Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Identifying High-Priority Ethical Challenges for Precision Emergency Medicine: Nominal Group Study

Background

Precision medicine promises to revolutionize health care by providing the right care to the right patient at the right time. However, the emergency department's unique mandate to treat "anyone, anywhere, anytime" creates critical tensions with precision medicine's requirements for comprehensive patient data and computational analysis. As emergency departments serve as health care's safety net and provide a growing proportion of acute care in America, identifying and addressing the ethical challenges of implementing precision medicine in this setting is crucial to prevent exacerbation of existing health care disparities. The rapid advancement of precision medicine technologies makes it imperative to understand these challenges before widespread implementation in emergency care settings.

Objective

This study aimed to identify high priority ethical concerns facing the implementation of precision medicine in the emergency department.

Methods

We conducted a qualitative study using a modified nominal group technique (NGT) with emergency physicians who had previous knowledge of precision medicine concepts. The NGT process consisted of four phases: (1) silent generation of ideas, (2) round-robin sharing of ideas, (3) structured discussion and clarification, and (4) thematic grouping of priorities. Participants represented diverse practice settings (county hospital, community hospital, academic center, and integrated managed care consortium) and subspecialties (education, ethics, pediatrics, diversity, equity, inclusion, and informatics) across various career stages from residents to late-career physicians.

Results

A total of 12 emergency physicians identified 82 initial challenges during individual ideation, which were consolidated to 48 unique challenges after removing duplicates and combining related items. The average participant contributed 6.8 (SD 2.9) challenges. These challenges were organized into a framework with 3 themes: values, privacy, and justice. The framework identified the need to address these themes across 3 time points of the precision medicine process: acquisition of data, actualization in the care setting, and the after effects of its use. This systematic organization revealed interrelated concerns spanning from data collection and bias to implementation challenges and long-term consequences for health care equity.

Conclusions

Our study developed a novel framework that maps critical ethical challenges across 3 domains (values, privacy, and justice) and 3 temporal stages of precision medicine implementation. This framework identifies high-priority areas for future research and policy development, particularly around data representation, privacy protection, and equitable access. Successfully addressing these challenges is essential to realize precision medicine's potential while preserving emergency medicine's core mission as health care's safety net.

The digitalization of emergency department triage: the perspectives of health professionals and patients

BACKGROUND

Digitalization in the healthcare sector offers several organizational advantages, ranging from enhanced service quality to cost savings. However, its adoption often progresses slowly and faces challenges, especially in critical settings like emergency departments, requiring prompt, clear, and efficient communication. As such, this study aims to comprehensively assess the factors influencing the preference for digitalized tools over traditional methods from the perspectives of both service providers and users.

METHODS

We employ two ad hoc stated preference surveys in which we ask respondents to reveal their preference in simulated triage scenarios. Three main alternatives are proposed: traditional procedures, a fully digitalized solution with no direct patient-professional interaction, and a hybrid option that combines traditional and digital aspects. Scenarios and alternatives vary according to predetermined attributes, selected among the features acknowledged to impact the triage efficiency and efficacy: the possibility to communicate in a known language, the completeness of information retrieved from the patient, the time dedicated to triage activity, and the level of privacy. Responses are analyzed by means of discrete choice models.

RESULTS

Our findings reveal a preference for the hybrid approach, wherein patients use digital tools to input relevant information, followed by an interview with healthcare professionals. Nevertheless, distinct alternative- and case-specific features can favor the preference toward other kinds of triage. Respondents prefer shorter triage times and the opportunity to interact in a known language, while the level of privacy does not significantly impact their choices. Interestingly, the presence of an algorithm assigning urgency code diminishes the probability that healthcare professionals select the fully digitalized option.

CONCLUSIONS

This study provides important insight into the utilization of digital tools in emergency departments. The results can be used by hospital managers and policy makers to develop digital tools that meet the needs of both users and healthcare professionals. This, in turn, may result in cost savings and improved quality of service.

Missing Medical Data in Neurological Emergency Care Compromise Patient Safety and Healthcare Resources

Background: Acute care of patients in the emergency department (ED) can be very challenging when patients attend EDs without their important medical information. This is especially problematic for multimorbid patients under polypharmacy. The aim of this study was to assess systematically the frequency and clinical relevance of incomplete medical data upon ED admission. Methods: The study was conducted in the neurological ED of a German tertiary hospital. The availability and accuracy of medical data of all neurological patients in the ED were assessed upon arrival. Treating ED physicians were asked about the acute care of the patients to clarify whether missing data resulted in delays or complications in the emergency treatment. Additionally, doctors responsible for the inpatient care of patients who were admitted to a ward via the ED were questioned about the course of the inpatient stay to monitor how initially missing data might have influenced the hospital stay. Results: Medical data of 27% of the 272 included patients were missing or incomplete upon admission in the ED. The ED physicians had to make additional phone calls to gather information in 57% of these cases (vs. 22% in patients with complete data, p < 0.0001). Delays between 5 and 240 min were documented due to initially missing data. Unnecessary diagnostic procedures (e.g., lumbar puncture) were performed in 5% of these patients, thus compromising patient safety. Even the inpatient stay was complicated by initially missing data, as doctors still had to spend time (between 10 and 180 min) to gain relevant information. Retrospectively, 5% of hospitalizations could have been avoided if all medical information had been available upon ED admission. Conclusions: Missing medical data caused complications and delays in acute as well as inpatient care of patients admitted to the neurological ED. This compromised patient safety and led to a waste of medical resources and valuable time of the responsible medical team. Therefore, a comprehensive, digital data management system is urgently needed to improve patient safety and facilitate efficient patient care in the ED and beyond.

Keeping medical information safe and confidential: a qualitative study on perceptions of Israeli physicians

BACKGROUND

Patients expect their information to remain confidential, and physicians have a legal and ethical obligation to keep it this way. Confidentiality is not just a legal requirement but a crucial element in establishing trust between patients and healthcare providers. Patients must feel confident that their personal and medical information is kept confidential and shared only with those who need to know. Previous studies have primarily concentrated on patients' perceptions of medical confidentiality, data privacy, and data protection issues. However, research on the practical practices and perceptions of medical confidentiality among hospital physicians is scant, underscoring the need for a deeper understanding of this critical issue.

METHODS

Through qualitative methods and as part of a large-scale study on aspects of patient dignity and responsiveness in Israel, physicians shared their views and practices on managing medical information.

RESULTS

The study revealed the practical challenges physicians face in upholding various aspects of data protection within hospital settings. These challenges, strategies, and deviations from data protection principles that physicians discussed are of significant practical relevance. The importance of patient consent and the practical measures for safeguarding patient information were also highlighted. While physicians acknowledged the importance of protecting patient information, they also grappled with the realities of doing so in a complex healthcare environment. In future healthcare policies, it is critical to ensure robust measures are in place to safeguard and uphold medical confidentiality. These can include specific measures to increase compliance, such as regularly monitoring compliance with confidentiality policies, producing safe and anonymous channels to voice concerns, and enforcing consequences for any breaches to ensure accountability.

CONCLUSIONS

While protecting medical information has emerged as an important goal, it is equally crucial to strike a balance between the need to share information to advance and provide quality medical care. Physicians and policymakers must navigate this delicate balance. Additionally, organizations should strengthen compliance to enhance their monitoring and enforcement of confidentiality policies. Ineffective implementation of medical confidentiality leads to theoretical guidelines that do not translate effectively into practice.

Retrospective Cohort Analysis of the Relationship Between Emergency Department Length of Stay and Timing of First Laboratory Orders

Background The efficiency of patient management in the Emergency Department (ED) is critical for optimizing healthcare delivery. Provider in triage (PIT) and similar ED flow models attempt to expedite throughput by decreasing the amount of time between patient arrival and initial order placement. The exact relationship between ED length of stay (LOS) and the timing of the first laboratory order, however, is unclear. The varying speed at which clinicians of different ages place laboratory orders and move patients through an ED also is understudied.  Methods A retrospective analysis was conducted using SQL from the Clarity data archive to pull all patient encounters in 2023. Linear regression models using Analysis ToolPak in Microsoft Excel were used to create and examine the relationship between LOS and the timing of the first laboratory order. Secondary outcomes using the same models were created to analyze the impact of clinician age on LOS and the relationship between clinician age and the timing of first laboratory orders.  Results Two hundred sixty-nine thousand eight hundred and eight ED visits were reviewed across three academic and 17 community emergency departments. We report a weak but statistically significant positive relationship between the timing of the first laboratory order and LOS (R² = 0.0378, p < 0.001). Secondary outcomes indicated a very weak negative correlation between clinician age and LOS (R² ≈ 0, p < 0.001) and no significant relationship between clinician age and the timing of the first laboratory order (R² ≈ 0, p > 0.05). Conclusion The timing of the first laboratory order is a significant, albeit weak, predictor of LOS in the ED. Clinician age has minimal impact on LOS and does not significantly influence the timing of the first laboratory order.

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

A Standard Framework for Evaluating Large Health Care Data and Related Resources

Since 2000, the availability and use of large health care data and related resources for conducting surveillance, research, and evaluations to guide clinical and public health decision-making has increased rapidly. These trends have been related to transformations in health care information technology and public as well as private-sector efforts for collecting, compiling, and supplying large volumes of data. This growing collection of robust and often timely data has enhanced the capability to increase the knowledge base guiding clinical and public health activities and also has increased the need for effective tools to assess the attributes of these resources and identify the types of scientific questions they are best suited to address. This

MMWR supplement presents a standard framework for evaluating large health care data and related resources, including constructs, criteria, and tools that investigators and evaluators can apply and adapt.

Privacy and confidentiality of emergency department patient information: Contemporary considerations and challenges

This article provides a brief review of moral and legal duties to respect confidentiality in emergency medicine. The article considers current challenges to confidentiality in emergency departments and proposes strategies to address them. It is offered as an update of the two-part review of confidentiality in emergency medicine in 2005 by Moskop et al published in 2005 in Annals of Emergency Medicine.

The evaluation of the Plan-Do-Study-Act cycles for a healthcare quality improvement intervention in primary care

BACKGROUND

The Plan-Do-Study-Act (PDSA) cycle is an iterative framework that has been gaining traction in primary care for quality improvement. However, its implementation remains understudied. This study evaluated the completion, achievement of goal, content quality, and enablers and barriers associated with completion of high-quality PDSA cycles in cardiovascular disease management in general practices.

METHODS

This study analysed data from intervention practices of the QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living people with coronary heart disease (QUEL) study. Content quality of cycles was assessed using a scoring system created based on established criteria of ideal PDSA cycles in the healthcare context. Practice-level factors associated with completion and cycles achieving the planned goal were explored through logistic regression models, and with content quality score through linear regression model. Enablers and barriers were assessed using thematic analysis of practices' responses to the PDSA sections.

RESULTS

Ninety-seven cycles were reported by 18/26 (69%) practices. Seventy-seven percent of the cycles were completed and 68% achieved the planned goal. Content quality was low, with a median score of 56% (interquartile interval: 44%, 67%). Odds of cycles that were completed and achieved what was planned increased by 3.6- and 9.6-fold, respectively, with more general practitioners (GPs) within practices. Content quality was higher by 15% with more GPs. Lack of interprofessional engagement was a barrier to implementation.

CONCLUSIONS

Cycles were well completed, but poor in content quality, with high variability between practices. Human or capital resources and organisational support may be critical for the completion and cycles achieving the planned goals.

Provenance Data Management in Health Information Systems: A Systematic Literature Review

AIMS

This article aims to perform a Systematic Literature Review (SLR) to better understand the structures of different methods, techniques, models, methodologies, and technologies related to provenance data management in health information systems (HISs). The SLR developed here seeks to answer the questions that contribute to describing the results.

METHOD

An SLR was performed on six databases using a search string. The backward and forward snowballing technique was also used. Eligible studies were all articles in English that presented on the use of different methods, techniques, models, methodologies, and technologies related to provenance data management in HISs. The quality of the included articles was assessed to obtain a better connection to the topic studied.

RESULTS

Of the 239 studies retrieved, 14 met the inclusion criteria described in this SLR. In order to complement the retrieved studies, 3 studies were included using the backward and forward snowballing technique, totaling 17 studies dedicated to the construction of this research. Most of the selected studies were published as conference papers, which is common when involving computer science in HISs. There was a more frequent use of data provenance models from the PROV family in different HISs combined with different technologies, among which blockchain and middleware stand out. Despite the advantages found, the lack of technological structure, data interoperability problems, and the technical unpreparedness of working professionals are still challenges encountered in the management of provenance data in HISs.

CONCLUSION

It was possible to conclude the existence of different methods, techniques, models, and combined technologies, which are presented in the proposal of a taxonomy that provides researchers with a new understanding about the management of provenance data in HISs.

Evaluating the success of Iran Electronic Health Record System (SEPAS) based on the DeLone and McLean model: a cross-sectional descriptive study

BACKGROUND

Quality dimensions are the most important criteria for predicting the success of an information system. The current study aims to evaluate the success of the Iran Electronic Health Record System (SEPAS) based on the DeLone and McLean model for information system success.

METHOD

This nationwide cross-sectional study was conducted in 2021. Participants were 468 health information management personnel who had working experience with SEPAS. Data were collected using a questionnaire based on the DeLone and McLean model. The validity and reliability of the questionnaire were confirmed. Data were analyzed using SPSS 22 through descriptive and analytic analysis including t-test and ANOVA.

RESULTS

Most participants were female (70.9%) and almost half of the participants mean age was between 30 and 40 years old (49.6%). The total mean of SEPAS success was 3.42 ± 0.53. According to the participants' perspectives "system quality" was the most influencing factor on SEPAS success. The least influencing factor was SEPAS "benefits". There was a significant relationship between the mean score of SEPAS success and age (p value = 0.001), Education level (p value = 0.01), and Work experience (p value < 0.001).

CONCLUSION

The total mean of system success was not acceptable. SEPAS has not been much successful in providing net benefits like provision of electronic services which locate patients in the center and improve the delivery of care to them. It sounds that SEPAS is not stable enough that means crashes sometimes. Hence, considering the required infrastructures for quick response and stability is more critical, especially when healthcare providers are supposed to use the SEPAS.

Advancing cardiovascular medicine with machine learning: Progress, potential, and perspective

Recent advances in machine learning (ML) have made it possible to analyze high-dimensional and complex data-such as free text, images, waveforms, videos, and sound-in an automated manner by successfully learning complex associations within these data. Cardiovascular medicine is particularly well poised to take advantage of these ML advances, due to the widespread digitization of medical data and the large number of diagnostic tests used to evaluate cardiovascular disease. Various ML approaches have successfully been applied to cardiovascular tests and diseases to automate interpretation, accurately perform measurements, and, in some cases, predict novel diagnoses from less invasive tests, effectively expanding the utility of more widely accessible diagnostic tests. Here, we present examples of some impactful advances in cardiovascular medicine using ML across a variety of modalities, with a focus on deep learning applications.

Targeted Electronic Patient Portal Messaging Increases Hepatitis C Virus Screening in Primary Care: a Randomized Study

IMPORTANCE

Electronic health record (EHR) tools such as direct-to-patient messaging and automated lab orders are effective at improving uptake of preventive health measures. It is unknown if patient engagement in primary care impacts efficacy of such messaging.

OBJECTIVE

To determine whether more engaged patients, defined as those who have an upcoming visit scheduled, are more likely to respond to a direct-to-patient message with an automated lab order for hepatitis C virus (HCV) screening.

DESIGN

Randomized trial PARTICIPANTS: One thousand six hundred randomly selected Stanford Primary Care patients, 800 with an upcoming visit within 6 months and 800 without, born between 1945 and 1965 who were due for HCV screening. Each group was randomly divided into cohorts of 400 subjects each. Subjects were followed for 1 year.

INTERVENTION

One 400 subject cohort in each group received a direct-to-patient message through the EHR portal with HCV antibody lab order.

MAIN OUTCOME AND MEASURE

The EHR was queried on a monthly basis for 6 months after the intervention to monitor which subjects completed HCV screening. For any subjects screened positive for HCV, follow-up through the cascade of HCV care was monitored, and if needed, scheduled by the study team.

KEY RESULTS

Of 1600 subjects, 538 (34%) completed HCV screening. In the stratum without an upcoming appointment, 18% in the control group completed screening compared to 26% in intervention group (p<0.01). Similarly, in the stratum with an upcoming appointment, 34% in the control group completed screening compared to 58% in the intervention group (p<0.01).

CONCLUSION

Direct-to-patient messaging coupled with automated lab orders improved HCV screening rates compared to standard of care, particularly in more engaged patients. Including this intervention in primary care can maximize screening with each visit, which is particularly valuable in times when physical throughput in the healthcare system may be low.

Satisfied or not satisfied? Electronic health records system implementation in Ghana: Health leaders' perspective

Background

Electronic Health Records (EHR) has been espoused to be an innovation from the paper-based system, with benefits such as fast access to patient information thereby facilitating healthcare provider communication, healthcare continuity and improved quality of care. However, it is the extent of the quality of the electronic health records that determines the access to these stated benefits. The quality of health care records indirectly contributes to patient safety because inaccurate patient data can lead to improper diagnosis and consequently wrong treatment of patients. Most hospitals in Ghana, have recently transitioned into the EHR system, hence, there is a need to assess its accuracy, impact on workflow, staff training on usage, support from the EHR team, and the overall satisfaction of the EHR system. As health leaders are at the frontline of its implementation, their views on the challenges and successes of the EHR system are imperative.

Method

This qualitative study sought to explore the views of the health leaders on the implemented electronic health records system in nine (9) hospitals within three (3) regions in Ghana. Following ethical approval, GHS-ERC:007/04/21, focus group discussions were conducted with a minimum of 10 hospital leaders in each facility. These included quasi, government and private hospitals. Data was collected between September and November 2021.

Results

The study found poor quality of records, lack of involvement of frontline clinicians in the development of the EHR system, inadequate training of staff and limited workstations as some of the challenges associated with the use of EHR in hospitals. Health leaders were generally not satisfied with the EHR system.

Conclusion

It is recommended that addressing inputs from end-users as well as circulating more computers will motivate EHR usage and acceptance. Provision of additional workstations for the various units and involvement of staff in the system development would be most prudent to enable health workers to accept the EHR system in improving the quality of care.

Electronic health record adopters: a typology based on patients' privacy concerns and perceived benefits

OBJECTIVES

Patients' adoption of electronic health records (EHRs) varies substantially. Although some countries, such as Estonia and Denmark, are sufficiently advanced in terms of EHR generalisation, others, such as France, are figuring out how to implement and disseminate EHRs. These governments must respond to patients' disparities to achieve the expected performance for healthcare systems and improve the quality of care delivery. This study investigates patients' perceived benefits and privacy concerns related to EHRs to develop a typology of patients, identify the characteristics of different clusters and propose practical measures for public policy-makers.

STUDY DESIGN

We conducted a cross-sectional study using online questionnaires.

METHODS

An online quantitative survey was carried out in France. The final sample of EHR non-users (N = 1076) was fitted to be representative of the French population by age and gender, region and socioprofessional status. Hierarchical and non-hierarchical cluster analyses were performed. Several robustness check analyses were also performed.

RESULTS

Cluster analyses identified four patient clusters: the worried, who show the highest mean privacy concern and risk levels related to health data disclosure; the ready adopters, who lack privacy concerns and risk and are the most motivated by EHR benefits; the concerned adopters, who express far fewer privacy concerns and perceive EHR benefits more favourably than the worried adopters; and the balanced adopters, who are relatively similar to the ready adopters in their EHR motives and are still concerned about their health data, suggesting a segment that is easier to convince. Comparing clusters regarding the intentions to create EHRs and willingness to disclose health data confirms that ready adopters, followed by balanced adopters, are more likely to create an EHR and disclose health data. The concerned adopters and, finally, the worried exhibit the lowest intentions for EHR creation and data disclosure.

CONCLUSIONS

The results provide meaningful insights into patient profiles and expectations. The findings underscore the need to implement targeting policies for each cluster and design concrete solutions for improving EHR performance.

Nursing minimum data sets: Findings from an umbrella review

OBJECTIVES

This study explores the evidence available on Nursing Minimum Data Sets (NMDSs) by summarising: (a) the main methodological and reporting features of the reviews published in this field to date; (b) the recommendations developed and published in such reviews regarding the NMDSs, and (c) the categories and items that should be included in the NMDSs according to the available reviews.

METHODS

An Umbrella Review was performed. A search of secondary studies published up to November 2021 that were focused on NMDSs for adult hospitalised patients was conducted using MEDLINE (via PubMed), CINAHL and Scopus databases. The included studies were critically evaluated by using the Checklist for Systematic Review and Research Syntheses. The full review process was performed according to the Preferred Reporting Items for Systematic reviews and the Meta-Analyses statement.

RESULTS

From the initial 1311 studies that were retrieved, a total of eight reviews published from 1995 to 2018 were included. Their methodological quality was variable; these reviews offered four types of recommendations, namely at the overall, clinical, research and management levels. Additionally, seven NMDSs emerged with different purposes, elements, target populations and taxonomies. A list of categories and items that should be included in NMDSs have been summarised.

CONCLUSIONS

Nurses are daily involved in the nursing care documentation; however, which elements are recorded is mainly defined at the local levels and relies on paper and pencil. NMDS might provide a point of reference, specifically in the time of health digitalisation. Alongside other priorities as underlined in available recommendations, and the need to improve the quality of the reviews in this field, there is a need to develop a common NMDS by establishing its core elements, deciding on a standardised language and identifying linkages with other datasets.

Medical data integration using HL7 standards for patient's early identification

Integration between information systems is critical, especially in the healthcare domain, since interoperability requirements are related to patients’ data confidentiality, safety, and satisfaction. The goal of this study is to propose a solution based on the integration between queue management solution (QMS) and the electronic medical records (EMR), using Health Level Seven (HL7) protocols and Extensible Markup Language (XML). The proposed solution facilitates the patient’s self-check-in within a healthcare organization in UAE. The solution aims to help in minimizing the waiting times within the outpatient department through early identification of patients who hold the Emirates national ID cards, i.e., whether an Emirati or expatriates. The integration components, solution design, and the custom-designed XML and HL7 messages were clarified in this paper. In addition, the study includes a simulation experiment through control and intervention weeks with 517 valid appointments. The experiment goal was to evaluate the patient’s total journey and each related clinical stage by comparing the “routine-based identification” with the “patient’s self-check-in” processes in case of booked appointments. As a key finding, the proposed solution is efficient and could reduce the “patient’s journey time” by more than 14 minutes and “time to identify” patients by 10 minutes. There was also a significant drop in the waiting time to triage and the time to finish the triage process. In conclusion, the proposed solution is considered innovative and can provide a positive added value for the patient’s whole journey.

Emergency Physician Perceptions of Electronic Health Record Usability and Safety

OBJECTIVES

Despite requirements for electronic health record (EHR) vendor usability testing, usability challenges persist, contributing to patient safety concerns. We sought to identify emergency physicians' perceived EHR usability and safety strengths and shortcomings across major EHR vendor products.

METHODS

Fifty-five emergency physicians from 4 different hospitals were interviewed. The interviews were qualitatively analyzed, and physician comments were aligned with a usability taxonomy to identify emerging themes by vendor and hospital.

RESULTS

Of the 194 comments about usability, the 3 most commonly discussed usability topics were Workflow Support (33.5% of comments), Visual Display (20.1%), and Data Entry (14.4%). Electronic health record usability strengths were centered on Visual Display, and the most common shortcoming was the lack of Workflow Support. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes were identified.

CONCLUSIONS

Usability shortcomings that spanned across hospitals and vendors may suggest a need for more applied research and improved design to resolve these issues. Shortcomings that are localized to a specific product or hospital may be due to customization and may be addressable by learning from other organizations.

Integrating Option Grid Patient Decision Aids in the Epic Electronic Health Record: Case Study at 5 Health Systems

Background

Some researchers argue that the successful implementation of patient decision aids (PDAs) into clinical workflows depends on their integration into electronic health records (EHRs). Anecdotally, we know that EHR integration is a complex and time-consuming task; yet, the process has not been examined in detail. As part of an implementation project, we examined the work involved in integrating an encounter PDA for symptomatic uterine fibroids into Epic EHR systems.

Objective

This study aims to identify the steps and time required to integrate a PDA into the Epic EHR system and examine facilitators and barriers to the integration effort.

Methods

We conducted a case study at 5 academic medical centers in the United States. A clinical champion at each institution liaised with their Epic EHR team to initiate the integration of the uterine fibroid Option Grid PDAs into clinician-facing menus. We scheduled regular meetings with the Epic software analysts and an expert Epic technologist to discuss how best to integrate the tools into Epic for use by clinicians with patients. The meetings were then recorded and transcribed. Two researchers independently coded the transcripts and field notes before categorizing the codes and conducting a thematic analysis to identify the facilitators and barriers to EHR integration. The steps were reviewed and edited by an Epic technologist to ensure their accuracy.

Results

Integrating the uterine fibroid Option Grid PDA into clinician-facing menus required an 18-month timeline and a 6-step process, as follows: task priority negotiation with Epic software teams, security risk assessment, technical review, Epic configuration; troubleshooting, and launch. The key facilitators of the process were the clinical champions who advocated for integration at the institutional level and the presence of an experienced technologist who guided Epic software analysts during the build. Another facilitator was the use of an emerging industry standard app platform (Health Level 7 Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources) as a means of integrating the Option Grid into existing systems. This standard platform enabled clinicians to access the tools by using single sign-on credentials and prevented protected health information from leaving the EHR. Key barriers were the lack of control over the Option Grid product developed by EBSCO (Elton B Stephens Company) Health; the periodic Epic upgrades that can result in a pause on new software configurations; and the unforeseen software problems with Option Grid (ie, inability to print the PDA), which delayed the launch of the PDA.

Conclusions

The integration of PDAs into the Epic EHR system requires a 6-step process and an 18-month timeline. The process required support and prioritization from a clinical champion, guidance from an experienced technologist, and a willing EHR software developer team.

Modeling patient-related workload in the emergency department using electronic health record data

INTRODUCTION

Understanding and managing clinician workload is important for clinician (nurses, physicians and advanced practice providers) occupational health as well as patient safety. Efforts have been made to develop strategies for managing clinician workload by improving patient assignment. The goal of the current study is to use electronic health record (EHR) data to predict the amount of work that individual patients contribute to clinician workload (patient-related workload).

METHODS

One month of EHR data was retrieved from an emergency department (ED). A list of workload indicators and five potential workload proxies were extracted from the data. Linear regression and four machine learning classification algorithms were utilized to model the relationship between the indicators and the proxies.

RESULTS

Linear regression proved that the indicators explained a substantial amount of variance of the proxies (four out of five proxies were modeled with R² > 0.80). Classification algorithms also showed success in classifying a patient as having high or low task demand based on data from early in the ED visit (e.g. 80 % accurate binary classification with data from the first hour).

CONCLUSION

The main contribution of this study is demonstrating the potential of using EHR data to predict patient-related workload automatically in the ED. The predicted workload can potentially help in managing clinician workload by supporting decisions around the assignment of new patients to providers. Future work should focus on identifying the relationship between workload proxies and actual workload, as well as improving prediction performance of regression and multi-class classification.

The anatomy of electronic patient record ethics: a framework to guide design, development, implementation, and use

BACKGROUND

This manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care.

METHODS

Development of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application.

RESULTS

The framework is divided into two parts: context and core functions. The first part 'context' entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR 'core functions' of data collection, data access, and digitally-enabled healthcare.

CONCLUSIONS

The primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge.

Making the Case for a P2P Personal Health Record

Improved health care services can benefit from a more seamless exchange of medical information between patients and health care providers. This exchange is especially important considering the increasing trends in mobility, comorbidity and outbreaks. However, current Electronic Health Records (EHR) tend to be institution-centric, often leaving the medical information of the patient fragmented and more importantly inaccessible to the patient for sharing with other health providers in a timely manner. Nearly a decade ago, several client–server models for personal health records (PHR) were proposed. The aim of these previous PHRs was to address data fragmentation issues. However, these models were not widely adopted by patients. This paper discusses the need for a new PHR model that can enhance the patient experience by making medical services more accessible. The aims of the proposed model are to (1) help patients maintain a complete lifelong health record, (2) facilitate timely communication and data sharing with health care providers from multiple institutions and (3) promote integration with advanced third-party services (e.g., risk prediction for chronic diseases) that require access to the patient’s health data. The proposed model is based on a Peer-to-Peer (P2P) network as opposed to the client–server architecture of the previous PHR models. This architecture consists of a central index server that manages the network and acts as a mediator, a peer client for patients and providers that allows them to manage health records and connect to the network, and a service client that enables third-party providers to offer services to the patients. This distributed architecture is essential since it promotes ownership of the health record by the patient instead of the health care institution. Moreover, it allows the patient to subscribe to an extended range of personalized e-health services.

Health Outcomes and Healthcare Efficiencies Associated with the Use of Electronic Health Records in Hospital Emergency Departments: a Systematic Review

Healthcare organisations and governments have invested heavily in electronic health records in anticipation that they will deliver improved health outcomes for consumers and efficiencies across emergency departments. Despite such investment, electronic health records designed to support emergency care have been poorly evaluated. Given the accelerated development and adoption of information technology across healthcare, it is timely that a systematic review of this evidence base is updated in order to drive improvements to design, interoperability and overall clinical utility of electronic health record systems implemented in emergency departments. To assess the impact of electronic health records on healthcare outcomes and efficiencies in the emergency department we carried out a systematic review of published studies on this topic. This is the first review to summarise the cost efficiencies associated with electronic health record use outside of just the United States of America. A systematic search was performed in three scientific databases (MEDLINE, EMcare and EMBASE), of literature published between January 2000 and September 2019. Studies were included in this review if they evaluated electronic health records or health information exchanges (and synonyms for these terms), reported patient outcome and/or healthcare efficiency benefits, were peer-reviewed and published in English. Out of 6635 articles, 23 studies met our inclusion criteria. Wide variation regarding electronic health record access in the emergency department was reported (1.46-56.6%), yet was most frequently reported as less than 20%. Seven different types of health outcomes and three different types of efficiency improvements associated with electronic health record use in the emergency department were identified. The most frequently reported findings were efficiencies, including reductions in diagnostic tests, imaging and costs. This review is the first to report moderate to significant increases in admission rates are associated with electronic health record use in the emergency department, contrasting the findings of previous reviews. Diversity in the methodology employed across the included studies emphasises the need for further research to examine the impact of electronic health record implementation and system design on the findings reported, in order to ensure return on investment for stakeholders and optimised consumer care.

Rapid health data repository allocation using predictive machine learning

Health-related data is stored in a number of repositories that are managed and controlled by different entities. For instance, Electronic Health Records are usually administered by governments. Electronic Medical Records are typically controlled by health care providers, whereas Personal Health Records are managed directly by patients. Recently, Blockchain-based health record systems largely regulated by technology have emerged as another type of repository. Repositories for storing health data differ from one another based on cost, level of security and quality of performance. Not only has the type of repositories increased in recent years, but the quantum of health data to be stored has increased. For instance, the advent of wearable sensors that capture physiological signs has resulted in an exponential growth in digital health data. The increase in the types of repository and amount of data has driven a need for intelligent processes to select appropriate repositories as data is collected. However, the storage allocation decision is complex and nuanced. The challenges are exacerbated when health data are continuously streamed, as is the case with wearable sensors. Although patients are not always solely responsible for determining which repository should be used, they typically have some input into this decision. Patients can be expected to have idiosyncratic preferences regarding storage decisions depending on their unique contexts. In this paper, we propose a predictive model for the storage of health data that can meet patient needs and make storage decisions rapidly, in real-time, even with data streaming from wearable sensors. The model is built with a machine learning classifier that learns the mapping between characteristics of health data and features of storage repositories from a training set generated synthetically from correlations evident from small samples of experts. Results from the evaluation demonstrate the viability of the machine learning technique used.

Management of supply chains with attribute-sensitive products: a comprehensive literature review and future research agenda

Purpose

Mismanagement of supply chain operations may lead to waste of products and incur substantial monetary losses. This is particularly true for products with attributes that hasten deterioration, e.g. time, temperature, humidity and barometric pressure. Attribute-sensitive products must be carefully monitored throughout all supply chain processes to ensure acceptable quality to the end customers. This paper presents a comprehensive review of the scientific literature on attribute sensitive products and on attribute sensitive supply chains. The collected studies were reviewed using the content analysis method, focusing on the following aspects of attribute sensitive products: (1) industries; (2) product categories; (3) decisions involved; (4) processes; (5) current issues; (6) sustainability concerns; (7) research methods used; (8) objectives of decision makers; (9) solution approaches used; (10) incentives driving management and (11) future research issues. Based on the analysis of findings, gaps are identified, and future research directions are proposed.

Design/methodology/approach

Literature review and content analysis.

Findings

The authors discovered that, while the importance of product attributes vary from one industry to the other, overall the time attribute was critical in all of the industries considered in this literature review. Coordination, customer satisfaction, reliability and safety were key issues in attribute sensitive product supply chains (asp-SCs). Similar to the typical supply chains, asp-SCs face economic, social and environmental sustainability issues. However, the majority of the studies in our analysis emphasized importance of the social sustainability. The majority of the papers were reviewed and analyzed and adopted the modeling approach as a research method. Furthermore, it was found that asp-SCs were mostly driven with customer demands and social pressure.

Research limitations/implications

Based on the literature review and content analysis, there are a number of directions for the work conducted in this study to be extended in several directions. First, the literature search could be expanded by relaxing some of the restrictions (e.g. include the conference papers and articles from on-line business journals). Second, additional scientific publishers can be considered (e.g. Emerald Insight–www.emeraldinsight.com; Inderscience–www.inderscience.com). The latter two extensions would allow a more precise assessment of published to date work on asp-SC operations. Third, our findings could be validated based on interviews with professionals and executives from companies dealing with asp-SCs. Such validation will allow identification of the differences between the state of the art and the state of practice.

Practical implications

Supply chains that handle attribute sensitive products (asps) must consider the complexity of products that significantly change their properties due to factors such as time, temperature, barometric pressure, humidity. Mismanagement of operations within such supply chains may lead to significant product waste, as well as substantial monetary losses.

Originality/value

This study presented a comprehensive literature review and content analysis of studies dealing with asps in the following industries: fashion, food, healthcare, humanitarian and pharmaceutical industries

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review

BACKGROUND

Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain.

METHODS

To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology.

RESULTS

The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters 'privacy', 'autonomy', 'risk/benefit', 'human relationships', and 'responsibility'. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved.

CONCLUSIONS

While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

Integrated Care Programs for People with Multimorbidity in European Countries: eHealth Adoption in Health Systems

INTRODUCTION

eHealth applications have the potential to provide new integrated care services to patients with multimorbidity (MM), also supporting multidisciplinary care. The aim of this paper is to explore how widely eHealth tools have been currently adopted in integrated care programs for (older) people with MM in European countries, including benefits and barriers concerning their adoption, according to some basic health system characteristics.

MATERIALS AND METHODS

In 2014, in the framework of the ICARE4EU project, expert organizations in 24 European countries identified 101 integrated care programs. Managers of the selected programs completed an online questionnaire on several dimensions, including the use of eHealth. We analyzed data from this questionnaire, in addition to qualitative information from six innovative programs which were studied in depth through case study methodology, according to characteristics of national health systems: a national health model (financing system), overall strength of primary care (PC) (structure/service delivery process), and level of (de)centralization of health system (executive powers in a country).

RESULTS

85 programs (out of 101) adopted at least one eHealth tool, and 42 of these targeted explicitly older people. In most cases, Electronic Health Records (EHRs) were used and some benefits emerged like improved care management and integration, although inadequate funding mechanisms represented a major barrier. The analysis by health system characteristics showed a greater adoption of eHealth applications in decentralized countries, in countries with a National Health Service (NHS) model, and in countries with a strong/medium level of PC development.

CONCLUSIONS

Although in the light of some limitations, findings indicate a relation between implementation of care programs using eHealth tools and basic characteristics of health systems, with decentralization of a health system, NHS model, and strong/medium PC having a key role. However adaptations of European health systems seem necessary, in order to provide a more innovative and integrated care.

Quantification and visualisation methods of data-driven chronic care delivery pathways: protocol for a systematic review and content analysis

INTRODUCTION

Chronic conditions require long periods of care and often involve repeated interactions with multiple healthcare providers. Faced with increasing illness burden and costs, healthcare systems are currently working towards integrated care to streamline these interactions and improve efficiency. To support this, one promising resource is the information on routine care delivery stored in various electronic healthcare databases (EHD). In chronic conditions, care delivery pathways (CDPs) can be constructed by linking multiple data sources and extracting time-stamped healthcare utilisation events and other medical data related to individual or groups of patients over specific time periods; CDPs may provide insights into current practice and ways of improving it. Several methods have been proposed in recent years to quantify and visualise CDPs. We present the protocol for a systematic review aiming to describe the content and development of CDP methods, to derive common recommendations for CDP construction.

METHODS AND ANALYSIS

This protocol followed the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols. A literature search will be performed in PubMed (MEDLINE), Scopus, IEEE, CINAHL and EMBASE, without date restrictions, to review published papers reporting data-driven chronic CDPs quantification and visualisation methods. We will describe them using several characteristics relevant for EHD use in long-term care, grouped into three domains: (1) clinical (what clinical information does the method use and how was it considered relevant?), (2) data science (what are the method's development and implementation characteristics?) and (3) behavioural (which behaviours and interactions does the method aim to promote among users and how?). Data extraction will be performed via deductive content analysis using previously defined characteristics and accompanied by an inductive analysis to identify and code additional relevant features. Results will be presented in descriptive format and used to compare current CDPs and generate recommendations for future CDP development initiatives.

ETHICS AND DISSEMINATION

Database searches will be initiated in May 2019. The review is expected to be completed by February 2020. Ethical approval is not required for this review. Results will be disseminated in peer-reviewed journals and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019140494.

Organizational Characteristics and the Adoption of Electronic Health Records Among Nursing Homes in One Southern State

Electronic health records (EHRs) can improve quality of care and patient safety, as demonstrated in a variety of health care settings. However, greater use of EHRs in nursing homes (NHs) is needed. To understand which NHs have and have not adopted EHR systems, all federally certified NHs in Arkansas (n = 223) were surveyed, with 27.9% responding. Non-responders were similar to responders on all characteristics except for staffing skill mix, with responders having a higher skill mix than non-responders. Two thirds of responding Arkansas NHs reported having an EHR system in use (69.8%), while only a few reported no plans for an EHR system (4.8%). NHs with greater resources and in competitive markets were more likely to implement EHR systems. Full implementation across all NHs may require intervention, which should be explored in future research. In addition, future investigation should consider the level of interoperability of EHR systems that are in place among NHs.

Frequent Mobile Electronic Medical Records Users Respond More Quickly to Emergency Department Consultation Requests: Retrospective Quantitative Study

Background

Specialty consultation is a critical aspect of emergency department (ED) practice, and a delay in providing consultation might have a significant clinical effect and worsen ED overcrowding. Although mobile electronic medical records (EMR) are being increasingly used and are known to improve the workflow of health care providers, limited studies have evaluated their effectiveness in real-life clinical scenarios.

Objective

For this study, we aimed to determine the association between response duration to an ED specialty consultation request and the frequency of mobile EMR use.

Methods

This retrospective study was conducted in an academic ED in Seoul, South Korea. We analyzed EMR and mobile EMR data from May 2018 to December 2018. Timestamps of ED consultation requests were retrieved from a PC-based EMR, and the response interval was calculated. Doctors’ log frequencies were obtained from the mobile EMR, and we merged data using doctors’ deidentification numbers. Pearson’s product-moment correlation was performed to identify this association. The primary outcome was the relationship between the frequency of mobile EMR usage and the time interval from ED request to consultation completion by specialty doctors. The secondary outcome was the relationship between the frequency of specialty doctors’ mobile EMR usage and the response time to consultation requests.

Results

A total of 25,454 consultations requests were made for 15,555 patients, and 252 specialty doctors provided ED specialty consultations. Of the 742 doctors who used the mobile EMR, 208 doctors used it for the specialty consultation process. After excluding the cases lacking essential information, 21,885 consultations with 208 doctors were included for analysis. According to the mobile EMR usage pattern, the average usage frequency of all users was 13.3 logs/day, and the average duration of the completion of the specialty consultation was 51.7 minutes. There was a significant inverse relationship between the frequency of mobile EMR usage and time interval from ED request to consultation completion by specialty doctors (coefficient=–0.19; 95% CI –0.32 to –0.06; P=.005). Secondary analysis with the response time was done. There was also a significant inverse relationship between the frequency of specialty doctors’ mobile EMR usage and the response time to consultation requests (coefficient=–0.18; 95% CI –0.30 to –0.04; P=.009).

Conclusions

Our findings suggest that frequent mobile EMR usage is associated with quicker response time to ED consultation requests.

Self-Check-In Kiosks Utilization and Their Association With Wait Times in Emergency Departments in the United States

BACKGROUND

Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied.

OBJECTIVES

To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs.

METHODS

Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times.

RESULTS

During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time.

CONCLUSIONS

Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis

BACKGROUND

Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue.

AIM

To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge.

DESIGN AND SETTING

A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland.

METHOD

The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process.

RESULTS

In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders.

CONCLUSION

The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

A comparative study of the utilisation of an electronic test-result management system in emergency and intensive care settings

The purpose of this qualitative study was to identify differences in the utilisation of an electronic medical record test-result management system between two acute care departments. Field observations (130 min) and semi-structured interviews (n = 24) were conducted in the Intensive Care Unit and Emergency Department of an Australian hospital. Work processes identified from audio transcripts were modelled using business process modelling. Comparison of the Emergency Department and Intensive Care Unit identified the following: (1) test ordering variations according to clinical roles, (2) differences in the use of electronic medical record functionality according to specific demands of the clinical environment and (3) the non-linear components of the test-result management process. Variations were identified in the number of process decisions, external collaborations and temporal process workflows. Modelling the business processes, collaboration and communication needs of individual clinical environments can aid in enhancing the quality and appositeness of health information technology interventions and thus contribute to improving patient safety. Future health information technology interventions/evaluations aimed at improving the safety of test-result management processes need to address both the nuances of the clinical environment and accommodate the individual work practices of clinicians within that environment.

Implementation of electronic records management systems

Purpose

Technology has influenced the implementation of electronic records management systems (ERMS) in government agencies. The high incidence of poor service delivery in government agencies is a key factor that has put pressure on the government to implement ERMS. Despite the potential benefits of implementing ERMS, the adoption and use of these programs has been slow and some systems have failed. Therefore, the purpose of this study is to assess how Tlokweng land board (TLB) implemented its electronic records management program using Kotter’s model and awareness, desire, knowledge, ability and reinforcement change model.

Design/methodology/approach

The study adopted a pragmatic paradigm and used a case study research design to collect data at TLB. The research made use of mixed methods approach to collect data using questionnaires, interviews and document reviews. Purposeful sampling was used to solicit data from 53 participants in the land board.

Findings

The findings of the study revealed that communication has been used as the most effective tool for managing change at TLB. However, TLB has not yet managed to reinforce the change implemented because of the lack of adequate training and motivation of change champions. Moreover, the change management team has little training on the change management framework produced by the Ministry of Lands and Housing.

Research limitations/implications

The study was limited to one land board in Botswana. Therefore, the findings may not be generalized to all land boards.

Originality/value

This is the first study to be conducted in Botswana that has assessed change management practices in the implementation of records management systems. This study therefore recommends adoption of the change management lens/framework by a records professional when implementing ERMS.

Integrating Artificial and Human Intelligence: A Partnership for Responsible Innovation in Biomedical Engineering and Medicine

Historically, the term "artificial intelligence" dates to 1956 when it was first used in a conference at Dartmouth College in the US. Since then, the development of artificial intelligence has in part been shaped by the field of neuroscience. By understanding the human brain, scientists have attempted to build new intelligent machines capable of performing complex tasks akin to humans. Indeed, future research into artificial intelligence will continue to benefit from the study of the human brain. While the development of artificial intelligence algorithms has been fast paced, the actual use of most artificial intelligence (AI) algorithms in biomedical engineering and clinical practice is still markedly below its conceivably broader potentials. This is partly because for any algorithm to be incorporated into existing workflows it has to stand the test of scientific validation, clinical and personal utility, application context, and is equitable as well. In this context, there is much to be gained by combining AI and human intelligence (HI). Harnessing Big Data, computing power and storage capacities, and addressing societal issues emergent from algorithm applications, demand deploying HI in tandem with AI. Very few countries, even economically developed states, lack adequate and critical governance frames to best understand and steer the AI innovation trajectories in health care. Drug discovery and translational pharmaceutical research stand to gain from AI technology provided they are also informed by HI. In this expert review, we analyze the ways in which AI applications are likely to traverse the continuum of life from birth to death, and encompassing not only humans but also all animal, plant, and other living organisms that are increasingly touched by AI. Examples of AI applications include digital health, diagnosis of diseases in newborns, remote monitoring of health by smart devices, real-time Big Data analytics for prompt diagnosis of heart attacks, and facial analysis software with consequences on civil liberties. While we underscore the need for integration of AI and HI, we note that AI technology does not have to replace medical specialists or scientists and rather, is in need of such expert HI. Altogether, AI and HI offer synergy for responsible innovation and veritable prospects for improving health care from prevention to diagnosis to therapeutics while unintended consequences of automation emergent from AI and algorithms should be borne in mind on scientific cultures, work force, and society at large.

Building Better Clinical Relationships With Patients: An Argument for Digital Health Solutions With Black Men

There is a rapid evolution of care delivery taking place across the globe in response to an explosion of novel health technologies. Growing in parallel to this expansion is the anticipation of mHealth technologies to drive patient-centered care into the future. Despite this hope, continuing reports of health inequities and lived experiences of substandard care fill national, state, and community health reports. The impact of these inequities is particularly pernicious on Black men and their long-term health status. As decades of robust evidence substantiates needed interventions, current progress is not seeing expected gains. In this commentary, we argue that at the heart of these inequities are issues of access, health literacy, institutional racism, and growing social distance between clinicians and Black men. To address these inequities, we suggest that digital interventions, designed to support decision-making, information exchange, and shared accountability have the best hope to overcome current inequities by promoting authentic relationships that ultimately drive better communication between Black men and their clinicians.

Variability in Doctors' Usage Paths of Mobile Electronic Health Records Across Specialties: Comprehensive Analysis of Log Data

Background

With the emergence of mobile devices, mobile electronic health record (mEHR) systems have been utilized by health care professionals (HCPs), including doctors, nurses, and other practitioners, to improve efficiency at the point of care. Although several studies on mEHR systems were conducted, including those analyzing their effects and HCPs’ usage frequency, only a few considered the specific workflows of doctors based on their specialties in which the work process differs greatly.

Objective

This study aimed to investigate the differences in mEHR usage paths across clinical specialties.

Methods

We collected the log data of 974 doctors who worked from August 2016 to August 2017 and used the mEHR system at the Samsung Medical Center, one of the biggest hospitals in South Korea. The doctors were classified into 3 groups based on their specialty: the physician, the surgeon, and other hospital-based physician (OHBP) groups. We used various descriptive and visualization methods to understand and compare doctors’ usage paths of mEHRs. First, the average numbers of log-ins per day and features used per log-in were examined over different specialties and positions. Second, the number of features used by each doctor was visualized via a heat map to provide an overview of mEHR usage across feature types and doctors’ specialties. Third, we conducted a path analysis via a Sankey diagram to describe main usage paths and association rule mining to find frequent paths in mEHR usage.

Results

The physician group logged on most frequently, whereas the OHBP group logged on least frequently. In fact, the number of log-ins per day of residents in the physician group was 4.4 times higher than that of staff members in the other groups. The heat map visualization showed a visible difference among specialty groups. The physician group used more consultation-related features, whereas the surgeon group used more surgery-related features. Generally, 50% of the doctors spent about 15 seconds at a time when using mEHRs. In the Sankey diagram, the physician group showed diverse usage patterns with higher complexity compared with the other 2 groups; in particular, their paths contained more loops, which reflected repetitive checks on multiple patients. The most frequent path included inpatient summary, which means that most users stopped at the point of summary and did not proceed to view more details.

Conclusions

The usage paths of mEHRs showed considerable differences among the specialty groups. Such differences can be accommodated into an mEHR design to enhance the efficiency of care.

Diversity in the emergency care for febrile children in Europe: a questionnaire study

OBJECTIVE

To provide an overview of care in emergency departments (EDs) across Europe in order to interpret observational data and implement interventions regarding the management of febrile children.

DESIGN AND SETTING

An electronic questionnaire was sent to the principal investigators of an ongoing study (PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management), www.perform2020.eu) in 11 European hospitals in eight countries: Austria, Germany, Greece, Latvia, the Netherlands, Slovenia, Spain and the UK.

OUTCOME MEASURES

The questionnaire covered indicators in three domains: local ED quality (supervision, guideline availability, paper vs electronic health records), organisation of healthcare (primary care, immunisation), and local factors influencing or reflecting resource use (availability of point-of-care tests, admission rates).

RESULTS

Reported admission rates ranged from 4% to 51%. In six settings (Athens, Graz, Ljubljana, Riga, Rotterdam, Santiago de Compostela), the supervising ED physicians were general paediatricians, in two (Liverpool, London) these were paediatric emergency physicians, in two (Nijmegen, Newcastle) supervision could take place by either a general paediatrician or a general emergency physician, and in one (München) this could be either a general paediatrician or a paediatric emergency physician. The supervising physician was present on site in all settings during office hours and in five out of eleven settings during out-of-office hours. Guidelines for fever and sepsis were available in all settings; however, the type of guideline that was used differed. Primary care was available in all settings during office hours and in eight during out-of-office hours. There were differences in routine immunisations as well as in additional immunisations that were offered; immunisation rates varied between and within countries.

CONCLUSION

Differences in local, regional and national aspects of care exist in the management of febrile children across Europe. This variability has to be considered when trying to interpret differences in the use of diagnostic tools, antibiotics and admission rates. Any future implementation of interventions or diagnostic tests will need to be aware of this European diversity.

Information Technology in Healthcare: HHC-MOTES, a Novel Set of Metrics to Analyse IT Sustainability in Different Areas

Sustainability, as a science, is the guideline of the present work. It aims to analyse, by means of a literature review, various areas of healthcare in which information technology (IT) has been- or could be-used, leading to several sources of sustainability, for example, cost savings, better teamwork, higher quality and efficiency of medical care. After a brief introduction analysing the strategic contexts in which innovation in general, and IT in particular, can be a source of general improvements in efficiency, cost savings and service quality, the research focuses on the healthcare system by discussing the different nature of private and public organizations in terms of adopting innovations and changes and discussing the issue of consumer health costs and consumer choices. The following part focuses on the qualitative benefits of IT in healthcare and discusses the importance of metrics for measuring performance, costs and efficiency in this area. The work then qualitatively introduces a new set of Key Performance Indicators (KPI), partly based on literature from different topics and existing and validated sets of metrics, analysing, under the point of view of sustainability, the implementation of IT in healthcare, namely in management, organization, technology, environment and social fields (HHC-MOTES framework). The model, inspired by and to sustainability, can be used as a decision support at the strategic management level as well as for the analysis and investigation of the effects of IT systems in the healthcare sector from various perspectives.