Effects of health information technology on patient outcomes: a systematic review

How patients distinguish between clinical and administrative predictive models in health care

OBJECTIVES

To understand patient perceptions of specific applications of predictive models in health care.

STUDY DESIGN

Original, cross-sectional national survey.

METHODS

We conducted a national online survey of US adults with the National Opinion Research Center from November to December 2021. Measures of internal consistency were used to identify how patients differentiate between clinical and administrative predictive models. Multivariable logistic regressions were used to identify relationships between comfort with various types of predictive models and patient demographics, perceptions of privacy protections, and experiences in the health care system.

RESULTS

A total of 1541 respondents completed the survey. After excluding observations with missing data for the variables of interest, the final analytic sample was 1488. We found that patients differentiate between clinical and administrative predictive models. Comfort with prediction of bill payment and missed appointments was especially low (21.6% and 36.6%, respectively). Comfort was higher with clinical predictive models, such as predicting stroke in an emergency (55.8%). Experiences of discrimination were significant negative predictors of comfort with administrative predictive models. Health system transparency around privacy policies was a significant positive predictor of comfort with both clinical and administrative predictive models.

CONCLUSIONS

Patients are more comfortable with clinical applications of predictive models than administrative ones. Privacy protections and transparency about how health care systems protect patient data may facilitate patient comfort with these technologies. However, larger inequities and negative experiences in health care remain important for how patients perceive administrative applications of prediction.

Characterization of Safety Events Involving Technology in Primary and Community Care

BACKGROUND

The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings.

OBJECTIVES

To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization.

METHODS

Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event.

RESULTS

Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions.

CONCLUSION

Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study

BACKGROUND

Chronic diseases are increasing worldwide, and the complexity of disease management is putting new demands on safe healthcare. Telemonitoring technology has the potential to improve self-care management with the support of healthcare professionals for people with chronic diseases living at home. Patient safety threats related to telemonitoring and how they may affect patients' and healthcare professionals' sense of security need attention. This study aimed to explore patients' and healthcare professionals' experiences of safety and sense of security when using telemonitoring of chronic conditions at home.

METHODS

Semi-structured interviews were conducted with twenty patients and nine healthcare professionals (nurses and physicians), recruited from four primary healthcare centers and one medical department in a region in southern Sweden using telemonitoring service for chronic conditions in home healthcare.

RESULTS

The main theme was that experiences of safety and a sense of security were intertwined and relied on patients´ and healthcare professionals´ mutual engagement in telemonitoring and managing symptoms together. Telemonitoring was perceived to increase symptom awareness and promote early detection of deterioration promoting patient safety. A sense of security emerged through having someone keeping track of symptoms and comprised aspects of availability, shared responsibility, technical confidence, and empowering patients in self-management. The meeting with technology changed healthcare professionals' work processes, and patients' daily routines, creating patient safety risks if combined with low health- and digital literacy and a naïve reliance on technology. Empowering patients' self-management ability and improving shared understanding of the patient's health status and symptom management were prerequisites for safe care and the patient´s sense of security.

CONCLUSIONS

Telemonitoring chronic conditions in the homecare context can promote a sense of security when care is co-created in a mutual understanding and responsibility. Attentiveness to the patient's health literacy, symptom management, and health-related safety behavior when using eHealth technology may enlighten and mitigate latent patient safety risks. A systems approach indicates that patient safety risks related to telemonitoring are not only associated with the patient's and healthcare professionals functioning and behavior or the human-technology interaction. Mitigating patient safety risks are likely also dependent on the complex management of home health and social care service.

Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial

BACKGROUND

Only half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices.

METHODS/DESIGN

We will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group.

DISCUSSION

The results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention.

CLINICALTRIALS

gov Identifier: NCT05588466.

Evaluation of the Evolution of Digital Nursing Interventions in an Emergency Unit: An Observational Study

This study aimed to examine the influence of new ICTs on the recording of nursing interventions in the Emergency Unit of the High Resolution Hospital (HRH) of Loja (Granada), Spain. A descriptive observational study was conducted to analyze the evolution of the Nursing Interventions (NIC) records in the Emergency Unit of the Loja HRH (Granada) from 2017 to 2021. Results showed that 11,076 NIC registrations were exploited, which increased by 51.2% from 2017 to 2021. The linear correlation between the NIC and the years was analyzed with Spearman's coefficient, obtaining a low level of correlation (p = 0.166), but one that is statistically significant (p < 0.001). The introduction of tablet devices in the emergency room of the Loja HRH (Granada) led to a significant increase in the percentage of NIC recorded and collated during the study period without increasing the number of emergencies attended. However, usability barriers of ICTs were detected, highlighting the need to guide and train health professionals in their use and in the culture of patient safety.

Simulated medical information system: education for aspiring healthcare information technologists

Objectives

To determine if a simulated medical information system can improve the level of understanding of healthcare information technology students.

Methods

The study involved 40 healthcare information technology students. All the students took the healthcare information technology course using the simulated medical information system. The primary outcome was a measure of their level of understanding assessed with a questionnaire using a five-point Likert-type scale. The questions were all included in the required knowledge for the Specific Behavioral Objectives for Healthcare Information Technologists (2016) and Senior Healthcare Information Technologists (ver. 1.1, 2017). To measure the level of understanding, median with 10th-90th percentile CI values for both sets of questionnaires were calculated for all the students. The Wilcoxon signed-rank test was used to compare level of understanding before and after the training.

Results

Some students were excluded because they failed to complete the questionnaires. For both Healthcare Information Technologists (n=37) and Senior Health Information Technologists (n=34), the level of understanding was significantly different before (median [10th-90th percentile]: 1175 [935-1271], 416 [302-513]) and after (1200 [1016-1472], 469.5 [351-527]) the training (p<0.05).

Conclusions

A simulated medical information system may be an effective tool for students to learn about healthcare information technology.

Use of electronic health record best practice alerts to improve adherence to American Urological Association vesicoureteral reflux guidelines

PURPOSE

To evaluate the effect of a guidelines-based best practice alerts (BPA) in the electronic health record (EHR) on adherence to American Urological Association (AUA) vesicoureteral reflux (VUR) guidelines.

METHODS

Retrospective cohort study of patients aged 0-17 years old with primary VUR with an initial urology clinic visit the year before or year after BPA implementation was done. Primary outcomes include obtaining vital signs, urinalysis, and ultrasound at initial and 1-year follow-up visit.

RESULTS

We identified 123 patients with initial visits during the study period, 58 of whom returned for 1-year follow-up visits. Patients seen post-BPA were more likely to have height measured at initial visit than those seen pre-BPA (47.3% vs. 11.8%, p < 0.001). The majority of patients were screened with weight (98.3%) and ultrasound (87.9%) at 1-year follow-up both before and after BPA implementation. Neither blood pressure measurements (59.1% vs. 55.6%, p > 0.5) nor urinalysis orders (23.8% vs. 19.4%, p > 0.05) significantly increased post-BPA.

CONCLUSION

The use of an EHR-based BPA increased the likelihood of obtaining height measurements by clinic intake staff but did not significantly affect provider adherence to other practice guideline recommendations. Our findings suggest that BPA implementation alone is not sufficient to impact provider uptake of VUR guideline recommendations.

The impact of clinical decision support systems on provider behavior in the inpatient setting: A systematic review and meta-analysis

BACKGROUND

Clinical decision support systems (CDSS) are used to improve processes of care. CDSS proliferation may have unintended consequences impacting effectiveness.

OBJECTIVE

To evaluate the effectiveness of CDSS in altering clinician behavior.

DESIGN

Electronic searches were performed in EMBASE, PubMed, and Cochrane Central Register of Control Trials for randomized controlled trials testing the impacted of CDSS on clinician behavior from 2000-2021. Extracted data included study design, CDSS attributed and outcomes, user characteristics, settings, and risk of bias. Eligible studies were analyzed qualitatively to describe CDSS types. Studies with sufficient outcome data were included in the meta-analysis.

SETTING AND PARTICIPANTS

Adult inpatients in the United States.

INTERVENTION

Clinical decision support system versus non-clinical decision support system.

MAIN OUTCOME AND MEASURE

A random-effects model measured the pooled risk difference (RD) and odds ratio of clinicians' adherence to CDSS; subgroup analyses tested differences in CDSS effectiveness over time and by CDSS type.

RESULTS

Qualitative synthesis included 22 studies. Eleven studies reported sufficient outcome data for inclusion in the meta-analysis. CDSS did not result in a statistically significant increase in clinician adoption of desired practicies (RD = 0.04 [95% confidence interval {CI} 0.00, 0.07]). CDSS from 2010-2015 (n = 5) did not increase clinician adoption of desired practice [RD -0.01, (95% CI -0.04, 0.02)].CDSS from 2016-2021 (n = 6) were associated with an increase in targeted practices [RD 0.07 (95% CI0.03, 0.12)], pInteraction = 0.004. EHR [RD 0.04 (95% CI 0.00, 0.08)] vs. non-EHR [RD 0.01 (95% CI -0.01, 0.04)] based CDSS interventions did not result in different adoption of desired practices (pInteraction = 0.27). The meta-analysis did not find an overall positive impact of CDSS on clinician behavior in the inpatient setting.

Clinical decision support for familial hypercholesterolemia (CDS-FH): Rationale and design of a cluster randomized trial in primary care

BACKGROUND

Familial hypercholesterolemia (FH) is an underdiagnosed and undertreated genetic disorder with high risk of premature atherosclerotic cardiovascular disease and death. Clinical decision support (CDS) systems have the potential to aid in the identification and management of patients with FH. Prior studies using computer-based systems to screen patients for FH have shown promising results, but there has been no randomized controlled trial conducted. The aim of the current cluster randomized study is to evaluate if a CDS can increase the identification of FH.

METHODS

We have developed a CDS integrated in the electronic health records that will be activated in patients with elevated cholesterol levels (total cholesterol >8 mmol/L or low-density lipoprotein-cholesterol >5.5 mmol/L, adjusted for age, ongoing lipid lowering therapy and presence of premature coronary artery disease) at increased risk for FH. When activated, the CDS will urge the physician to send an automatically generated referral to the local lipid clinic for further evaluation. To evaluate the effects of the CDS, all primary care clinics will be cluster randomized 1:1 to either CDS intervention or standard care in a Swedish region with almost 500,000 inhabitants. The primary endpoint will be the number of patients diagnosed with FH at 30 months. Resource use and long-term health consequences will be estimated to assess the cost-effectiveness of the intervention.

CONCLUSION

Despite increasing awareness of FH, the condition remains underdiagnosed and undertreated. The present study will investigate whether a CDS can increase the number of patients being diagnosed with FH.

Prospects of Hospital Information Systems and Patient Safety in Japan

Objectives

Approximately 20 years have passed since hospital information systems (HISs) featuring full-scale electronic medical records were first implemented in Japan. Patient safety is one of the most important of the several “safety” roles that HISs are expected to fulfill. However, insufficient research has analyzed the contribution of HISs to patient safety. This paper reviews the history of HISs in connection with patient safety in Japan and discusses the future of the patient safety function of HISs in a favorable environment for digitization.

Methods

A review on the history of HISs with functions that contribute to patient safety was conducted, analyzing evidence from reports published by the Japanese government and papers on patient safety and HISs published in various countries.

Results

Patient safety has become a concern, and initiatives to promote patient safety have progressed simultaneously with the spread of HISs. To address the problem of patient safety, most large hospitals prioritize patients’ welfare when building HISs. However, no HIS-associated reduction in adverse events due to medical treatment could be confirmed.

Conclusions

HISs are expected to help prevent medical accidents, such as patient- and drug-related errors. It is hoped that the patient safety functions of HISs will become generalized and contribute to patient safety in the future. To achieve this, the government and academic societies should provide regulations and guidelines on HISs and patient safety to the medical community and medical-device vendors. Furthermore, departments responsible for HISs and patient safety should collaborate to gather evidence for the effectiveness of HISs.

Electronic healthcare applications and programs among healthcare workers in Riyadh and conflict management

Objective

Electronic healthcare applications and programmes enable the use of computers, networks, and information technology to improve healthcare quality and patient safety, and secure confidential access to health information in order to enable individuals and communities to make the best possible health decisions. We study conflicts challenging users of e-health electronic applications and programmes in Riyadh.

Methods

We use a cross-sectional descriptive design to target all healthcare professionals who interact with e-health applications and programmes. Healthcare providers took a questionnaire survey online.

Results

Of the 169 responses to our questionnaire, 78.1% are female, and 46.2% are aged between 31 and 40 years. As many as 59.2% always use these applications, and 33.7% use them occasionally. Only 7.10% of the participants rarely or never use them. As many as 31.4% recognized that these applications led to conflicts at the workplace. Of these, 50.6%, 13.6%, and 35.8% stated that they caused decision-related, ethical, and other types of conflicts, respectively.

Conclusion

We conducted this study among healthcare providers in Riyadh, KSA, and found that the use of e-health applications and programmes encountered some difficulties.

Patient Safety Threats in Information Management Using Health Information Technology in Ambulatory Cancer Care: An Exploratory, Prospective Study

BACKGROUND

Cancer care is complex, involving highly toxic drugs, critically ill patients, and various different care providers. Because it is important for clinicians to have the latest and complete information about the patient available, this study focused on patient safety issues in information management developing from health information technology (HIT) use in oncology ambulatory infusion centers.

OBJECTIVE

The aim was to exploratively and prospectively assess patient safety risks from an expert perspective: instead of retrospectively analyzing safety events, we assessed the information management hazards inherent to the daily work processes; instead of asking healthcare workers at the front line, we used them as information sources to construct our patient safety expert view on the hazards.

METHODS

The work processes of clinicians in three ambulatory infusion centers were assessed and evaluated based on interviews and observations with a nurse and a physician of each unit. The 125 identified patient safety issues were described and sorted into thematic groups.

RESULTS

A broad range of patient safety issues was identified, such as data fragmentation, or information islands, meaning that patient data are stored across different cases or software and that different professional groups do not use the same set of information.

CONCLUSIONS

The current design and implementation of HIT systems do not support adequate information management: clinicians needed to play very close attention and improvise to avoid errors in using HIT and treat cancer patients safely. It is important to take the clinical front-end practice into account when evaluating or planning further HIT improvements.

The Role of Health Information Technology in Pneumococcal Vaccination Uptake Among Adults with Heart Disease

Background: Health information technology (HIT) may influence pneumococcal vaccination uptake in high-risk populations. This study assessed the association of HIT utilization on pneumococcal vaccine (PCV) uptake among adults ≥40 years with heart disease. Methods: This was a cross-sectional study of 2,134 individuals representing 16,813,593 United States adults ≥40 years with heart disease using the National Health Interview Survey data. The independent variables were use of the Internet to (1) look up health information, (2) fill a prescription, and (3) schedule a medical appointment, and use of an e-mail (4) communicate with a health care provider. The dependent variable was PCV uptake. Chi-square analysis was used to evaluate group differences, and a multiple logistic regression was used to analyze the association between HIT utilization and PCV uptake. Results: Those who use the Internet to fill up a prescription and to communicate with their health care provider were more likely to take up the PCV (adjusted odds ratio [AOR] 1.56; 95% confidence interval [CI] 1.03-2.37, p = 0.035) and (AOR 1.95; 95% CI 1.23-3.10, p = 0.005) respectively. Compared with those who did not use HIT in any form, those who used HIT in at least three or four forms had a higher PCV uptake (AORs 1.93; 95% CI 1.19-3.13, p = 0.008) and (AOR 2.33 95% CI 1.22-4.47, p = 0.011) respectively. Conclusion: Our analysis shows a positive association of HIT utilization and PCV uptake. It further stresses the importance of electronic health in preventive medicine. This implies that HIT can be used purposively in other aspects of preventive health. Larger studies should evaluate the relationship between different uses of HIT and the uptake of different vaccines.

The relationship between health IT characteristics and organizational variables among German healthcare workers

Health information technologies (HITs) are widely employed in healthcare and are supposed to improve quality of care and patient safety. However, so far, their implementation has shown mixed results, which might be explainable by understudied psychological factors of human-HIT interaction. Therefore, the present study investigates the association between the perception of HIT characteristics and psychological and organizational variables among 445 healthcare workers via a cross-sectional online survey in Germany. The proposed hypotheses were tested using structural equation modeling. The results showed that good HIT usability was associated with lower levels of techno-overload and lower IT-related strain. In turn, experiencing techno-overload and IT-related strain was associated with lower job satisfaction. An effective error management culture at the workplace was linked to higher job satisfaction and a slightly lower frequency of self-reported medical errors. About 69% of surveyed healthcare workers reported making errors less frequently than their colleagues, suggesting a bias in either the perception or reporting of errors. In conclusion, the study's findings indicate that ensuring high perceived usability when implementing HITs is crucial to avoiding frustration among healthcare workers and keeping them satisfied. Additionally healthcare facilities should invest in error management programs since error management culture is linked to other important organizational variables.

Marques PA, Barker TH. Interventions to Reduce Patient Identification Errors in the Hospital Setting: A Systematic Review

Background:

Patient identification is considered as a fundamental part of the care process and a relevant resource for safety practices in hospital settings.

Objective:

We aimed to review the literature on interventions to reduce patient identification errors in hospital settings.

Methods:

A systematic review of effectiveness using The Joanna Briggs Institute (JBI) methodology was conducted. A three-step search strategy was utilised to explore primary research published up to March 2020 in English, Spanish, and Portuguese across eight databases. Grey literature was also assessed. The titles and abstracts of the studies were screened for assessment of the inclusion criteria. Two reviewers independently appraised the full text of the selected studies and extracted data using standardised tools from JBI. Due to the heterogeneity of studies and insufficient data for statistical pooling, meta-analysis was not feasible. Therefore, the results were synthesised narratively.

Results:

Twelve studies met the review criteria; all were rated at a moderate risk of bias and four different groups of interventions were identified: educational staff interventions alone and those combined with a partnership with families and patients through education; and information technology interventions alone, and combined with an educational staff strategy. Although most studies showed a statistically significant reduction in patient identification errors, the overall quality of the evidence was considered very low.

Conclusion:

High-quality research is needed to understand the real impact of interventions to reduce patient identification errors. Nurses should recognise the importance of patient identification practices as a part of their overall commitment to improving patient safety.

PROSPERO Registration Number: CRD42018085236

Decision-support tools via mobile devices to improve quality of care in primary healthcare settings

BACKGROUND

The ubiquity of mobile devices has made it possible for clinical decision-support systems (CDSS) to become available to healthcare providers on handheld devices at the point-of-care, including in low- and middle-income countries. The use of CDSS by providers can potentially improve adherence to treatment protocols and patient outcomes. However, the evidence on the effect of the use of CDSS on mobile devices needs to be synthesized. This review was carried out to support a World Health Organization (WHO) guideline that aimed to inform investments on the use of decision-support tools on digital devices to strengthen primary healthcare.

OBJECTIVES

To assess the effects of digital clinical decision-support systems (CDSS) accessible via mobile devices by primary healthcare providers in the context of primary care settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, POPLINE, and two trial registries from 1 January 2000 to 9 October 2020. We conducted a grey literature search using mHealthevidence.org and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies.

SELECTION CRITERIA

Study design: we included randomized trials, including full-text studies, conference abstracts, and unpublished data irrespective of publication status or language of publication.  Types of participants: we included studies of all cadres of healthcare providers, including lay health workers and other individuals (administrative, managerial, and supervisory staff) involved in the delivery of primary healthcare services using clinical decision-support tools; and studies of clients or patients receiving care from primary healthcare providers using digital decision-support tools. Types of interventions: we included studies comparing digital CDSS accessible via mobile devices with non-digital CDSS or no intervention, in the context of primary care. CDSS could include clinical protocols, checklists, and other job-aids which supported risk prioritization of patients. Mobile devices included mobile phones of any type (but not analogue landline telephones), as well as tablets, personal digital assistants, and smartphones. We excluded studies where digital CDSS were used on laptops or integrated with electronic medical records or other types of longitudinal tracking of clients.

DATA COLLECTION AND ANALYSIS

A machine learning classifier that gave each record a probability score of being a randomized trial screened all search results. Two review authors screened titles and abstracts of studies with more than 10% probability of being a randomized trial, and one review author screened those with less than 10% probability of being a randomized trial. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. We used the GRADE approach to assess the certainty of the evidence for the most important outcomes.

MAIN RESULTS

Eight randomized trials across varying healthcare contexts in the USA,. India, China, Guatemala, Ghana, and Kenya, met our inclusion criteria. A range of healthcare providers (facility and community-based, formally trained, and lay workers) used digital CDSS. Care was provided for the management of specific conditions such as cardiovascular disease, gastrointestinal risk assessment, and maternal and child health. The certainty of evidence ranged from very low to moderate, and we often downgraded evidence for risk of bias and imprecision. We are uncertain of the effect of this intervention on providers' adherence to recommended practice due to the very low certainty evidence (2 studies, 185 participants). The effect of the intervention on patients' and clients' health behaviours such as smoking and treatment adherence is mixed, with substantial variation across outcomes for similar types of behaviour (2 studies, 2262 participants). The intervention probably makes little or no difference to smoking rates among people at risk of cardiovascular disease but probably increases other types of desired behaviour among patients, such as adherence to treatment. The effect of the intervention on patients'/clients' health status and well-being  is also mixed (5 studies, 69,767 participants). It probably makes little or no difference to some types of health outcomes, but we are uncertain about other health outcomes, including maternal and neonatal deaths, due to very low-certainty evidence. The intervention may slightly improve patient or client acceptability and satisfaction (1 study, 187 participants). We found no studies that reported the time between the presentation of an illness and appropriate management, provider acceptability or satisfaction, resource use, or unintended consequences.

AUTHORS' CONCLUSIONS

We are uncertain about the effectiveness of mobile phone-based decision-support tools on several outcomes, including adherence to recommended practice. None of the studies had a quality of care framework and focused only on specific health areas.   We need well-designed research that takes a systems lens to assess these issues.

Preparing for the Improving Medicare Post-Acute Care Transformation Act: Incorporating A Sociotechnical Perspective to Enhance a Health Information Technology Evaluation Framework Applied to Post-Acute Care

The Improving Medicare Post-Acute Care Transformation Act, which mandates electronic sharing of standardized patient data by post-acute care clinical settings, will likely spur further health information technology adoption and evaluation. To support evaluation, the study objective was to clarify components of an evidence-based health information technology evaluation framework, Health Information Technology Reference-based Evaluation Framework, by using the framework in home healthcare and incorporating a sociotechnical perspective in the health information technology evaluation. With 36 observations among three diverse home healthcare agencies, researchers conducted a recorded think-aloud process as nurses documented the home healthcare admission in the EHR. Thematic analysis revealed 15 themes that provided clarification for almost one-third of Health Information Technology Reference-based Evaluation Framework components and added a new concept. All themes reflected a sociotechnical perspective. The new theme added to the Health Information Technology Reference-based Evaluation Framework reflected the sociotechnical perspective: routine use. We anticipate the enhanced Health Information Technology Reference-based Evaluation Framework to be used by evaluators from diverse disciplines, to further facilitate context-dependent health information technology adoption in post-acute care settings.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.

MATERIALS AND METHODS

We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.

RESULTS

There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18-8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72-0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.

DISCUSSION AND CONCLUSION

Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

Effectiveness of a clinical decision-support tool on adherence to prescribing and practice guidelines of high-risk antidepressant medications in geriatric patients

Introduction

TCAs and paroxetine, a SSRI, are associated with safety risks in geriatric patients because of anticholinergic properties. The purpose of this project was to evaluate the impact of a clinical decision-support tool (CDST) on adherence with medication prescribing and practice guidance to enhance patient safety.

Methods

Mental health clinical pharmacy specialists and clinical pharmacy leadership led a multidisciplinary creation and integration of a CDST within a Veterans Health Administration EHR. The CDST focused on the following elements when prescribing TCAs and paroxetine in geriatric patients: clinical justification for initiation of the medication, provision of patient/caregiver education specific to the medication prescribed, evaluation of comprehension of education provided, medication reconciliation, and follow-up completed within 30 days of medication initiation. Following activation of the CDST in the EHR, measures were evaluated before intervention and after intervention.

Results

After intervention, an increase was observed in the primary outcome of the proportion of patients having documentation of all of the following: clinical justification for medication initiation, provision of patient/caregiver education, evaluation of comprehension of education provided, medication reconciliation, and follow-up completed within 30 days of medication initiation (P = .01). Individual proportions of patients with documented medication reconciliation and follow-up completed within 30 days significantly increased. All other secondary outcomes numerically increased but did not reach statistical significance.

Discussion

Improvement was seen in adherence with prescribing and practice guidance following the implementation of the CDST. This suggests the beneficial role of CDSTs within the EHR to optimize patient safety.

Implementation of distributed automated medication dispensing units in a new hospital: Nursing and pharmacy experience

AIMS AND OBJECTIVES

To explore the structures, processes and outcomes involved in an Automated Medication Dispensing system implementation and its impact on patient safety.

BACKGROUND

Increasing digitalisation of medication prescribing, dispensing, administration and stock management has occurred over the past two decades. While automated medication dispensing units aim to provide safe, high-quality, patient-centred care, the implementation may result in unintended consequences leading to suboptimal outcomes.

DESIGN

This study uses a qualitative approach guided by Donabedian's structure, process and outcome framework.

METHODS

Twenty-six registered nurses and pharmacy assistant staff, from clinical areas equipped with automated medication dispensing cabinets, participated in semi-structured interviews. In-depth, thematic analysis explored the structures and processes. Together with interview data, content analysis of text data generated by internal risk management and critical incident reporting systems was undertaken to evaluate outcomes. Findings were considered in light of the Interactive Sociotechnical Analysis approach to health information technology. The COREQ checklist was used in preparation of this article.

RESULTS

Pharmacy assistants reported better satisfaction with the system at implementation than nurses. Training provided for nurses and their involvement in system implementation was reported as insufficient; however, nurses' use of and satisfaction with the system improved over time. A recursive relationship between the changes imposed by the system and nurses' creative problem solving (workarounds) used to manage these changes, impacted work productivity for nurses and safety for patients.

CONCLUSIONS

The individualised nature of "workarounds" employed offered both risks and opportunities which require further identification, investigation and management.

RELEVANCE TO CLINICAL PRACTICE

Nurses are the majority of the health workforce. Digitalisation of traditionally paper-based activities in health care, impacting nursing work, requires similar strategies to any practice change.

The impact on health outcomes of implementing electronic health records to support the care of older people in residential aged care: A scoping review

AIM

The implementation of electronic health records (EHRs) in the aged care sector has been shown to improve efficiency and quality of care, administrative and funding processes. The aim of this study was to examine whether implementing EHRs and/or interventions leveraging EHRs in residential aged care facilities has any impact on health outcomes for residents and to review and summarise any published evidence.

METHODS

Using the Joanna Briggs Institute guidelines for conducting scoping reviews, we searched PubMed, CINAHL, Embase, Cochrane and Scopus databases for articles describing the impact of EHRs and/or EHR-based interventions on health outcomes for residents in residential aged care. We included journal articles published in English between 2009 and 2019. After identifying articles meeting the inclusion criteria, we extracted individual findings and produced a narrative summary.

RESULTS

Out of 6576 articles identified through database searches, seven met our inclusion criteria. The articles varied in study design, experimental methods, sample sizes and health outcomes assessed but there were no randomised controlled trials: four articles employed quantitative methods and three employed both quantitative and qualitative methods. The implementation of EHR-based interventions had positive impact on outcomes related to excessive weight loss, malnutrition, mobility, weighing of residents and use of antipsychotic medicines but had mixed impact (i.e., positive impact in some studies but non-significant or negative impact in others) on pressure ulcers, activities of daily living, behavioural symptoms, use of physical restraints and signs of depression. We also found that these interventions had no statistically significant impact on medication discrepancies, adverse drug events, falls or mortality.

CONCLUSION

In conclusion, research in this area is not yet comprehensive enough to reach a definitive conclusion on the impact of EHR-based interventions on health outcomes in residential aged care. As provider organisations increasingly implement EHRs, more research is needed to study their impact on resident health outcomes and examine how this impact eventuates.

Measures of electronic health record use in outpatient settings across vendors

Electronic health record (EHR) log data capture clinical workflows and are a rich source of information to understand variation in practice patterns. Variation in how EHRs are used to document and support care delivery is associated with clinical and operational outcomes, including measures of provider well-being and burnout. Standardized measures that describe EHR use would facilitate generalizability and cross-institution, cross-vendor research. Here, we describe the current state of outpatient EHR use measures offered by various EHR vendors, guided by our prior conceptual work that proposed seven core measures to describe EHR use. We evaluate these measures and other reporting options provided by vendors for maturity and similarity to previously proposed standardized measures. Working toward improved standardization of EHR use measures can enable and accelerate high-impact research on physician burnout and job satisfaction as well as organizational efficiency and patient health.

Effectiveness of Theory-Based Health Information Technology Interventions on Coronary Artery Disease Self-Management Behavior: A Clinical Randomized Waitlist-Controlled Trial

Purpose

Secondary prevention of coronary artery disease, self‐management behavior, and blood pressure control are important to cardiovascular event prevention and promotion of quality of life (QOL), but they are underutilized. The purpose of this study was to investigate the effects of a self‐efficacy theory–based health information technology intervention implemented through blood control and patient self‐management.

Design

A clinical randomized waitlist‐controlled trial.

Methods

The study was conducted at a medical center in Taipei, Taiwan. A total of 60 subjects were randomly assigned to either the immediate intervention (experimental) group or the waitlist control group. The primary endpoint was systolic blood pressure at 3 months; secondary end points included self‐management behavior and QOL. Treatment for the immediate intervention group lasted 3 months, while the waitlist control group received routine care for the first 3 months, at which point they crossed over to the intervention arm and received the same intervention as the experimental group for another 3 months. Both groups were evaluated by questionnaires and physiological measurements at both 3 and 6 months postadmission. The results were analyzed using generalized estimating equations.

Results

Systolic blood pressure significantly improved for the intervention group participants at 3 months, when there was also significant improvement in self‐management behavior and QOL. There was no significant or appreciable effect of time spent in the waitlist condition, with treatments in the two conditions being similarly effective.

Conclusion

The use of a theory‐based health information technology treatment compared with usual care resulted in a significant improvement in systolic blood pressure, self‐management behavior, and QOL in patients with coronary artery disease.

Clinical Relevance

This treatment would be a useful strategy for clinical care of cardiovascular disease patients, improving their disease self‐management. It also may help guide further digital health care strategies during the COVID‐19 pandemic.

The Effect of Innovation Capabilities of Health Care Organizations on the Quality of Health Information Technology: Model Development With Cross-sectional Data

Background

Large health organizations often struggle to build complex health information technology (HIT) solutions and are faced with ever-growing pressure to continuously innovate their information systems. Limited research has been conducted that explores the relationship between organizations’ innovative capabilities and HIT quality in the sense of achieving high-quality support for patient care processes.

Objective

The aim of this study is to explain how core constructs of organizational innovation capabilities are linked to HIT quality based on a conceptual sociotechnical model on innovation and quality of HIT, called the IQ_HIT model, to help determine how better information provision in health organizations can be achieved.

Methods

We designed a survey to assess various domains of HIT quality, innovation capabilities of health organizations, and context variables and administered it to hospital chief information officers across Austria, Germany, and Switzerland. Data from 232 hospitals were used to empirically fit the model using partial least squares structural equation modeling to reveal associations and mediating and moderating effects.

Results

The resulting empirical IQ_HIT model reveals several associations between the analyzed constructs, which can be summarized in 2 main insights. First, it illustrates the linkage between the constructs measuring HIT quality by showing that the professionalism of information management explains the degree of HIT workflow support (R²=0.56), which in turn explains the perceived HIT quality (R²=0.53). Second, the model shows that HIT quality was positively influenced by innovation capabilities related to the top management team, the information technology department, and the organization at large. The assessment of the model’s statistical quality criteria indicated valid model specifications, including sufficient convergent and discriminant validity for measuring the latent constructs that underlie the measures of HIT quality and innovation capabilities.

Conclusions

The proposed sociotechnical IQ_HIT model points to the key role of professional information management for HIT workflow support in patient care and perceived HIT quality from the viewpoint of hospital chief information officers. Furthermore, it highlights that organizational innovation capabilities, particularly with respect to the top management team, facilitate HIT quality and suggests that health organizations establish this link by applying professional information management practices. The model may serve to stimulate further scientific work in the field of HIT adoption and diffusion and to provide practical guidance to managers, policy makers, and educators on how to achieve better patient care using HIT.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study

PURPOSE

To identify factors in community pharmacy that facilitate error recovery from medication incidents (MIs) and explore medication safety prevention strategies from the pharmacist perspective.

METHODS

Thirty community pharmacies in Sydney, Australia, participated in a 30-month prospective incident reporting program of MIs classified in the Advanced Incident Management System (AIMS) and the analysis triangulated with case studies. The main outcome measures were the relative frequencies and patterns in MI detection, minimisation, restorative actions and prevention recommendations of community pharmacists.

RESULTS

Participants reported 1013 incidents with 831 recovered near misses and 165 purported patient harm. MIs were mainly initiated at the prescribing (68.2%) and dispensing (22.6%) stages, and most were resolved at the pharmacy (76.9%). Detection was efficient within the first 24 h in 54.6% of MIs, but 26.1% required one month or longer; 37.2% occurred after the patient consumed the medicine. The combination of specific actions/attributes (85.5%), appropriate interventions (81.6%) and effective communication (77.7%) minimised MIs. An array of remedial actions were conducted by participants including notification, referral, advice, modification of medication regimen, risk management and documentation corrections. Recommended prevention strategies involved espousal of medication safety culture (97.8%), better application of policies/procedures (84.6%) and improvements in healthcare providers' education (79.9%).

CONCLUSION

Incident reporting provided insights on the human and organisational factors involved in the recovery of MIs in community pharmacy. Optimising existing safeguards and redesigning certain structures and processes may enhance the resilience of the medication use system in primary care.

Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects

Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.

Basics of practice management: managing many for the care of one

In today's changing health care landscape, it has become necessary that providers have a fundamental understanding of practice management as pertinent to the care they provide. The reproductive endocrinology and infertility (REI) practice is a uniquely complex setting with many component parts, necessitating frequent assessment and collaboration to provide safe, quality, and cost-effective care. In this review, we aim to describe the basics of medical practice management, divided into six sections: practice models; operations; patient safety; patient experience; employee recruitment; development, and satisfaction; and technology. These topics will be presented with a focus on the application of these principles to the REI practice.

Informatics Experience Can Help Predict Doctor of Nursing Practice Student Mastery of Informatics Competencies

With information technology increasingly guiding nursing practice, Doctor of Nursing Practice students must be prepared to use informatics to optimize patient outcomes despite their varied experience and education. Understanding how students' baseline experience affects their mastery of informatics competencies could help faculty design Doctor of Nursing Practice course content. Therefore, the aim of this retrospective descriptive study was to evaluate whether Doctor of Nursing Practice students' baseline informatics experience affected their mastery of four competencies: meaningful use, datasets, e-health, and clinical support systems. Participants were Doctor of Nursing Practice students (n = 55) enrolled in an online informatics course. Participant experience was compared to competency mastery using χ tests. Logistic regression was performed to assess the effect of experience and highest degree obtained on competency mastery. Analysis revealed that participants with meaningful use experience were significantly more likely to master the meaningful use competency than were those without it. Relevant experience did not predict mastery of dataset competencies. Participants with e-health experience were significantly more likely to master the e-health competency (applying e-health resources to vulnerable patients' learning needs). While not significant, a greater percentage of students with clinical support systems experience mastered the clinical support systems competency. Informatics courses might need to be designed to address students' needs based on their experience.

Health information technology and hospital performance the role of health information quality in teaching hospitals

The research purposed in this paper is to investigate the impact of the health information technology on hospital performance through the health information quality as mediating variable, as new evidence from the teaching hospitals in the north of Jordan. Research design and methodology approach based on a survey that is conducted to collect the requested data to develop a model connect between the health information technologies, health information quality and hospital performance by using the Structural Equation Modeling approach. The research findings show that there is an intertwined and reciprocal relation between Health Information Technologies (HITs), hospital performance, and health information quality. HITs have direct positive impacts on both hospital performance and health information quality. Health information quality has also a direct impact on hospital performance. Besides, health information quality functioned as a partial mediator between HITs and hospital performance. The study did not examine the factors that influence the relationship between HITs, hospital performance and health information quality. This paper is evidence for the investor in the healthcare sector to invest more in HITs and health information quality, where the expected results are productivity improvement, performance leveraging and error reduction. The research originality is to introduce new evidence support literature form the Middle East countries is the main contribution of this paper.

Optimizing health IT to improve health system performance: A work in progress

BACKGROUND

Despite significant investments in health information technology (IT), the technology has not yielded the intended performance effects or transformational change. We describe activities that health systems are pursuing to better leverage health IT to improve performance.

METHODS

We conducted semi-structured telephone interviews with C-suite executives from 24 U.S. health systems in four states during 2017-2019 and analyzed the data using a qualitative thematic approach.

RESULTS

Health systems reported two broad categories of activities: laying the foundation to improve performance with IT and using IT to improve performance. Within these categories, health systems were engaged in similar activities but varied greatly in their progress. The most substantial effort was devoted to the first category, which enabled rather than directly improved performance, and included consolidating to a single electronic health record (EHR) platform and common data across the health system, standardizing data elements, and standardizing care processes before using the EHR to implement them. Only after accomplishing such foundational activities were health systems able to focus on using the technology to improve performance through activities such as using data and analytics to monitor and provide feedback, improving uptake of evidence-based medicine, addressing variation and overuse, improving system-wide prevention and population health management, and making care more convenient.

CONCLUSIONS AND IMPLICATIONS

Leveraging IT to improve performance requires significant and sustained effort by health systems, in addition to significant investments in hardware and software. To accelerate change, better mechanisms for creating and disseminating best practices and providing advanced technical assistance are needed.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Nurses' experiences and viewpoints about the benefits of adopting information technology in health care: a qualitative study in Iran

Background

Information technology (IT) plays an important role in nursing practice. Hence, nurses’ experiences and viewpoints about IT integration into healthcare help improve nurses’ adoption of IT. This study aimed to explore the nurses’ experiences and viewpoints about the benefits of IT integration and adoption in healthcare.

Methods

This study was conducted with a qualitative research approach. Participants included 14 nurses from four hospitals affiliated to a large medical university in Iran, who were selected using a purposive sampling method. Data were collected through semi-structured interviews and analyzed using the conventional content analysis of Lundman and Graneheim.

Results

Six categories in the study reflected the nurses’ experiences and viewpoints about the benefits of integrating IT into health care. These categories included improving the quality and efficiency of medical services and care, facilitating the communication management in the technological environment, improving information documentation, management, and monitoring, improving resource management, improving management performance and policymaking, and facilitating pathways of organizational and professional growth.

Conclusions

Lessons learned in this study can help overcoming the barriers of IT adoption, and developing appropriate strategies to familiarize nurses with the benefits of IT in healthcare settings. Healthcare managers are recommended to investigate the experiences of nurses with IT in their hospitals and organize courses to orient hesitant nurses toward adopting IT.

Improving the informatics competency of critical care nurses: results of an interventional study in the southeast of Iran

BACKGROUND

Nursing informatics (NI) along with growth and development of health information technology (HIT) is becoming a fundamental part of all domains of nursing practice especially in critical care settings. Nurses are expected to equip with NI competency for providing patient-centered evidence-based care. Therefore, it is important and necessary to improve nurses' NI competency through educational programs for effective using of HIT. This study aimed to evaluate the impact of a training program on NI competency of critical care nurses.

METHODS

This interventional study was conducted in 2019. Stratified sampling technique was used to select 60 nurses working in critical care units of three hospitals affiliated with a large University of Medical Sciences in the southeast of Iran. These nurses were assigned randomly and equally to the control and intervention groups. NI competency was trained to the intervention group in a three-day workshop. Data were collected using demographic questionnaire and the adapted Nursing Informatics Competency Assessment Tool (NICAT) before and 1 month after the intervention. Rahman in the US (2015) developed and validated the original NICAT to assess self-reported NI competency of nurses with 30 items and three dimensions (Computer literacy, Informatics literacy Information management skills). The NICAT is scored on a five-point Likert scale and the overall score ranges from 30 to150. Two medical informatics specialists and eight nursing faculty members approved the validity of the adapted version of NICAT and its reliability was confirmed by Cronbach's alpha (95%).

RESULTS

All 60 participants completed the educational program and returned the completed questionnaire. Majority of participants in the intervention and control groups were female (83.30%), married nurses (70.90, 73.30%) aged 30-40 years (51.6, 35.5%). In the pretest stage, both intervention and control groups were competent in terms of the NI competency and its dimensions, and no significant difference was observed between them (p = 0.65). However, in the posttest, the NI competency and its dimensions in the intervention group significantly increased with a large effect size compared with the control group (p = 0.001). This difference showed that the intervention group was proficient in the posttest stage. The highest mean difference in the intervention group was associated with the informatics literacy dimension and the lowest mean difference was associated with the informatics management skills dimension.

CONCLUSIONS

The improved scores of NI competency and its dimensions after using the training program implied the effectiveness of this method in enhancing the NI competency of nurses working in the critical care units. The application of the training program in diverse domains of nursing practice shows its high efficiency. The project is fundamental for improving nurses' NI competency through continuous educational programs in Iran, other cultures and contexts.

Customer relationship management systems (CRMS) in the healthcare environment: A systematic literature review

Customer relationship management (CRM) is an innovative technology that seeks to improve customer satisfaction, loyalty, and profitability by acquiring, developing, and maintaining effective customer relationships and interactions with stakeholders. Numerous researches on CRM have made significant progress in several areas such as telecommunications, banking, and manufacturing, but research specific to the healthcare environment is very limited. This systematic review aims to categorise, summarise, synthesise, and appraise the research on CRM in the healthcare environment, considering the absence of coherent and comprehensive scholarship of disparate data on CRM. Various databases were used to conduct a comprehensive search of studies that examine CRM in the healthcare environment (including hospitals, clinics, medical centres, and nursing homes). Analysis and evaluation of 19 carefully selected studies revealed three main research categories: (i) social CRM 'eCRM'; (ii) implementing CRMS; and (iii) adopting CRMS; with positive outcomes for CRM both in terms of patients relationship/communication with hospital, satisfaction, medical treatment/outcomes and empowerment and hospitals medical operation, productivity, cost, performance, efficiency and service quality. This is the first systematic review to comprehensively synthesise and summarise empirical evidence from disparate CRM research data (quantitative, qualitative, and mixed) in the healthcare environment. Our results revealed that substantial gaps exist in the knowledge of using CRM in the healthcare environment. Future research should focus on exploring: (i) other potential factors, such as patient characteristics, culture (of both the patient and hospital), knowledge management, trust, security, and privacy for implementing and adopting CRMS and (ii) other CRM categories, such as mobile CRM (mCRM) and data mining CRM.

The influence of peer beliefs on nurses' use of new health information technology: A social network analysis

Implementation of health information technology fails at an alarming rate because intended users often choose not to use it. Implementation theory and frameworks suggest that social networks may influence individuals' use, but empirical study remains limited. Furthermore, neither theory nor research has identified whose beliefs within the network matter most for implementation. We examine the relationship between an individual's system use and the beliefs of his or her peers. We assess the relationship for two peer groups: the entire group of peers and the subset that shares the individual's beliefs about the system. We used data collected from an academic hospital in the United States that had recently implemented a bar code medication administration system, a technology meant to increase medication safety. We administered a survey to nurses (N = 207) in six clinical units approximately 3-5 months (April-June 2013) after the "go-live" of the system to identify peer groups and beliefs about system usefulness. We calculated mean peer belief for the entire peer group and sharedness of belief using a homophily measure. From the hospital's electronic health record system, we obtained nurses' system use during the 3-month data collection period. We used multivariable linear regression to examine relationships. We found no effect of mean peer beliefs on individual system use. However, sharedness of belief about usefulness was positively associated with individual system use. Individuals' own positive belief was only associated with greater system use when shared with peers. Our findings indicate a significant role of social networks in implementation, and specifically that shared beliefs between an individual and his or her peer network may be critical to implementation success, more so than the beliefs across the entire peer group. Reinforcement by the social network appears to dictate whether individuals' own beliefs translate into system use.

Real-Time Automated Hazard Detection Framework for Health Information Technology Systems

An increase in the reliability of Health Information Technology (HIT) will facilitate institutional trust and credibility of the systems. In this paper, we present an end-to-end framework for improving the reliability and performance of HIT systems. Specifically, we describe the system model, present some of the methods that drive the model, and discuss an initial implementation of two of the proposed methods using data from the Veterans Affairs HIT and Corporate Data Warehouse systems. The contributions of this paper, thus, include (1) the design of a system model for monitoring and detecting hazards in HIT systems, (2) a data-driven approach for analysing the health care data warehouse, (3) analytical methods for characterising and analysing failures in HIT systems, and (4) a tool architecture for generating and reporting hazards in HIT systems. Our goal is to work towards an automated system that will help identify opportunities for improvements in HIT systems.

Networked information technologies and patient safety: a protocol for a realist synthesis

BACKGROUND

There is a widespread belief that information technologies will improve diagnosis, treatment and care. Evidence about their effectiveness in health care is, however, mixed. It is not clear why this is the case, given the remarkable advances in hardware and software over the last 20 years. This review focuses on interoperable information technologies, which governments are currently advocating and funding. These link organisations across a health economy, with a view to enabling health and care professionals to coordinate their work with one another and to access patient data wherever it is stored. Given the mixed evidence about information technologies in general, and current policies and funding, there is a need to establish the value of investments in this class of system. The aim of this review is to establish how, why and in what circumstances interoperable systems affect patient safety.

METHODS

A realist synthesis will be undertaken, to understand how and why inter-organisational systems reduce patients' clinical risks, or fail to do so. The review will follow the steps in most published realist syntheses, including (1) clarifying the scope of the review and identifying candidate programme and mid-range theories to evaluate, (2) searching for evidence, (3) appraising primary studies in terms of their rigour and relevance and extracting evidence, (4) synthesising evidence, (5) identifying recommendations, based on assessment of the extent to which findings can be generalised to other settings.

DISCUSSION

The findings of this realist synthesis will shed light on how and why an important class of systems, that span organisations in a health economy, will contribute to changes in patients' clinical risks. We anticipate that the findings will be generalizable, in two ways. First, a refined mid-range theory will contribute to our understanding of the underlying mechanisms that, for a range of information technologies, lead to changes in clinical practices and hence patients' risks (or not). Second, many governments are funding and implementing cross-organisational IT networks. The findings can inform policies on their design and implementation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017073004.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting

INTRODUCTION

Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults.

OBJECTIVE

To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting.

METHODS

A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up.

RESULTS

A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05).

CONCLUSION

No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Digital health and patient safety: Technology is not a magic wand

The use of novel health information technology provides avenues for potentially significant patient benefit. However, it is also timely to take a step back and to consider whether the use of these technologies is safe - or more precisely what the current evidence for their safety is, and what kinds of evidence we should be looking for in order to create a convincing argument for patient safety. This special issue on patient safety includes eight papers that demonstrate an increasing focus on qualitative approaches and a growing recognition that the sociotechnical lens of examining health information technology-associated change is important. We encourage a balanced approach to technology adoption that embraces innovation, but nonetheless insists upon suitable concerns for safety and evaluation of outcomes.

Challenges to electronic clinical quality measurement using third-party platforms in primary care practices: the healthy hearts in the heartland experience

Third-party platforms have emerged to support small primary care practices for calculating and reporting electronic clinical quality measures (eCQM) for federal programs like The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS). Yet little is known about the capabilities and limitations of electronic health record systems (EHRs) to enable data access for these programs. We connected 116 small- to medium-sized practices with seven different EHRs to popHealth, an open-source eCQM platform. We identified the prevalence of following problems with eCQM data for data extraction in seven different EHRs: (1) Lack of coded data in five of seven; (2) Incorrectly categorized data in four of seven; (3) Isosemantic data (data within the incorrect context) in four of seven; (4) Coding that could not be directly evaluated in six of seven; (5) Errors in date assignment and labeled as historical values in five of seven; and (6) Inadequate data to assign the correct code in two of seven. We recommend specific enhancements to EHR systems that can promote effective eCQM implementation and reporting to MACRA and MIPS.

Critical care information display approaches and design frameworks: A systematic review and meta-analysis

OBJECTIVE

To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians.

METHODS

We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author.

RESULTS

Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible.

CONCLUSION

Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.

Implementing eScreening technology in four VA clinics: a mixed-method study

Background

Technology-based self-assessment (TB-SA) benefits patients and providers and has shown feasibility, ease of use, efficiency, and cost savings. A promising TB-SA, the VA eScreening program, has shown promise for the efficient and effective collection of mental and physical health information. To assist adoption of eScreening by healthcare providers, we assessed technology-related as well as individual- and system-level factors that might influence the implementation of eScreening in four diverse VA clinics.

Methods

This was a mixed-method, pre-post, quasi-experimental study originally designed as a quality improvement project. The clinics were selected to represent a range of environments that could potentially benefit from TB-SA and that made use of the variety eScreening functions. Because of limited resources, the implementation strategy consisted of staff education, training, and technical support as needed. Data was collected using pre- and post-implementation interviews or focus groups of leadership and clinical staff, eScreening usage data, and post-implementation surveys. Data was gathered on: 1) usability of eScreening; 2) knowledge about and acceptability and 3) facilitators and barriers to the successful implementation of eScreening.

Results

Overall, staff feedback about eScreening was positive. Knowledge about eScreening ranged widely between the clinics. Nearly all staff felt eScreening would fit well into their clinical setting at pre-implementation; however some felt it was a poor fit with emergent cases and older adults at post-implementation. Lack of adequate personnel support and perceived leadership support were barriers to implementation. Adequate training and technical assistance were cited as important facilitators. One clinic fully implemented eScreening, two partially implemented, and one clinic did not implement eScreening as part of normal practice after 6 months as measured by usage data and self-report. Organizational engagement survey scores were higher among clinics with full or partial implementation and low in the clinic that did not implement.

Conclusions

Despite some added work load for some staff and perceived lack of leadership support, eScreening was at least partially implemented in three clinics. The technology itself posed no barriers in any of the settings. An implementation strategy that accounts for increased work burden and includes accountability may help in future eScreening implementation efforts.

Note. This abstract was previously published (e.g., Annals of Behavioral Medicine 53: S1–S842, 2019).

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4436-z) contains supplementary material, which is available to authorized users.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Objective

To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports.

Methods

We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns.

Results

We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features.

Conclusions

Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Knowledge Translation Strategies Used by Healthcare Professionals in Child Health Settings: An Updated Systematic Review

PROBLEM

Strategies assisting healthcare professionals to make evidence-based decisions are crucial for quality patient care and outcomes. To date, there is one systematic review (Albrecht et al., 2016) examining knowledge translation (KT) efforts in child health settings. This systematic review aims to provide an update on current evidence identifying KT interventions implementing research into child health settings.

ELIGIBILITY CRITERIA

Nine electronic databases were searched, restricted by date (2011-2018) and language (English). Eligibility included: 1) randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) interventions implementing research into child health practice; and 3) outcomes were measured at the healthcare professional/process, patient, or economic level.

SAMPLE

Health care professionals working in child health settings.

RESULTS

48 studies (38 RCT, 7 CBA, 3 CCT) were included. Studies employed single (n = 34) and multiple (n = 14) interventions. The methodological quality of studies was moderate (n = 18), strong (n = 16) and weak (n = 14). Studies showing significant, positive effects included (n = 9) RCTs, (n = 3) CBAs and (n = 2) CCTs. These studies employed (n = 11) single KT interventions and (n = 3) multiple KT interventions. Interventions included educational (n = 6), reminders (n = 3), computerized decision supports (n = 2), multidisciplinary teams (n = 2) and financial and educational interventions combined (n = 1).

CONCLUSIONS

Effective KT strategies used by health care professionals in child health settings were found to be online education curriculums and computerized decision supports or reminders.

IMPLICATIONS

This review update serves as an up-to-date 'state of the science' on KT strategies used in pediatric health professionals' clinical practice, assessed by the most rigorous research designs.

Implementation of a new health information technology for the management of cancer chemotherapies

Background

Cancer chemotherapy drugs are classified as high-risk molecules. Safety of the cancer chemotherapy process is often achieved with the implementation of a health information technology to each step or to the entire process. However, computerisation could lead to the emergence of new unintended medication errors. The aim of the study was to evaluate the impact of new software designed for the management of anticancer chemotherapies.

Method

The cartography of the process and the failure modes, effects and criticality analysis were performed by a multidisciplinary team. Criticality indexes were calculated considering or not the implementation of the commercial software (CytoWeb). Quality and satisfactory indicators were measured before the implementation and during the use of the software.

Results

Our results demonstrated the complexity of the cancer chemotherapy process in the hospital. Risk analysis highlighted the positive impact of CytoWeb on the process safety but pointed out some steps that were not positively influenced by the software. Although a decrease of 38.6% of error rate was observed with the electronic system, new unintended medication errors emerged. These errors were due to inadequate use of the software (encoding of the wrong drug, the wrong dose, the wrong patient parameters or lab results and lack of prescriber adherence). Our satisfaction survey showed that the hospital pharmacists and doctors were less satisfied by the software than the nurses, mostly in terms of task achievement and time saving. Survey's results highlighted some weaknesses in the user training and in the collaboration between the medical staff.

Conclusions

Our work showed the emergence of unintended medication errors linked to computerisation that were due to an inadequate use of the software. Other issues were highlighted such as the lack of collaboration between the medical staff, the lack of prescriber implication and weaknesses in the user training or in the information related to CytoWeb.

[Patient safety hazards resulting from information technology usage in outpatient oncology infusion centers: A prospective analysis of information management]

OBJECTIVES

Thorough management of patient information is crucial in cancer care in order to avoid errors. Clinicians need complete, up-to-date information to be able to develop an adequate mental model of the patient's situation. The aim of the present study was to identify patient safety hazards coming with the use of health information technology (HIT): patient safety hazards in three outpatient oncology infusion centers were assessed and priority topics identified. Additionally, the number of information sources clinicians have to use in order to get an idea of the patient's situation was systematically assessed. Interviews and observations were conducted with one nurse and one doctor of each ambulatory infusion center.

PRINCIPAL RESULTS

Information management-related patient safety hazards were omnipresent in daily care: eleven topics were identified from 125 assessed patient safety hazards. Three of them were particularly relevant to the clinicians' development of an adequate mental model about the patient: patient-related information was not stored in one place but often fragmented in different HIT systems; despite the introduction of HIT, paper documentation remained in place for certain information, making access difficult and increasing the number of relevant sources; the lack of usability of the HIT systems made it difficult to retrieve patient information in a timely manner. Clinicians needed to use between 5 and 11 sources of information to get a more complete picture of a patient's situation.

MAJOR CONCLUSIONS

Overall, it has been shown that the design of the HIT systems is not sufficiently adapted to the work processes and does not support clinicians in being fully informed about a patient. The topics identified point to future system design and areas for improvement. In this process, it is very important to align the real work requirements with the design of the HIT and to evaluate and monitor the actual implementation and use of HIT.

Current challenges in health information technology-related patient safety

We identify and describe nine key, short-term, challenges to help healthcare organizations, health information technology developers, researchers, policymakers, and funders focus their efforts on health information technology-related patient safety. Categorized according to the stage of the health information technology lifecycle where they appear, these challenges relate to (1) developing models, methods, and tools to enable risk assessment; (2) developing standard user interface design features and functions; (3) ensuring the safety of software in an interfaced, network-enabled clinical environment; (4) implementing a method for unambiguous patient identification (1-4 Design and Development stage); (5) developing and implementing decision support which improves safety; (6) identifying practices to safely manage information technology system transitions (5 and 6 Implementation and Use stage); (7) developing real-time methods to enable automated surveillance and monitoring of system performance and safety; (8) establishing the cultural and legal framework/safe harbor to allow sharing information about hazards and adverse events; and (9) developing models and methods for consumers/patients to improve health information technology safety (7-9 Monitoring, Evaluation, and Optimization stage). These challenges represent key "to-do's" that must be completed before we can expect to have safe, reliable, and efficient health information technology-based systems required to care for patients.