The computer-based patient record challenges towards timeless and spaceless medical practice

User acceptance of inter-organizational electronic medical records

This paper reports the findings of the first stage of an ongoing, longitudinal study into primary care practitioners’ views of an electronic medical records (EMR) system for maternity patients. All doctors and midwives holding maternity care contracts with a large urban hospital in New Zealand were sent a questionnaire soliciting their views on a planned EMR system linking the hospital and the primary care sectors.

The questionnaire was based on Davis’ technology acceptance model (TAM) [1]. The results show that while Davis’ two key factors of perceived ease of use and perceived usefulness were important to medical professionals, other features of the proposed system and the wider organizational environment also influenced the respondents’ willingness to utilize the proposed system.

Determinants of telemedicine acceptance in selected public hospitals in Malaysia: clinical perspective

The purpose of this study is to explore the determinants of telemedicine acceptance in selected public hospitals in Malaysia and to investigate the effect of health culture on the relationship between these determinants and telemedicine acceptance. Data were gathered by means of a survey of physicians and nurses as the main group of users of telemedicine technology from hospitals that are currently using telemedicine technology. The results indicated that government policies, top management support, perception of usefulness and computer self-efficiency have a positive and significant impact on telemedicine acceptance by public hospitals in Malaysia. The results also confirmed the moderating role of health culture on the relationship between government policies as well as perceived usefulness on telemedicine acceptance by Malaysian hospitals. The results are useful for decision-makers as well as managers to recognize the potential role of telemedicine and assist in the process of implementation, adoption and utilization, and, therefore, spread the usage of telemedicine technology in more hospitals in the country.

Context-based electronic health record: toward patient specific healthcare

Due to the increasingly data-intensive clinical environment, physicians now have unprecedented access to detailed clinical information from a multitude of sources. However, applying this information to guide medical decisions for a specific patient case remains challenging. One issue is related to presenting information to the practitioner: displaying a large (irrelevant) amount of information often leads to information overload. Next-generation interfaces for the electronic health record (EHR) should not only make patient data easily searchable and accessible, but also synthesize fragments of evidence documented in the entire record to understand the etiology of a disease and its clinical manifestation in individual patients. In this paper, we describe our efforts toward creating a context-based EHR, which employs biomedical ontologies and (graphical) disease models as sources of domain knowledge to identify relevant parts of the record to display. We hypothesize that knowledge (e.g., variables, relationships) from these sources can be used to standardize, annotate, and contextualize information from the patient record, improving access to relevant parts of the record and informing medical decision making. To achieve this goal, we describe a framework that aggregates and extracts findings and attributes from free-text clinical reports, maps findings to concepts in available knowledge sources, and generates a tailored presentation of the record based on the information needs of the user. We have implemented this framework in a system called Adaptive EHR, demonstrating its capabilities to present and synthesize information from neurooncology patients. This paper highlights the challenges and potential applications of leveraging disease models to improve the access, integration, and interpretation of clinical patient data.

Understanding managerial behaviour during initial steps of a clinical information system adoption

BACKGROUND

While the study of the information technology (IT) implementation process and its outcomes has received considerable attention, the examination of pre-adoption and pre-implementation stages of configurable IT uptake appear largely under-investigated. This paper explores managerial behaviour during the periods prior the effective implementation of a clinical information system (CIS) by two Canadian university multi-hospital centers.

METHODS

Adopting a structurationist theoretical stance and a case study research design, the processes by which CIS managers' patterns of discourse contribute to the configuration of the new technology in their respective organizational contexts were longitudinally examined over 33 months.

RESULTS

Although managers seemed to be aware of the risks and organizational impact of the adoption of a new clinical information system, their decisions and actions over the periods examined appeared rather to be driven by financial constraints and power struggles between different groups involved in the process. Furthermore, they largely emphasized technological aspects of the implementation, with organizational dimensions being put aside. In view of these results, the notion of 'rhetorical ambivalence' is proposed. Results are further discussed in relation to the significance of initial decisions and actions for the subsequent implementation phases of the technology being configured.

CONCLUSIONS

Theoretical and empirically grounded, the paper contributes to the underdeveloped body of literature on information system pre-implementation processes by revealing the crucial role played by managers during the initial phases of a CIS adoption.

Developing and validating a model to predict the success of an IHCS implementation: the Readiness for Implementation Model

OBJECTIVE

To develop and validate the Readiness for Implementation Model (RIM). This model predicts a healthcare organization's potential for success in implementing an interactive health communication system (IHCS). The model consists of seven weighted factors, with each factor containing five to seven elements.

DESIGN

Two decision-analytic approaches, self-explicated and conjoint analysis, were used to measure the weights of the RIM with a sample of 410 experts. The RIM model with weights was then validated in a prospective study of 25 IHCS implementation cases.

MEASUREMENTS

Orthogonal main effects design was used to develop 700 conjoint-analysis profiles, which varied on seven factors. Each of the 410 experts rated the importance and desirability of the factors and their levels, as well as a set of 10 different profiles. For the prospective 25-case validation, three time-repeated measures of the RIM scores were collected for comparison with the implementation outcomes.

RESULTS

Two of the seven factors, 'organizational motivation' and 'meeting user needs,' were found to be most important in predicting implementation readiness. No statistically significant difference was found in the predictive validity of the two approaches (self-explicated and conjoint analysis). The RIM was a better predictor for the 1-year implementation outcome than the half-year outcome.

LIMITATIONS

The expert sample, the order of the survey tasks, the additive model, and basing the RIM cut-off score on experience are possible limitations of the study.

CONCLUSION

The RIM needs to be empirically evaluated in institutions adopting IHCS and sustaining the system in the long term.

Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals

This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.

Success in health information exchange projects: solving the implementation puzzle

Interest in health information exchange (HIE), defined as the use of information technology to support the electronic transfer of clinical information across health care organizations, continues to grow among those pursuing greater patient safety and health care accessibility and efficiency. In this paper, we present the results of a longitudinal multiple-case study of two large-scale HIE implementation projects carried out in real time over 3-year and 2-year periods in Québec, Canada. Data were primarily collected through semi-structured interviews (n=52) with key informants, namely implementation team members and targeted users. These were supplemented with non-participants observation of team meetings and by the analysis of organizational documents. The cross-case comparison was particularly relevant given that project circumstances led to contrasting outcomes: while one project failed, the other was a success. A risk management analysis was performed taking a process view in order to capture the complexity of project implementations as evolving phenomena that are affected by interdependent pre-existing and emergent risks that tend to change over time. The longitudinal case analysis clearly demonstrates that the risk factors were closely intertwined. Systematic ripple effects from one risk factor to another were observed. This risk interdependence evolved dynamically over time, with a snowball effect that rendered a change of path progressively more difficult as time passed. The results of the cross-case analysis demonstrate a direct relationship between the quality of an implementation strategy and project outcomes.

Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

CONTEXT

The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches.

METHODS

Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation.

FINDINGS

Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful").

CONCLUSIONS

The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.

Health IT success and failure: recommendations from literature and an AMIA workshop

With the United States joining other countries in national efforts to reap the many benefits that use of health information technology can bring for health care quality and savings, sobering reports recall the complexity and difficulties of implementing even smaller-scale systems. Despite best practice research that identified success factors for health information technology projects, a majority, in some sense, still fail. Similar problems plague a variety of different kinds of applications, and have done so for many years. Ten AMIA working groups sponsored a workshop at the AMIA Fall 2006 Symposium. It was entitled "Avoiding The F-Word: IT Project Morbidity, Mortality, and Immortality" and focused on this under-addressed problem. PARTICIPANTS discussed communication, workflow, and quality; the complexity of information technology undertakings; the need to integrate all aspects of projects, work environments, and regulatory and policy requirements; and the difficulty of getting all the parts and participants in harmony. While recognizing that there still are technical issues related to functionality and interoperability, discussion affirmed the emerging consensus that problems are due to sociological, cultural, and financial issues, and hence are more managerial than technical. Participants drew on lessons from experience and research in identifying important issues, action items, and recommendations to address the following: what "success" and "failure" mean, what contributes to making successful or unsuccessful systems, how to use failure as an enhanced learning opportunity for continued improvement, how system successes or failures should be studied, and what AMIA should do to enhance opportunities for successes. The workshop laid out a research agenda and recommended action items, reflecting the conviction that AMIA members and AMIA as an organization can take a leadership role to make projects more practical and likely to succeed in health care settings.

Expanding multi-disciplinary approaches to healthcare information technologies: what does information systems offer medical informatics?

The effective use of information technology (IT) is a crucial component for the delivery of effective services in health care. Current approaches to medical informatics (MI) research have significantly contributed to the success of IT use in health care but important challenges remain to be addressed. We believe that expanding the multi-disciplinary basis for MI research is important to meeting these research challenges. In this paper, we outline theories and methods used in information systems (IS) research that we believe can inform our understanding of health care IT applications and outcomes. To do so, we discuss some general differences in the focus and methods of MI and IS research to identify broad opportunities. We then review conceptual and methodological approaches in IS that have been applied in health care IT research. These include: technology-use mediation, collaborative work, genre theory, interpretive research, action research, and modeling. Examples of these theories and methods in healthcare IS research are illustrated.

Measuring mobile patient safety information system success: an empirical study

OBJECTIVE

The Health Risk Reminders and Surveillance (HRRS) system was designed to deliver critical abnormal test results of severely ill patients from Laboratory, Radiology, and Pathology departments to physicians within 5 min using cell phone text messages. This paper explores the success of the HRRS system.

METHOD

This study employed an augmented version of the DeLone and McLean IS success model. Seven variables (system quality, information quality, system use, user satisfaction, mobile healthcare anxiety, impact on the individual and impact on the organization) were used to evaluate the success of the HRRS system. The interrelationships between the seven variables were hypothesized and the hypotheses were empirically tested.

RESULTS

The results indicate that the information quality of the HRRS system is positively associated with both system use and user satisfaction. In addition, system use is positively associated with user satisfaction, which is also positively associated with mobile healthcare anxiety. Moreover, results indicate that impact on the individual is positively associated with both user satisfaction and mobile healthcare anxiety. Finally, the impact of the organization is positively associated with impact on the individual.

CONCLUSION

The results of the study provide an expanded understanding of the factors that contribute to mobile patient safety information system (IS) success. Implications of the relationship between system use and physician mobile healthcare anxiety are discussed.

A risk assessment of two interorganizational clinical information systems

A risk analysis framework was used to examine the implementation barriers that may hamper the successful implementation of interorganizational clinical information systems (ICIS). In terms of study design, an extensive literature review was first performed in order to elaborate a comprehensive model of project risk factors. To test the applicability of the model, we next conducted a longitudinal multiple-case study of two large-scale ICIS demonstration projects carried out in Quebec, Canada. Variations in the levels of several risk dimensions measured throughout the duration of the projects were analyzed to determine their impact on successful implementation. The analysis shows that the proposed framework, composed of five risk dimensions, was very robust, and suitable for conducting a thorough risk analysis. The results also show that there are links between the quality of the risk management and the level of project outcomes. To be successful, it is important that the implementation efforts be distributed proportionally according to the importance of each of the risk factors. Furthermore, because the risks evolve dynamically, there is a need for high responsiveness to emerging implementation problems. Thus, implementation success lies in the ability of the project management team to be aware of and to manage several risk threats simultaneously and coherently since they evolve dynamically through time and interact with one another.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Patients' attitudes towards sharing their health information

OBJECTIVES

The current policies of the governments of Australia and New Zealand encourage the use of electronic information systems to exchange patient information between various stakeholders. This research investigated (1) the attitudes of patients toward sharing their medical information and (2) whether patients considered themselves to be well-informed about the uses that are made of their information.

METHODS

A questionnaire survey of adult primary-care patients was conducted in five clinics within a medium sized New Zealand city. Outcome measures were the proportions of respondents willing to share different categories of their information with different classes of recipients. Patients' evaluations of their knowledge about the uses made of their information were also collected.

RESULTS

Over 200 responses were collected from five clinics. Respondents' attitudes toward sharing their information were found to be influenced by three factors. (1) Identity of recipient: whilst respondents were generally willing to have their information shared between health professionals, they were increasingly unwilling for it to be distributed to other stakeholders, such as administrators, researchers or other government departments. (2) Level of anonymity: respondents were more prepared to share anonymous information. (3) Type of information: respondents were increasingly unwilling to share their information as it takes on a more personal nature. Respondents were also found to be very poorly informed about the use of their information, 90% of respondents indicated that they had either incomplete or no knowledge of how their information was shared and 79% had no knowledge of the uses of their National Health Index (NHI) number. The findings also indicate that respondents would prefer to be consulted about the distribution of their information.

CONCLUSIONS

These findings indicate that many respondents were unwilling to have their personal information distributed other than for purposes of clinical care and a sizeable proportion of the respondents would like to be consulted before their information is released. The high level of interest and concern that this research revealed among respondents, suggests that more attention should be directed towards ensuring that patients are fully informed about current information sharing practices. The findings also imply that the design and development of future systems should also incorporate sophisticated and flexible access control policies that can be adapted to meet the preferences of individual patients.

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

Translating research into practice: organizational issues in implementing automated decision support for hypertension in three medical centers

Information technology can support the implementation of clinical research findings in practice settings. Technology can address the quality gap in health care by providing automated decision support to clinicians that integrates guideline knowledge with electronic patient data to present real-time, patient-specific recommendations. However, technical success in implementing decision support systems may not translate directly into system use by clinicians. Successful technology integration into clinical work settings requires explicit attention to the organizational context. We describe the application of a "sociotechnical" approach to integration of ATHENA DSS, a decision support system for the treatment of hypertension, into geographically dispersed primary care clinics. We applied an iterative technical design in response to organizational input and obtained ongoing endorsements of the project by the organization's administrative and clinical leadership. Conscious attention to organizational context at the time of development, deployment, and maintenance of the system was associated with extensive clinician use of the system.

Measuring disparities in information capture timeliness across healthcare settings: effects on data quality

The emergence of evidence-based medicine in the United States has created an industry-wide environment where the quality of data maintained by healthcare organizations is becoming a critical factor in the delivery of medical care. Such a transition necessitates a corresponding need for consistent data collection and maintenance methods. In this study results of a national survey of health information managers were used to assess prevalence of a standard data quality practice, the adoption of policies related to timeliness of data capture. Findings from this survey show that, on a national level, only a slight majority of respondents indicated adoption of timeliness policies. About 61% of respondents indicate they have policies and procedures addressing data timeliness, although persistent patterns of nonadoption were found. We examine how the timeliness of data collection might serve as part of an overall data collection strategy that managers can employ to improve the quality of their information.

Determinants of success of inpatient clinical information systems: a literature review

We reviewed the English and Dutch literature on evaluations of patient care information systems that require data entry by health care professionals published from 1991 to 2001. Our objectives were to identify attributes that were used to assess the success of such systems and to test the ability of a framework developed by Delone and McLean for management information systems(1) to categorize these attributes correctly. The framework includes six dimensions or success factors: system quality, information quality, usage, user satisfaction, individual impact, and organizational impact. Thirty-three papers were selected for complete review. Types of study design included descriptive, correlational, comparative, and case studies. A variety of relevant attributes could be assigned to the six dimensions in the Delone and McLean framework, but some attributes, predominantly in cases of failure, did not fit any of the categories. They related to contingent factors, such as organizational culture. Our review points out the need for more thorough evaluations of patient care information systems that look at a wide range of factors that can affect the relative success or failure of these systems.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.

Evaluating informatics applications--some alternative approaches: theory, social interactionism, and call for methodological pluralism

A review of evaluation literature concerning CDSSs indicates that randomized controlled clinical trials (RCTs) are the 'gold standard' for evaluation. While this approach is excellent for studying system or clinical performance, it is not well suited to answering questions concerning whether systems will be used or how they will be used. Because lack of use of CDSS has been of concern for some years, other evaluation research designs are needed to address those issues. This paper critiques RCT and experimental evaluation approaches and presents alternative approaches to evaluation that address questions outside the scope of the usual RCT and experimental designs. A wide range of literature is summarized to illustrate the value of evaluations that take into account social, organizational, professional, and other contextual considerations. Many of these studies go beyond the usual measures of systems performance or physicians' behavior by focusing on 'fit' of the system with other aspects of professional and organizational life. Because there is little explicit theory that informs many evaluations, the paper then reviews CDSS evaluations informed by social science theories. Lastly, it proposes a theoretical social science base of social interactionism. An example of such an approach is given. It involves a CDSS in psychiatry and is based on Kaplan's 4Cs, which focus on communication, control, care, and context. Although the example is a CDSS, the evaluation approach also is useful for clinical guideline implementation and other medical informatics applications. Similarly, although the discussion is about social interactionism, the more important point is the need to broaden evaluation through a variety of methods and approaches that investigate social, cultural, organizational, cognitive, and other contextual concerns. Methodological pluralism and a variety of research questions can increase understanding of many influences concerning informatics applications development and deployment.

Evaluating informatics applications--clinical decision support systems literature review

This paper reviews clinical decision support systems (CDSS) literature, with a focus on evaluation. The literature indicates a general consensus that clinical decision support systems are thought to have the potential to improve care. Evidence is more equivocal for guidelines and for systems to aid physicians with diagnosis. There also is general consensus that a variety of systems are little used despite demonstrated or potential benefits. In the evaluation literature, the main emphasis is on how clinical performance changes. Most studies use an experimental or randomized controlled clinical trials design (RCT) to assess system performance or to focus on changes in clinical performance that could affect patient care. Few studies involve field tests of a CDSS and almost none use a naturalistic design in routine clinical settings with real patients. In addition, there is little theoretical discussion, although papers are permeated by a rationalist perspective that excludes contextual issues related to how and why systems are used. The studies mostly concern physicians rather than other clinicians. Further, CDSS evaluation studies appear to be insulated from evaluations of other informatics applications. Consequently, there is a lack of information useful for understanding why CDSSs may or may not be effective, resulting in making less informed decisions about these technologies and, by extension, other medical informatics applications.