The Search for Synergy: Interrelating Medical Work and Patient Care Information Systems

The Health Care Sector's Experience of Blockchain: A Cross-disciplinary Investigation of Its Real Transformative Potential

BACKGROUND

Academic literature highlights blockchain's potential to transform health care, particularly by seamlessly and securely integrating existing data silos while enabling patients to exercise automated, fine-grained control over access to their electronic health records. However, no serious scholarly attempt has been made to assess how these technologies have in fact been applied to real-world health care contexts.

OBJECTIVE

The primary aim of this paper is to assess whether blockchain's theoretical potential to deliver transformative benefits to health care is likely to become a reality by undertaking a critical investigation of the health care sector's actual experience of blockchain technologies to date.

METHODS

This mixed methods study entailed a series of iterative, in-depth, theoretically oriented, desk-based investigations and 2 focus group investigations. It builds on the findings of a companion research study documenting real-world engagement with blockchain technologies in health care. Data were sourced from academic and gray literature from multiple disciplinary perspectives concerned with the configuration, design, and functionality of blockchain technologies. The analysis proceeded in 3 stages. First, it undertook a qualitative investigation of observed patterns of blockchain for health care engagement to identify the application domains, data-sharing problems, and the challenges encountered to date. Second, it critically compared these experiences with claims about blockchain's potential benefits in health care. Third, it developed a theoretical account of challenges that arise in implementing blockchain in health care contexts, thus providing a firmer foundation for appraising its future prospects in health care.

RESULTS

Health care organizations have actively experimented with blockchain technologies since 2016 and have demonstrated proof of concept for several applications (use cases) primarily concerned with administrative data and to facilitate medical research by enabling algorithmic models to be trained on multiple disparately located sets of patient data in a secure, privacy-preserving manner. However, blockchain technology is yet to be implemented at scale in health care, remaining largely in its infancy. These early experiences have demonstrated blockchain's potential to generate meaningful value to health care by facilitating data sharing between organizations in circumstances where computational trust can overcome a lack of social trust that might otherwise prevent valuable cooperation. Although there are genuine prospects of using blockchain to bring about positive transformations in health care, the successful development of blockchain for health care applications faces a number of very significant, multidimensional, and highly complex challenges. Early experience suggests that blockchain is unlikely to rapidly and radically revolutionize health care.

CONCLUSIONS

The successful development of blockchain for health care applications faces numerous significant, multidimensional, and complex challenges that will not be easily overcome, suggesting that blockchain technologies are unlikely to revolutionize health care in the near future.

Modeling the Implementation Context of a Telemedicine Service: Work Domain Analysis in a Surgical Setting

BACKGROUND

A telemedicine service enabling remote surgical consultation had shown promising results. When the service was to be scaled up, it was unclear how contextual variations among different clinical sites could affect the clinical outcomes and implementation of the service. It is generally recognized that contextual factors and work system complexities affect the implementation and outcomes of telemedicine. However, it is methodologically challenging to account for context in complex health care settings. We conducted a work domain analysis (WDA), an engineering method for modeling and analyzing complex work environments, to investigate and represent contextual influences when a telemedicine service was to be scaled up to multiple hospitals.

OBJECTIVE

We wanted to systematically characterize the implementation contexts at the clinics participating in the scale-up process. Conducting a WDA would allow us to identify, in a systematic manner, the functional constraints that shape clinical work at the implementation sites and set the sites apart. The findings could then be valuable for informed implementation and assessment of the telemedicine service.

METHODS

We conducted observations and semistructured interviews with a variety of stakeholders. Thematic analysis was guided by concepts derived from the WDA framework. We identified objects, functions, priorities, and values that shape clinical procedures. An iterative "discovery and modeling" approach allowed us to first focus on one clinic and then readjust the scope as our understanding of the work systems deepened.

RESULTS

We characterized three sets of constraints (ie, facets) in the domain: the treatment facet, administrative facet (providing resources for procedures), and development facet (training, quality improvement, and research). The constraints included medical equipment affecting treatment options; administrative processes affecting access to staff and facilities; values and priorities affecting assessments during endoscopic retrograde cholangiopancreatography; and resources for conducting the procedure.

CONCLUSIONS

The surgical work system is embedded in multiple sets of constraints that can be modeled as facets of the system. We found variations between the implementation sites that might interact negatively with the telemedicine service. However, there may be enough motivation and resources to overcome these initial disruptions given that values and priorities are shared across the sites. Contrasting the development facets at different sites highlighted the differences in resources for training and research. In some cases, this could indicate a risk that organizational demands for efficiency and effectiveness might be prioritized over the long-term outcomes provided by the telemedicine service, or a reduced willingness or ability to accept a service that is not yet fully developed or adapted. WDA proved effective in representing and analyzing these complex clinical contexts in the face of technological change. The models serve as examples of how to analyze and represent a complex sociotechnical context during telemedicine design, implementation, and assessment.

The impact of using electronic patient records on practices of reading and writing

The aim of this study was to investigate the use of electronic patient records in daily practice. In four wards of a large hospital district in Finland, N = 43 patients' care and activities were observed and analysed in terms of the Grounded Theory method. The findings revealed that using electronic patient records created a particular process of writing and reading. Wireless technology enabled simultaneous patient involvement and point-of-care documentation, additionally supporting real-time reading. Remote and retrospective documentation was distant in terms of both space and time. The remoteness caused double documentation, reduced accuracy and less-efficient use of time. 'Non-reading' practices were witnessed in retrospective reading, causing delays in patient care and increase in workload. Similarly, if documentation was insufficient or non-existent, the consequences were found to be detrimental to the patients. The use of an electronic patient record system has a significant impact on patient care. Therefore, it is crucial to develop wireless technology and interdisciplinary collaboration in order to improve and support high-quality patient care.

Rethinking resistance to ‘big IT’: a sociological study of why and when healthcare staff do not use nationally mandated information and communication technologies

Background

Nationally mandated information and communication technology (ICT) systems are often locally resented and little used. This problem is sometimes framed in behaviourist terms, depicting the intended user of technology as a rational actor whose resistance stems from Luddism and/or ignorance, and viewing solutions in terms of training, incentives and sanctions. The implication is that if we get the ‘rewards’ and ‘punishments’ right, people will use technologies. Previous research in the social sciences, notably sociotechnical systems theory, actor–network theory and normalisation process theory, have considered the human, social and organisational context of technology use (and non-use). However, these have all had limitations in explaining the particular phenomenon of resistance to nationally mandated ICT systems.

Objective

To develop a sociologically informed theory of resistance to nationally mandated ICT systems.

Theoretical approach

We drew on Anthony Giddens’ notion of expert systems (comprising bureaucratic rules and classification systems delivered through technology) as well as theories of professional roles and ethical practice. A defining characteristic of expert systems is that they can produce ‘action at a distance’, allowing managerial control to be exerted over local practice. To the extent that people use them as intended, these systems invariably ‘empty out’ social situations by imposing rules and categories that are insensitive to local contingencies or the unfolding detail of social situations.

Study design and setting

Secondary analysis of data from case studies of three nationally mandated ICT systems in the English NHS, collected over the period 2007–10.

Results

Our analysis focused mainly on the Choose and Book system for outpatient referrals, introduced in 2004, which remained unpopular and little used throughout the period of our research (i.e. 2007–13). We identified four foci of resistance: to the policy of choice that Choose and Book symbolised and purported to deliver; to accommodating the technology’s sociomaterial constraints; to interference with doctors’ contextual judgements; and to adjusting to the altered social relations consequent on its use. More generally, use of the mandated system tended to constrain practice towards a focus on (the efficiency of) means rather than (the moral value of) ends. A similar pattern of complex sociological reasons for resistance was also seen in the other two technologies studied (electronic templates for chronic disease management and the Summary Care Record), though important differences surfaced and were explained in terms of the policy inscribed in the technology and its material features.

Conclusion

‘Resistance’ is a complex phenomenon with sociomaterial and normative components; it is unlikely to be overcome using atheoretical behaviourist techniques. To guide the study of resistance to ICT systems in health care, we offer a new theoretical and empirical approach, based around a set of questions about the policy that the technology is intended to support; the technology’s material properties; the balance between (bureaucratic) means and (professional) ends; and the implications for social roles, relationship and interactions.

We suggest avenues for future research, including methodology (e.g. extending the scope and scale of ethnographic research in ICT infrastracture), theory development (e.g. relating to the complexities of multi-professional team working) and empirical (e.g. how our findings might inform the design and implementation of technologies that are less likely to be resisted).

Funding

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

Organizational learning in the implementation and adoption of national electronic health records: Case studies of two hospitals participating in the National Programme for Information Technology in England

Objective:

To explore the role of organizational learning in enabling implementation and supporting adoption of electronic health record systems into two English hospitals.

Methods and setting:

In the course of conducting our prospective and sociotechnical evaluation of the implementation and adoption of electronic health record into 12 “early adopter” hospitals across England, we identified two hospitals implementing virtually identical versions of the same “off-the-shelf” software (Millennium) within a comparable timeframe. We undertook a longitudinal qualitative case study–based analysis of these two hospitals (referred to hereafter as Alpha and Omega) and their implementation experiences. Data included the following: 63 in-depth interviews with various groups of internal and external stakeholders; 41-h on-site observation; and content analysis of 218 documents of various types. Analysis was both inductive and deductive, the latter being informed by the “sociotechnical changing” theoretical perspective.

Results:

Although Alpha and Omega shared a number of contextual similarities, our evaluation revealed fundamental differences in visions of electronic health record and the implementation strategy between the hospitals, which resulted in distinct local consequences of electronic health record implementation and impacted adoption. Both hospitals did not, during our evaluation, see the hoped-for benefits to the organization as a result of the introduction of electronic health record, such as speeding-up tasks. Nonetheless, the Millennium software worked out to be easier to use at Omega. Interorganizational learning was at the heart of this difference.

Conclusion:

Despite the turbulent overall national “roll out” of electronic health record systems into the English hospitals, considerable opportunities for organizational learning were offered by sequential delivery of the electronic health record software into “early adopter” hospitals. We argue that understanding the process of organizational learning and its enabling factors has the potential to support efforts at implementing national electronic health record implementation endeavors.

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

OBJECTIVE

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

MATERIALS AND METHODS

The study uses ethnographic methods to explore the mediators' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

RESULTS

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

DISCUSSION

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users' practices and norms, credibility with users, and knowledge of the technology and users' technical abilities. We describe three additional factors observed in this case: 'influence on system developers,' 'influence on institutional authorities,' and 'understanding the network of organizational relationships that shape the users' work.'

CONCLUSION

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.

Reviewing the impact of computerized provider order entry on clinical outcomes: The quality of systematic reviews

PURPOSE

Computerized provider order entry (CPOE) is central to current efforts at improving clinical care. Understanding the quality of the evidence for CPOE is important to the practical decision of implementation, patient safety and future design efforts. This paper presents the results of a systematic analysis of the quality of systematic reviews of empirical CPOE research.

METHODS

The systematic search process included PubMed, CINAHL, Scopus, Cochrane, INSPEC, and PsychInfo databases from the years 1987-mid 2010 in English only. All reviews with a focus on CPOE, electronic ordering, Electronic Health Record, or Health Information Technology were included. Studies were excluded if they did not mention a systematic review in the title or text, report a formal search process, report results of the search, or specifically include a separate section on CPOE in the results. Quality was assessed using systematic criteria developed by Oxman and Guyatt, QUOROM, and PRISMA. All three authors conducted the reviews independently. Disagreements were resolved through discussion. Descriptive data was extracted.

RESULTS

The search process yielded 185 initial unique references with 13 final reviews meeting the inclusion criteria. The rating of overall quality in the Oxman and Guyatt scale averaged 4.9 out of a possible 7 and the average mean of the sum of the other questions was 5.69. The overall QUOROM/PRISMA ratings averaged 63% completion and ranging from 45% to 81%.

CONCLUSIONS

The quality of these reviews were moderate. Only one study conducted a full quantitative synthesis, and overall heterogeneity was reported as very high in the 3 studies that measured it. Recommendations emphasize clarifying the phenomenon of CPOE by avoiding reporting conclusions across sub-group analyses, increasing emphasis on the development of theoretical models, including more quantitative assessments, and increasing breadth of outcomes.

An exploration of the impact of computerized patient documentation on clinical collaboration

PURPOSE

The purpose of this study was to explore the experience of experienced users of computerized patient documentation for the purpose of collaboration and coordination. A secondary analysis of qualitative data using Clark's theoretical framework of communication was conducted with the goal of bringing research findings into design.

METHODS

Physicians, nurses and administrative staff volunteered to participate in focus groups at 4 VA sites. Each focus group lasted 1.5h and targeted experience and issues with using computerized documentation. All focus groups were audio-taped and transcribed and submitted to extensive qualitative analysis using ATLAS, iterative identification of concepts and categories. The communication category was targeted for secondary theoretical analysis in order to deepen understanding of the findings. Clark's theory of communication, joint action and common ground heuristics was used to analyze concepts.

RESULTS

Key concepts included: (1) CPD has changed the way that narrative documentation is used in clinical settings to include more communication functions, strategies to establish joint action in both negative and positive ways; (2) functionality added to CPD to increase the efficiency of input may have increased the efficiency of CPD to support shared situation models, joint and action and the establishment of common ground; (3) new usage of CPD may increase tensions between clinical and administrative roles as the role of narrative is re-defined.

CONCLUSIONS

This study demonstrates how socio-technical systems co-evolve to support essential human function of coordination and collaboration. Users adapted the system in unique and useful ways that provide insight to future development.

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.

Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system

OBJECTIVE

To compare how nurses in two different paper-based systems perceive the impact of a computerized physician order entry (CPOE) system on their medication-related activities.

SETTING

13 non-surgical, adult inpatient wards in a Dutch academic hospital.

METHODS

Questionnaire survey of 295 nurses before and 304 nurses after the implementation of a CPOE system. These nurses worked with two different paper-based medication systems before the implementation: 'Kardex-system' and 'TIMED-system'. In the Kardex-system, the structure of the nursing medication work was similar to that of after the CPOE implementation, while in the TIMED-system, it was different. 'Adaptive Structuration Theory' (AST) was used to interpret the results.

RESULTS

The response rates were 52.2% (154/295) before and 44.7% (136/304) after the implementation. Kardex-nurses reported more positive effects than TIMED-nurses. TIMED-nurses reported that the computerized system was more inflexible, more difficult to work with, and slower than the TIMED-system. In the TIMED group, the overall mean score of the computerized process was not significantly different from that of the paper-based process. Moreover, nurses in both groups were more satisfied with the post-implementation process than with the pre-implementation process. Nevertheless, none of groups reported a better workflow support in the computerized system when compared to that of the paper-based systems.

CONCLUSIONS

Our findings suggest that not only the technology but also large differences between pre- and post-implementation work structure influence the perceptions of users, and probably make the transition more difficult. This study also suggests that greater satisfaction with a system may not necessarily be a reflection of better workflow support.

The product and process of referral

With the growing complexities of health care delivery in western industrialized countries, the need for inter-organizational communication is increasingly emphasized. In this paper, we focus on a system - ZorgDomein - that was developed to optimize GP-medical specialist communication. Contrary to the notion of 'shared' or 'integrated care' that often assumes a 'seamless' health care, we will focus on the negotiated order of GP-specialist cooperation, showing the precarious localized arrangements that allow both a bridging and a separation of professional activities concerning patient care. Furthermore, we analyze how ZorgDomein changes the arrangements to maintain a working order. The main focus of the article is on the way GP-specialist referrals are on the one hand conceptualized as discrete events of information sharing, while on the other hand are part of a process of care. We will argue that in standardization attempts by national and local actors, embodied within the technology, information exchange between first and secondary care is made into a product. This conceptualization and materialization neglects the process in which this information comes about or is being created. We discuss the consequences of this for the design and use of the technology.

A grounded theory guided approach to palliative care systems design

As healthcare looks for new and innovative ways to deliver more services with less resources we are increasingly turning to informatics based solutions. However, the means by which information systems (IS) are both designed and implemented will impact how successful the system will be at enhancing care delivery. We believe a key component to successful IS design is the methodological rigor by which design requirements are gleaned and applied. This paper describes our use of a grounded theory (GT) guided methodology for designing an ontology of palliative care severe pain management. In this paper we illustrate how the methodological rigor of GT was applied to three palliative information sources to allow us to gain an understanding of how severe pain is managed. We then illustrate how that understanding was formalized into an ontology and applied to IS design of a computer based tool to enhance education around palliative care severe pain management.

OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record

In studies on success and failure of ICT applications in health care, the 'context' is often used to explain the failure of a system and seldom to explain the success of a system. Science and Technology Studies (STS) have showed that for understanding success and failure of phenomena, one has to take a symmetrical approach and thus use the same concept for analyzing success and failure. In this article we analyze the success of OZIS, a communication protocol that makes it possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. Though OZIS serves a common goal - reducing medication errors - the stakeholders that are involved also have other, competing, interests. By focussing on the context and more specifically the interests of the stakeholders, we will show how the success of OZIS can be explained. By doing this, we will also show that this context is highly dynamic and that continuously changing incentives and constraints within the context lead to both facilitating and threatening the success of OZIS.

Three-Layer Model for the design of a Protocol Support System

OBJECTIVE

The aim of the PropeR project is to investigate the impact of Active Computerized Protocol Support (ACPS) on daily care processes in different settings (home care and hospital care). ACPS consists of an active Protocol Support System (PSS) that is linked to an Electronic Patient Record system. The aim of this paper is to describe how we have taken the organizational and social aspects into account in the hospital setting and the consequences of this approach for the design of the PSS.

METHODS

Socio-technical approaches have been applied. Observations and interviews with various health care providers were performed at the hematology and oncology department of the University Hospital Maastricht. Ten extensive sessions with a specialist physician and research nurse took place to further elaborate a study protocol and to discuss how it is integrated in daily practice. The knowledge editor component of Gaston was used to build a computer interpretable version of the selected protocol.

RESULTS AND CONCLUSIONS

To support the representation of a study protocol integrated in routine clinical care, a Three-Layer Model was developed. This model distinguishes the protocol description, local adaptations to the protocol and communication as three separate layers. These layers have been incorporated into the knowledge acquisition tool Gaston. The Three-Layer Model makes easy updating possible, and also supports transferability of computerized (study) protocols to other organizations.