Managing interoperability and complexity in health systems

Optimising ePrescribing in hospitals through the interoperability of systems and processes: a qualitative study in the UK, US, Norway and the Netherlands

BACKGROUND

Investment in the implementation of hospital ePrescribing systems has been a priority in many economically-developed countries in order to modernise the delivery of healthcare. However, maximum gains in the safety, quality and efficiency of care are unlikely to be fully realised unless ePrescribing systems are further optimised in a local context. Typical barriers to optimal use are often encountered in relation to a lack of systemic capacity and preparedness to meet various levels of interoperability requirements, including at the data, systems and services levels. This lack of systemic interoperability may in turn limit the opportunities and benefits potentially arising from implementing novel digital heath systems.

METHODS

We undertook n = 54 qualitative interviews with key stakeholders at nine digitally advanced hospital sites across the UK, US, Norway and the Netherlands. We included hospitals featuring 'standalone, best of breed' systems, which were interfaced locally, and multi-component and integrated electronic health record enterprise systems. We analysed the data inductively, looking at strategies and constraints for ePrescribing interoperability within and beyond hospital systems.

RESULTS

Our thematic analysis identified 4 main drivers for increasing ePrescribing systems interoperability: (1) improving patient safety (2) improving integration & continuity of care (3) optimising care pathways and providing tailored decision support to meet local and contextualised care priorities and (4) to enable full patient care services interoperability in a variety of settings and contexts. These 4 interoperability dimensions were not always pursued equally at each implementation site, and these were often dependent on the specific national, policy, organisational or technical contexts of the ePrescribing implementations. Safety and efficiency objectives drove optimisation targeted at infrastructure and governance at all levels. Constraints to interoperability came from factors such as legacy systems, but barriers to interoperability of processes came from system capability, hospital policy and staff culture.

CONCLUSIONS

Achieving interoperability is key in making ePrescribing systems both safe and useable. Data resources exist at macro, meso and micro levels, as do the governance interventions necessary to achieve system interoperability. Strategic objectives, most notably improved safety, often motivated hospitals to push for evolution across the entire data architecture of which they formed a part. However, hospitals negotiated this terrain with varying degrees of centralised coordination. Hospitals were heavily reliant on staff buy-in to ensure that systems interoperability was built upon to achieve effective data sharing and use. Positive outcomes were founded on a culture of agreement about the usefulness of access by stakeholders, including prescribers, policymakers, vendors and lab technicians, which was reflected in an alignment of governance goals with system design.

An Automated Bioinformatics Pipeline Informing Near-Real-Time Public Health Responses to New HIV Diagnoses in a Statewide HIV Epidemic

Molecular HIV cluster data can guide public health responses towards ending the HIV epidemic. Currently, real-time data integration, analysis, and interpretation are challenging, leading to a delayed public health response. We present a comprehensive methodology for addressing these challenges through data integration, analysis, and reporting. We integrated heterogeneous data sources across systems and developed an open-source, automatic bioinformatics pipeline that provides molecular HIV cluster data to inform public health responses to new statewide HIV-1 diagnoses, overcoming data management, computational, and analytical challenges. We demonstrate implementation of this pipeline in a statewide HIV epidemic and use it to compare the impact of specific phylogenetic and distance-only methods and datasets on molecular HIV cluster analyses. The pipeline was applied to 18 monthly datasets generated between January 2020 and June 2022 in Rhode Island, USA, that provide statewide molecular HIV data to support routine public health case management by a multi-disciplinary team. The resulting cluster analyses and near-real-time reporting guided public health actions in 37 phylogenetically clustered cases out of 57 new HIV-1 diagnoses. Of the 37, only 21 (57%) clustered by distance-only methods. Through a unique academic-public health partnership, an automated open-source pipeline was developed and applied to prospective, routine analysis of statewide molecular HIV data in near-real-time. This collaboration informed public health actions to optimize disruption of HIV transmission.

Integrated care with digital health innovation: pressing challenges

Purpose

Digital health care has emerged as one of the most important means to deliver integrated care by care providers in recent years. As the use of digital health increases, there are some pressing issues such as interoperability of data across different healthcare information systems, regulatory environment and security and privacy of patient’s information which need to be discussed and addressed in order to reduce information silos and to ensure efficient and seamless use of digital health technologies. The purpose of this paper is to address these issues.

Design/methodology/approach

In this paper the authors outline the key concepts of interoperability, key challenges pertaining in achieving interoperability and concepts of security and privacy in context of digital health models of integrated care.

Findings

The study suggests that standardization of digital health information systems and connecting existing systems to health network, addressing privacy and security related issues through a comprehensive but supportive regulatory environment and educating citizens and healthcare providers are some of the ways to achieve effective use of digital health in models of integrated care.

Originality/value

Although the concepts of privacy and interoperability are not new, however, as per best of the authors’ knowledge, this is the first attempt to discuss the challenges and possible actions to meet the objective of achieving integrated care through digital innovation.

The complex case of EHRs: examining the factors impacting the EHR user experience

Physicians can spend more time completing administrative tasks in their electronic health record (EHR) than engaging in direct face time with patients. Increasing rates of burnout associated with EHR use necessitate improvements in how EHRs are developed and used. Although EHR design often bears the brunt of the blame for frustrations expressed by physicians, the EHR user experience is influenced by a variety of factors, including decisions made by entities other than the developers and end users, such as regulators, policymakers, and administrators. Identifying these key influences can help create a deeper understanding of the challenges in developing a better EHR user experience. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs.

The new European interoperability framework as a facilitator of digital transformation for citizen empowerment

Healthcare is a highly regulated domain. Seamless, online access to integrated electronic health records for citizens is still far from becoming a reality. The implementation of personally managed health data systems still needs to overcome several interoperability, usability, ethics, security, and regulatory issues to deliver the envisioned benefits. This paper offers a policy viewpoint on how the new European Interoperability Framework (EIF) may benefit the implementation of eHealth systems for the management of personal health information for citizens. Interoperability facilitates sharing of health and illness experiences, coordinated care and research for citizen empowerment and improved health outcomes. The adoption of principles relevant to core interoperability and generic user needs and expectations, as described in the new EIF, in line with European and national regulations are quite essential for the development of safe and secure patient access services to support mobility. An interoperability framework facilitates the creation of the appropriate context in which personal health record applications can be designed and implemented in support of disease specific solutions, such as chronic non-malignant pain, diabetes and cancer. It is evident that no solution will fit all circumstances. However, the new EIF, when adapted for personally managed health data, provides a useful and relevant framework to facilitate implementation and adoption of personal health record systems within a coordinated care environment. Practical implications of this work relate to the need of multi-disciplinary cooperation and European level compatibility and sustainability of the underlying infrastructures required to support reliable and secure access to and sharing of medical data, as well as the readiness to address continuously evolving functional and non-functional requirements for regional, national, and cross-border settings.

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom

Background

Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale.

Objective

The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale” (dallas) from 2012-2015.

Methods

The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem.

Results

We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness.

Conclusions

Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

Nutritional Considerations for Healthy Aging and Reduction in Age-Related Chronic Disease

A projected doubling in the global population of people aged ≥60 y by the year 2050 has major health and economic implications, especially in developing regions. Burdens of unhealthy aging associated with chronic noncommunicable and other age-related diseases may be largely preventable with lifestyle modification, including diet. However, as adults age they become at risk of "nutritional frailty," which can compromise their ability to meet nutritional requirements at a time when specific nutrient needs may be high. This review highlights the role of nutrition science in promoting healthy aging and in improving the prognosis in cases of age-related diseases. It serves to identify key knowledge gaps and implementation challenges to support adequate nutrition for healthy aging, including applicability of metrics used in body-composition and diet adequacy for older adults and mechanisms to reduce nutritional frailty and to promote diet resilience. This review also discusses management recommendations for several leading chronic conditions common in aging populations, including cognitive decline and dementia, sarcopenia, and compromised immunity to infectious disease. The role of health systems in incorporating nutrition care routinely for those aged ≥60 y and living independently and current actions to address nutritional status before hospitalization and the development of disease are discussed.

Standard Information Models for Representing Adverse Sensitivity Information in Clinical Documents

BACKGROUND

Adverse sensitivity (e.g., allergy and intolerance) information is a critical component of any electronic health record system. While several standards exist for structured entry of adverse sensitivity information, many clinicians record this data as free text.

OBJECTIVES

This study aimed to 1) identify and compare the existing common adverse sensitivity information models, and 2) to evaluate the coverage of the adverse sensitivity information models for representing allergy information on a subset of inpatient and outpatient adverse sensitivity clinical notes.

METHODS

We compared four common adverse sensitivity information models: Health Level 7 Allergy and Intolerance Domain Analysis Model, HL7-DAM; the Fast Healthcare Interoperability Resources, FHIR; the Consolidated Continuity of Care Document, C-CDA; and OpenEHR, and evaluated their coverage on a corpus of inpatient and outpatient notes (n = 120).

RESULTS

We found that allergy specialists' notes had the highest frequency of adverse sensitivity attributes per note, whereas emergency department notes had the fewest attributes. Overall, the models had many similarities in the central attributes which covered between 75% and 95% of adverse sensitivity information contained within the notes. However, representations of some attributes (especially the value-sets) were not well aligned between the models, which is likely to present an obstacle for achieving data interoperability. Also, adverse sensitivity exceptions were not well represented among the information models.

CONCLUSIONS

Although we found that common adverse sensitivity models cover a significant portion of relevant information in the clinical notes, our results highlight areas needed to be reconciled between the standards for data interoperability.

Overview of recent trans-institutional health network projects in Japan and Germany

Worldwide populations are aging and countries have to prepare for the effects of demographic change in health care. Health information exchange (HIE), which is the process of moving patient information across health care providers electronically, can help overcome health data fragmentation and open opportunities to improve patient care in terms of quality, economy and efficiency. Since Japan and Germany are among the first countries strongly impacted by demographic changes of aging populations, we report on current developments about health information systems carrying out HIE based on case studies in both countries. Four projects that address the improvement of HIE within a defined region have been selected and investigated: the German project of the Lower Saxony Bank of Health and the Japanese projects Chiba ITnet, Nagasaki AjisaiNet and the National Disaster and Backup System of Japan. The project descriptions are based on relevant English publications, on-site visits and interviews with developers and users. The projects are introduced in terms of their basic architecture and implementation, their present status and future objectives. The projects' developments are still in progress and all have to cope with significant challenges before they will be able to provide a fully working trans-institutional health network solution.