) and its associated receptors are involved in the regulation of pro-inflammatory and haemopoietic processes. This study was designed to investigate regulation of expression MIP-1alpha and its receptors by other haemopoietic cytokines. Murine bone marrow macrophages (BMM) were treated with or without GM-CSF or IL-3 and expression of MIP-1alpha, other chemokines and their receptors examined by Northern blotting. Receptor levels were also examined using Scatchard analysis and functional tests. Treatment of BMM with GM-CSF revealed a striking increase in MIP-1alpha mRNA levels, relative to untreated cells with a corresponding increase in MIP-1alpha protein. A similar increase in mRNA levels was found when BMM were treated with IL-3. An increase in the expression of three other beta-chemokines namely MIP-1beta, MCP-1 and MCP-3, was also found following treatment with GM-CSF or IL-3. We have additionally examined the expression of the known beta-chemokine receptors in BMM and observed an increase in CCR1 mRNA levels following treatment with GM-CSF and IL-3, but no change was seen in the level of CCR5 expression. The increase in CCR1 expression was reflected in an increase in the number of cell surface receptors for MIP-1alpha on the GM-CSF treated BMM and in an enhanced response of the GM-CSF treated BMM to CCR1 ligands. These data suggest that GM-CSF and IL-3 may be involved in mechanisms regulating expression levels of MIP-1alpha and its receptors.
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Affiliation(s)
- D I Jarmin
- The Beatson Institute for Cancer Research Campaign Beatson Laboratories, Bearsden, Glasgow, United Kingdom
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Ryan KM, al-Mulla F, Jamieson T, Birnie GD. Hemizygosity of the MAX gene locus in HL60 cells. Cancer Genet Cytogenet 1998; 107:93-7. [PMID: 9844600 DOI: 10.1016/s0165-4608(98)00091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The oncogenic activity of c-MYC is well known, and genetic aberrations in this locus are associated with a variety of human neoplasms. Because the encoded MYC protein has transcriptional activity only when dimerized with MAX, it is possible that mutations of MAX also could have phenotypic consequences. We have now found, by fluorescence in situ hybridization and quantified Southern blot analyses, that the MAX gene has been reduced to hemizygosity in HL60 cells. Although the sequence of the coding region of the remaining allele of the MAX gene is not mutated, this reduction in gene dosage may be the cause of a lower abundance of MAX protein in these cells that could result in an imbalance in the complex transcription factor network in which MAX has a pivotal role.
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Affiliation(s)
- K M Ryan
- Beatson Institute for Cancer Research, CRC Beatson Laboratories, Glasgow, Scotland
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Affiliation(s)
- J P Chute
- Division of Hematology/Oncology, National Naval Medical Center, Bethesda, MD 20889, USA
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Battersby C, Hartley K, Fletcher AE, Markowe HJ, Brown RG, Styles W, Carne S, Jamieson T, Koppel I, Fraser S. Cognitive function in hypertension: a community based study. J Hum Hypertens 1993; 7:117-23. [PMID: 8510083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cognitive function was investigated in a random sample of subjects on the general practitioners' registry of hypertensive patients in an inner city area and matched with normotensive controls. The response rate was 66% giving 90 matched pairs, average age 63 yrs, with 47% men. There was no difference in educational background or measures of reading ability between the two groups. Cognitive function tests showed a consistent trend of poorer performance in hypertensives, with significant differences in Verbal Learning (immediate recall and retention). Age was inversely related to cognitive function, but no additional deterioration with increasing age was shown in hypertensives.
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Affiliation(s)
- C Battersby
- Epidemiology Research Unit, Royal Postgraduate Medical School, London, UK
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Abstract
Transcription of the c-myc gene is initiated mainly from two promoters, P1 and P2. By S1 nuclease analysis we found that there is 8 times more P2- than P1-initiated RNA in total RNA from HL60 cells. The half-lives of P1- and P2-initiated transcripts are 26 and 18 min, respectively, so the difference in the relative abundance of the mRNAs is not due to differences in their stabilities. The relative rates of transcription from the P1 and P2 promoters, estimated by in vitro nuclear run-on analysis, were found to differ by about 10-fold, sufficient to account for the difference in the steady-state levels of the two mRNAs. The abundance of c-myc mRNA changes dramatically during differentiation of HL60 cells. Dimethyl sulphoxide causes a very rapid reduction in total c-myc mRNA, while with phorbol ester a transient increase occurs followed by a more gradual decline. At no time during these dramatic alterations were significant changes detected in the relative abundance of P1- and P2-initiated mRNAs, or in their stabilities.
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MESH Headings
- Cell Transformation, Neoplastic/drug effects
- Dimethyl Sulfoxide/pharmacology
- Gene Expression Regulation, Neoplastic/genetics
- Humans
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/metabolism
- Leukemia, Promyelocytic, Acute/pathology
- Promoter Regions, Genetic/genetics
- Proto-Oncogene Proteins c-myc/genetics
- Proto-Oncogene Proteins c-myc/metabolism
- RNA, Messenger/drug effects
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Tetradecanoylphorbol Acetate/pharmacology
- Transcription, Genetic/drug effects
- Transcription, Genetic/physiology
- Tumor Cells, Cultured
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Affiliation(s)
- J K Vass
- CRC Beatson Laboratories, Beatson Institute for Cancer Research, Bearsden, Glasgow, United Kingdom
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Abstract
Of the corticosteroid preparations available, the intermediate-acting agents are the preparations most commonly used in the rheumatic diseases. Careful tailoring of dosage is important to avoid adrenal atrophy and signs of adrenocortical hypofunction. The best regimen in a given patient depends on the amount of antiinflammatory and immunosuppressive activity required. The therapeutic strategies in use include pulse therapy, daily high-dose therapy, daily low-dose therapy, and alternate-day dosing. The latter two methods are preferable because of the decreased likelihood of adverse reactions, yet are not sufficient in cases of fulminant systemic inflammatory processes.
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Pasch S, Jamieson T. Going home with COLD: is your patient ready? Can Nurse 1975; 71:24-5. [PMID: 1192395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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