Health information system implementation: a qualitative meta-analysis

Perceived factors influencing the success of pain neuroscience education in chronic musculoskeletal pain: a meta-synthesis of qualitative studies

PURPOSE

We aimed to identify the factors influencing the success of Pain Neuroscience Education (PNE) in chronic musculoskeletal (MSK) pain from the perspective of those experiencing PNE first-hand.

MATERIALS AND METHODS

We conducted a meta-synthesis of qualitative studies. Articles were found on MEDLINE via Pubmed, EMBASE, Cochrane Library, CINHAL, and PsycINFO up to April 2023. Eligible qualitative studies focussed on adults (>16 years old) with a diagnosis of chronic primary or secondary MSK pain who performed PNE. Thematic synthesis by Thomas and Harden was followed. The Critical Appraisal Skills Programme (CASP) tool ensured the quality of the studies, while the Confidence in Evidence from the Reviews of Qualitative Research (CERQual) approach facilitated data confidence assessment.

RESULTS

Nine studies were included (188 participants). Three analytical themes were developed: (i) "Efficient Communication of Information", emphasising the importance of accurate content transmission; (ii) "Emotional Support and Well-being", recognising emotional aspects as integral to treatment; and (iii) "Empowerment Promotion", focusing on information retention and personal transformation. The studies showed good quality, with moderate confidence in the evidence.

CONCLUSIONS

The perceived factors influencing the success of PNE are intricately related to the domain of communication, the emotional dimension of personal experience, and the capacity to be empowered.

An empirical investigation into the preferences of the elderly for user interface design in personal electronic health record systems

Background

With the continuous advancement of digital technologies, electronic Personal Health Records (ePHR) offer end-users greater control and convenience over their health data. Although ePHR are perceived as innovative tools in medical services that provide patient-centered care and disease prevention, many system interfaces are inclined toward younger users, overlooking investigations pertinent to elderly users. Our objective is to uncover the preferences of the elderly for an ideal ePHR system interface.

Materials and methods

Relying on a literature review, we identified six interface attributes. Utilizing conjoint analysis, we constructed 16 representative design scenarios based on orthogonal design by combining different attribute levels. We invited 187 elderly participants to evaluate these scenarios. Data analysis was performed using SPSS 26.0. The results indicate that among the ePHR interface design attributes, the elderly prioritize color attributes, followed by the notification method. Designs with contrasting color schemes, skeuomorphic design approaches, and icon-centric menu navigation with segmented layouts, and voice notifications when a message is received, are the most preferred interface design choices.

Discussion

This research elucidates the ideal interface design elements for ePHR as perceived by the elderly, offering valuable references for age-friendly design considerations in ePHR systems.

Results

Implementing these insights can aid in promoting mobile health services among the elderly demographic, enhancing their user experience in health management interfaces. This, in turn, fosters the widespread adoption of mobile health service technologies, further advancing the development of a healthy aging society.

Living with migraine: A meta-synthesis of qualitative studies

Introduction

Migraine is one of the top ten causes of disability worldwide. However, migraine is still underrated in society, and the quality of care for this disease is scant. Qualitative research allows for giving voice to people and understanding the impact of their disease through their experience of it. This study aims at synthesising the state of the art of qualitative studies focused on how people with migraine experience their life and pathology.

Methods

MEDLINE via PubMed, EMBASE, CINAHL, PsycINFO, and Cochrane Library were consulted up to November 2021 for qualitative studies. Studies to be eligible had to focus on adults (age > 18 years) with a diagnosis of primary episodic or chronic migraine following the International Classification of Headache. The quality of the study was analysed using the CASP (Critical Appraisal Skills Programme) tool. The synthesis was done through a thematic analysis. CERQual (Confidence in Evidence from Reviews of Qualitative research) approach was used to assess the confidence in retrieved evidence.

Results

Ten studies were included, counting 262 people with migraine. Our synthesis produced four main themes. (1) “Negative impact of migraine symptoms on overall life” as migraine negatively impacts people's whole life. (2) “Impact of migraine on family, work and social relationship” as migraine reduces the possibility to focus at work and interact with people. (3) “Impact of migraine on emotional health” as people with migraine experience psychological distress. (4) “Coping strategies to deal with migraine” such as keep on living one's own life, no matter the symptoms.

Conclusions

Migraine negatively impacts people's whole life, from private to social and work sphere. People with migraine feel stigmatised as others struggle with understanding their condition. Hence, it is necessary to improve awareness among society of this disabling condition, and the quality of care of these people, tackling this disease from a social and health-policy point of view.

Understanding Healthcare Providers’ Electronic Health Record (EHR) Interface Preferences via Conjoint Analysis

OBJECTIVE

The emergence of Electronic Health Records (EHRs) has been beneficial in processing administrative and clinical data for quality healthcare information. Despite being patient-centered, a number of these technologies have a fractional consideration of the human-computer interaction, which affects the healthcare professionals as end-users. This attempted to surface the healthcare providers' preferences of an ideal EHR system interface in the community setting.

MATERIALS AND METHOD

Using an orthogonal main effect design of conjoint analysis, a select group of healthcare providers (n = 300) were asked to sort choice cards, which contains five (5) attributes of EHR interface with specific level. Data were analyzed using Sawtooth v.18 and SPSS v.21.

RESULTS

High importance was given to color scheme and device platform. Further, the part-worth analysis revealed the preference for an EHR with the following attributes: (a) smartphone device, (b) triadic color, (c) minimalist design, (d) chunked layout and (e) icon-centered menu.

DISCUSSION

Visual interest and technology needs of the community healthcare providers shaped their preferences. These provide substantial perspectives on how to improve usability of EHR interface systems.

CONCLUSION

Findings underscored the expanded roles of the healthcare professionals in the successful development of EHR systems.

Nurses' knowledge of and attitude to nursing information systems

BACKGROUND

The use of a nursing information system (NIS) provides significant benefit to the nurses in the management of real-time patient data and contributes to improving the operational effectiveness of nursing services.

AIM

To assess the knowledge of, attitude towards and use of an NIS.

METHODS

A prospective cross-sectional study was carried out among 230 hospital nurses in India, using a validated questionnaire including demographic characteristics, and questions on knowledge of, attitude towards and use of an NIS.

FINDINGS

The study found that more than 70% of nurses had good computer skills and knowledge about the information system. About 75% of the nurses reported that the NIS could be a tool to support them in improving patient care, and medical documentation, although 42% claimed that the use of NIS depersonalises nursing care. Seventy-one per cent of the nurses expressed the need for formal education and training on using an NIS during and after their nursing education.

CONCLUSION

Training and demonstration of NISs during nurse education would improve nurses' knowledge, build confidence and positive attitudes, and enhance the acceptability and sustainability of NISs in healthcare settings.

Trust in pathways? Professionals' sensemaking of care pathways in the Norwegian mental health services system

BACKGROUND

In January 2019, care pathways within specialist mental health and substance abuse treatment services were officially launched in Norway. The care pathway introduced timeframes for assessment and treatment, allowing a maximum of 6 weeks to finish assessment and provide the patient with a diagnosis, in addition to allowing a maximum of 6 weeks from diagnosis to the first evaluation. The different action points required coding. The system was based on goals to improve services by focusing on user participation, coordinated patient flow, avoidance of unnecessary waiting time, improvement of equal access to services regardless of geographic location, and increased emphasis on physical health and lifestyle. The purpose of our study was to examine how mental health professionals made sense of care pathways and furthermore, how issues of trust affected the process of implementation.

METHODS

Our multiple case study included four outpatient clinics for adults in four community mental health centres (CMHCs) in different parts of Norway. Qualitative data were collected through in-depth individual and focus group interviews and analysed using systematic text condensation. The informants were treatment personnel and leaders in four different outpatient clinics for adults.

RESULTS

The results indicated four distinct themes or reactions to the care pathway and its implementation: 1) lack of clarity regarding the overall goals and content of the care pathway; 2) the increased burden of coding, registration and administrative work, which professionals experienced as a stressor; 3) an IT and medical record system that did not correspond to the coding of the care pathway; and 4) an unrealistic distinction between assessment and treatment. These themes/reactions increased the health professionals' distrust towards the care pathway, and a process of sensemaking encouraged them to reduce the importance of the care pathway system and its implementation.

CONCLUSION

Theories of trust help in understanding how mental health professionals interpret care pathway implementation. Distrust and resistance towards the care pathways overshadow some of the overall quality goals of the care pathway, a view that was indeed shared by mental health professionals.

Electronic Health Record Implementations and Insufficient Training Endanger Nurses' Well-being: Cross-sectional Survey Study

Background

High expectations have been set for the implementations of health information systems (HIS) in health care. However, nurses have been dissatisfied after implementations of HIS. In particular, poorly functioning electronic health records (EHRs) have been found to induce stress and cognitive workload. Moreover, the need to learn new systems may require considerable effort from nurses. Thus, EHR implementations may have an effect on the well-being of nurses.

Objective

This study aimed to examine the associations of EHR-to-EHR implementations and the sufficiency of related training with perceived stress related to information systems (SRIS), time pressure, and cognitive failures among registered nurses. Moreover, we examined the moderating effect of the employment sector (hospital, primary care, social services, and others) on these associations.

Methods

This study was a cross-sectional survey study of 3610 registered Finnish nurses in 2020. EHR implementation was measured by assessing whether the work unit of each respondent had implemented or will implement a new EHR (1) within the last 6 months, (2) within the last 12 months, (3) in the next 12 months, and (4) at no point within the last 12 months or in the forthcoming 12 months. The associations were examined using analyses of covariance adjusted for age, gender, and employment sector.

Results

The highest levels of SRIS (adjusted mean 4.07, SE 0.05) and time pressure (adjusted mean 4.55, SE 0.06) were observed among those who had experienced an EHR implementation within the last 6 months. The lowest levels of SRIS (adjusted mean 3.26, SE 0.04), time pressure (adjusted mean 4.41, SE 0.05), and cognitive failures (adjusted mean 1.84, SE 0.02) were observed among those who did not experience any completed or forthcoming implementations within 12 months. Nurses who perceived that they had received sufficient implementation-related training experienced less SRIS (F₁=153.40, P<.001), time pressure (F₁=80.95, P<.001), and cognitive failures (F₁=34.96, P<.001) than those who had received insufficient training. Recent implementations and insufficient training were especially strongly associated with high levels of SRIS in hospitals.

Conclusions

EHR implementations and insufficient training related to these implementations may endanger the well-being of nurses and even lead to errors. Thus, it is extremely important for organizations to offer comprehensive training before, during, and after implementations. Moreover, easy-to-use systems that allow transition periods, a re-engineering approach, and user involvement may be beneficial to nurses in the implementation process. Training and other improvements would be especially important in hospitals.

Integrating a Web-Based Self-Management Tool (Managing Joint Pain on the Web and Through Resources) for People With Osteoarthritis-Related Joint Pain With a Web-Based Social Network Support Tool (Generating Engagement in Network Involvement): Design, Development, and Early Evaluation

BACKGROUND

Joint pain caused by osteoarthritis (OA) is highly prevalent and can be extremely debilitating. Programs to support self-management of joint pain can be effective; however, most programs are designed to build self-efficacy and rarely engage social networks. Digital interventions are considered acceptable by people with joint pain. However, many existing resources are not accessible for or developed alongside people with lower health literacy, which disproportionately affects people with OA.

OBJECTIVE

This study aims to design and develop an accessible digital self-management tool for people with joint pain and integrate this with an existing social network activation tool (Generating Engagement in Network Involvement [GENIE]) and to explore the feasibility of these linked tools for supporting the management of joint pain.

METHODS

The study was conducted in 2 phases: a design and development stage and a small-scale evaluation. The first phase followed the person-based approach to establish guiding principles for the development of a new site (Managing joint Pain On the Web and through Resources [EMPOWER]) and its integration with GENIE. People with joint pain were recruited from libraries, a community café, and an exercise scheme to take part in 3 focus groups. EMPOWER was tested and refined using think-aloud interviews (n=6). In the second phase, participants were recruited through the web via libraries to participate in a small-scale evaluation using the LifeGuide platform to record use over a 1-month period. Participants (n=6) were asked to complete evaluation questionnaires on their experiences. The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was used to explore the feasibility of the sites.

RESULTS

The focus groups established guiding principles for the development of the tool. These included ensuring accessibility and relevance for people with OA-related joint pain and recognizing that joint pain is the reason for seeking support, trust, social facilitation, and goal setting. Think-aloud interviews identified issues with user experience and site navigation and the need for professional input for referral and goal setting, confusion, and tensions over the role of GENIE and site connectivity. Participants expected the sites to be specific to their pain-related needs. EMPOWER was accessed 18 times; 6 users registered with the site during the evaluation study. Participants mostly explored information pages on being active and being a healthy weight. Only one participant undertook goal setting and 4 participants visited the GENIE website.

CONCLUSIONS

Using the NASSS framework, we identified the complexity associated with integrating EMPOWER and GENIE. The value proposition domain highlighted the technical and conceptual complexity associated with integrating approaches. Although identified as theoretically achievable, the integration of differing propositions may have caused cognitive and practical burdens for users. Nevertheless, we believe that both approaches have a distinct role in the self-management of joint pain.

Routine Health Information System (RHIS) improvements for strengthened health system management

BACKGROUND

A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management.

OBJECTIVES

To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence).

AUTHORS' CONCLUSIONS

The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Rethinking the electronic health record through the quadruple aim: time to align its value with the health system

Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The “quadruple aim” consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.

eRegTime, Efficiency of Health Information Management Using an Electronic Registry for Maternal and Child Health: Protocol for a Time-Motion Study in a Cluster Randomized Trial

BACKGROUND

Paper-based routine health information systems often require repetitive data entry. In the West Bank, the primary health care system for maternal and child health was entirely paper-based, with care providers spending considerable amounts of time maintaining multiple files and client registers. As part of the phased national implementation of an electronic health information system, some of the primary health care clinics are now using an electronic registry (eRegistry) for maternal and child health. The eRegistry consists of client-level data entered by care providers at the point-of-care and supports several digital health interventions that are triggered by the documented clinical data, including guideline-based clinical decision support and automated public health reports.

OBJECTIVE

The aim of the eRegTime study is to investigate whether the use of the eRegistry leads to changes in time-efficiency in health information management by the care providers, compared with the paper-based systems.

METHODS

This is a substudy in a cluster randomized controlled trial (the eRegQual study) and uses the time-motion observational study design. The primary outcome is the time spent on health information management for antenatal care, informed and defined by workflow mapping in the clinics. We performed sample size estimations to enable the detection of a 25% change in time-efficiency with a 90% power using an intracluster correlation coefficient of 0.1 and an alpha of .05. We observed care providers for full workdays in 24 randomly selected primary health care clinics-12 using the eRegistry and 12 still using paper. Linear mixed effects models will be used to compare the time spent on health information management per client per care provider.

RESULTS

Although the objective of the eRegQual study is to assess the effectiveness of the eRegistry in improving quality of antenatal care, the results of the eRegTime study will contribute to process evaluation, supplementing the findings of the larger trial.

CONCLUSIONS

Electronic health tools are expected to reduce workload for the care providers and thus improve efficiency of clinical work. To achieve these benefits, the implementation of such systems requires both integration with existing workflows and the creation of new workflows. Studies assessing the time-efficiency of electronic health information systems can inform policy decisions for implementations in resource-limited low- and middle-income settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13653.

Barriers and Facilitators When Implementing Web-Based Disease Monitoring and Management as a Substitution for Regular Outpatient Care in Pediatric Asthma: Qualitative Survey Study

Background

Despite their potential benefits, many electronic health (eHealth) innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic.

Objective

The purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients’ (or their parents) satisfaction with this eHealth innovation.

Methods

Between April and November 2015, we recruited 76 health care professionals (from 14 hospitals). During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period.

Results

Major perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients (“personalized eHealth”), easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency.

Conclusions

The implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations.

A Systematic Review of the Technology Acceptance Model in Health Informatics

BACKGROUND

One common model utilized to understand clinical staff and patients' technology adoption is the technology acceptance model (TAM).

OBJECTIVE

This article reviews published research on TAM use in health information systems development and implementation with regard to application areas and model extensions after its initial introduction.

METHOD

An electronic literature search supplemented by citation searching was conducted on February 2017 of the Web of Science, PubMed, and Scopus databases, yielding a total of 492 references. Upon eliminating duplicates and applying inclusion and exclusion criteria, 134 articles were retained. These articles were appraised and divided into three categories according to research topic: studies using the original TAM, studies using an extended TAM, and acceptance model comparisons including the TAM.

RESULTS

The review identified three main information and communication technology (ICT) application areas for the TAM in health services: telemedicine, electronic health records, and mobile applications. The original TAM was found to have been extended to fit dynamic health service environments by integration of components from theoretical frameworks such as the theory of planned behavior and unified theory of acceptance and use of technology, as well as by adding variables in specific contextual settings. These variables frequently reflected the concepts subjective norm and self-efficacy, but also compatibility, experience, training, anxiety, habit, and facilitators were considered.

CONCLUSION

Telemedicine applications were between 1999 and 2017, the ICT application area most frequently studied using the TAM, implying that acceptance of this technology was a major challenge when exploiting ICT to develop health service organizations during this period. A majority of the reviewed articles reported extensions of the original TAM, suggesting that no optimal TAM version for use in health services has been established. Although the review results indicate a continuous progress, there are still areas that can be expanded and improved to increase the predictive performance of the TAM.

A Systematic Investigation on Barriers and Critical Success Factors for Clinical Information Systems in Integrated Care Settings

OBJECTIVES

Clinical Information Systems (CIS) have ever since the introduction of information technology in healthcare played an important role to support healthcare professionals and the process of treatment. With the rise of the concept of integrated care organizational borders, the sole focus on data aggregation or healthcare professionals as users disappear more and more. The manuscript discusses the concept of CISs and investigates critical success factors for CISs in the context of integrated care and in the course of time.

METHODS

In order to identify critical success factors and barriers for CISs a systematic literature review was conducted based on the results from PubMed and Cochrane, using MaxQDA. Search results were thereby limited to reviews or meta-analysis.

RESULTS

We have found 1919 references of which 40 met the inclusion criteria. The analysis of the manuscripts resulted in a comprehensive list of success factors and barriers related to CISs in integrated care settings. Most barriers were user-related whereas for the success factors an even distribution of organizational, technical and user-related factors was observed. The vast majority of publications was focused on healthcare professionals.

CONCLUSION

It is important to incorporate experiences made/ collected over time, as the problems encountered seem to remain almost unvaried. In order to support further systematic investigations on the topic it is necessary to rethink existing concepts and definitions to realign them with the ideas of integrated care.

Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update)

Background

There is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health.

Methods

MEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR).

Results

Forty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation.

Conclusion

This systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary.

Trial registration

PROSPERO, CRD42015017661

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0510-7) contains supplementary material, which is available to authorized users.

Development of hospital information systems: user participation and factors affecting it

Introduction:

Given the large volume of data generated in hospitals, in order to efficiently management them; using hospital information system (HIS) is critical. User participation is one of the major factors in the success of HIS that in turn leads Information needs and processes to be correctly predicted and also their commitment to the development of HIS to be augmented. The purpose of this study is to investigate the participation rate of users in different stages of HIS development as well as to identify the factors affecting it.

Method and materials:

This is a descriptive–cross sectional study which was inducted in 2014. The study population consists of 140 HIS users (from different types of job including physicians, nurses, laboratory, radiology and HIM staffs) from Teaching Hospitals Affiliated to Urmia University of Medical Sciences. Data were collected using a self-structured questionnaire which was estimated as both reliable and valid. The data were analyzed by SPSS software descriptive statistics and analytical statistics (t-test and chi-square).

Results:

The highest participation rate of users in the four-stage development of the HIS was related to the implementation phase (2.88) and the lowest participation rate was related to analysis (1.23). The test results showed that the rate of user participation was not satisfactory in none of the stages of development (P< 0.05). The most important factors in increasing user participation include established teamwork from end-users and the support of top managers from HIS development.

Conclusion:

According to the results obtained from the study, it seems that health care administrators must have a detailed plan for user participation prior to the development and purchase of HIS so that they identify the real needs as well as increase their commitment and motivations to develop, maintain and upgrade the system, and in this way, the success of the system will be assured.

Prioritizing barriers to successful implementation of hospital information systems

Hospital information systems (HIS) are often implemented to enhance the quality of care, as well as to improve the efficiency and safety of health care services. However, there are various barriers for their successful implementation. The aim of this paper is to prioritize these barriers. This research is a cross sectional analytic-descriptive study. The study populations were hospital managers, IT department administrators, and clinical supervisors at the academic and non-academic hospitals of two cities in Iran. The data was collected by a questionnaire that its content validity was confirmed by three specialists. Its reliability was confirmed using Cronbach's alpha (α = 0.78). Questionnaire contained five dimensions and 39 implementation barriers. The collected data was analyzed by descriptive and analytical statistics using the Kendall Rank Correlation Coefficient and Chi2 tests. The findings of the study revealed that lack of powerful information networks, error in data entry, technical problems related to system design, lack of organizational training, lack of users' knowledge about system and working with it, and negative attitudes of providers and patients toward systems are the most important barriers of HIS implementation. Prioritizing of these barriers helps policy makers to decide what to do when planning for HIS utilization.

Adherence factors to paperless primary healthcare: a focus group study

Background: Information and communication technology (ICT) and paperless practices have been shown to improve “existing processes in the workplace” “as well as being an important component of modern primary healthcare”. The aim of our study was to analyse the attitudes of health-care professionals and patients with regard to paperless practice and the most frequently used information and communication technology tools in Slovenian primary healthcare.

Methods and participants: Qualitative methodology using focus groups of 22 primary care physicians, 14 nurses and 18 patients.

Results: The areas recognised by all participants as important for further information and communication technology development were: computer-supported decision making, accessibility and completeness of personal e-health data, emergency cases, support for chronic disease management, ICT related time savings, e-prescriptions and e-discharge letters. The most important identified barriers impeding the use of ICT were: the heavy workload of primary care physicians and nurses, health insurance reimbursement rules and duplication of work using both paper and electronic health records.

Conclusions: This study highlighted a number of strengths of ICT use in primary care as well as numerous areas where changes in procedures and improvement of ICT tools to support them are needed.

Quality and safety implications of emergency department information systems

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services "meaningful use" incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals' electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital's or physician group's approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order-wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system's ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems.

Health Care Provider Adoption of eHealth: Systematic Literature Review

Background

eHealth is an application of information and communication technologies across the whole range of functions that affect health. The benefits of eHealth (eg, improvement of health care operational efficiency and quality of patient care) have previously been documented in the literature. Health care providers (eg, medical doctors) are the key driving force in pushing eHealth initiatives. Without their acceptance and actual use, those eHealth benefits would be unlikely to be reaped.

Objective

To identify and synthesize influential factors to health care providers’ acceptance of various eHealth systems.

Methods

This systematic literature review was conducted in four steps. The first two steps facilitated the location and identification of relevant articles. The third step extracted key information from those articles including the studies’ characteristics and results. In the last step, identified factors were analyzed and grouped in accordance with the Unified Theory of Acceptance and Use of Technology (UTAUT).

Results

This study included 93 papers that have studied health care providers’ acceptance of eHealth. From these papers, 40 factors were identified and grouped into 7 clusters: (1) health care provider characteristics, (2) medical practice characteristics, (3) voluntariness of use, (4) performance expectancy, (5) effort expectancy, (6) social influence, and (7) facilitating or inhibiting conditions.

Conclusions

The grouping results demonstrated that the UTAUT model is useful for organizing the literature but has its limitations. Due to the complex contextual dynamics of health care settings, our work suggested that there would be potential to extend theories on information technology adoption, which is of great benefit to readers interested in learning more on the topic. Practically, these findings may help health care decision makers proactively introduce interventions to encourage acceptance of eHealth and may also assist health policy makers refine relevant policies to promote the eHealth innovation.

Addressing critical issues in the development of an Oncology Information System

PURPOSES

This paper presents the experience on the design and implementation of a user-centered Oncology Information System developed for the Medical Oncology Department at the "Hospital Universitario Virgen de la Victoria", in Málaga, Spain. The project focused on the aspects considered in the literature as critical factors for a successful deployment and usage of a health information system.

METHODS

System usability, adequate technology, integration of clinical routines, real-time statistical analysis of data, information confidentiality and standard protocol-based external interconnection were the key aspects considered.

RESULTS

The developed system is based on a web application with a modular and layered architecture accounting for usability, ease of maintenance and further system development. Evaluation of system usability was carried at three and fifteen months after system deployment to analyze the advantages/disadvantages experienced by the end-users.

CONCLUSIONS

A thorough prior analysis of clinical activities and workflows, the use of the adequate technology, and the availability of data analysis tools will almost guarantee success in the deployment of an Oncology Information System.

Electronic hand-drafting and picture management system

The Department of Health of Executive Yuan in Taiwan (R.O.C.) is implementing a five-stage project entitled Electronic Medical Record (EMR) converting all health records from written to electronic form. Traditionally, physicians record patients' symptoms, related examinations, and suggested treatments on paper medical records. Currently when implementing the EMR, all text files and image files in the Hospital Information System (HIS) and Picture Archiving and Communication Systems (PACS) are kept separate. The current medical system environment is unable to combine text files, hand-drafted files, and photographs in the same system, so it is difficult to support physicians with the recording of medical data. Furthermore, in surgical and other related departments, physicians need immediate access to medical records in order to understand the details of a patient's condition. In order to address these problems, the Department of Health has implemented an EMR project, with the primary goal of building an electronic hand-drafting and picture management system (HDP system) that can be used by medical personnel to record medical information in a convenient way. This system can simultaneously edit text files, hand-drafted files, and image files and then integrate these data into Portable Document Format (PDF) files. In addition, the output is designed to fit a variety of formats in order to meet various laws and regulations. By combining the HDP system with HIS and PACS, the applicability can be enhanced to fit various scenarios and can assist the medical industry in moving into the final phase of EMR.

The impact of eHealth on the quality and safety of health care: a systematic overview

BACKGROUND

There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.

METHODS AND FINDINGS

We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

CONCLUSIONS

There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.

Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting

Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input-output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference's recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.

A user-centered, object-oriented methodology for developing Health Information Systems: a Clinical Information System (CIS) example

The aim of this study is to present our perspectives on healthcare analysis and design and the lessons learned from our experience with the development of a distributed, object-oriented Clinical Information System (CIS). In order to overcome known issues regarding development, implementation and finally acceptance of a CIS by the physicians we decided to develop a novel object-oriented methodology by integrating usability principles and techniques in a simplified version of a well established software engineering process (SEP), the Unified Process (UP). A multilayer architecture has been defined and implemented with the use of a vendor application framework. Our first experiences from a pilot implementation of our CIS are positive. This approach allowed us to gain a socio-technical understanding of the domain and enabled us to identify all the important factors that define both the structure and the behavior of a Health Information System.

Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations theory

Background

Computerized provider order entry (CPOE) systems have been introduced to reduce medication errors, increase safety, improve work-flow efficiency, and increase medical service quality at the moment of prescription. Making the impact of CPOE systems more observable may facilitate their adoption by users. We set out to examine factors associated with the adoption of a CPOE system for inter-organizational and intra-organizational care.

Methods

The diffusion of innovation theory was used to understand physicians' and nurses' attitudes and thoughts about implementation and use of the CPOE system. Two online survey questionnaires were distributed to all physicians and nurses using a CPOE system in county-wide healthcare organizations. The number of complete questionnaires analyzed was 134 from 200 nurses (67.0%) and 176 from 741 physicians (23.8%). Data were analyzed using descriptive-analytical statistical methods.

Results

More nurses (56.7%) than physicians (31.3%) stated that the CPOE system introduction had worked well in their clinical setting (P < 0.001). Similarly, more physicians (73.9%) than nurses (50.7%) reported that they found the system not adapted to their specific professional practice (P = < 0.001). Also more physicians (25.0%) than nurses (13.4%) stated that they did want to return to the previous system (P = 0.041). We found that in particular the received relative advantages of the CPOE system were estimated to be significantly (P < 0.001) higher among nurses (39.6%) than physicians (16.5%). However, physicians' agreements with the compatibility of the CPOE and with its complexity were significantly higher than the nurses (P < 0.001).

Conclusions

Qualifications for CPOE adoption as defined by three attributes of diffusion of innovation theory were not satisfied in the study setting. CPOE systems are introduced as a response to the present limitations in paper-based systems. In consequence, user expectations are often high on their relative advantages as well as on a low level of complexity. Building CPOE systems therefore requires designs that can provide rather important additional advantages, e.g. by preventing prescription errors and ultimately improving patient safety and safety of clinical work. The decision-making process leading to the implementation and use of CPOE systems in healthcare therefore has to be improved. As any change in health service settings usually faces resistance, we emphasize that CPOE system designers and healthcare decision-makers should continually collect users' feedback about the systems, while not forgetting that it also is necessary to inform the users about the potential benefits involved.