Workarounds in the Shadow System: An Ethnographic Study of Requirements for Documentation and Cooperation in a Clinical Advisory Center

OBJECTIVE

Hospital information systems (HIS) are meant to manage complex work processes across healthcare organizations. We describe limitations of HIS to address local information requirements and how they are circumvented at different organizational levels. Results can be used to better support collaboration in socio-technical systems.

BACKGROUND

Workarounds describe a mismatch between a technology's purpose and its actual use, whereas shadow systems are unofficial IT systems circumventing limitations of official systems to support workflows. Boundary infrastructures are conceptualized as the entirety of all (in)formal digital and analog systems connecting different communities of practice in a socio-technical system.

METHODS

An ethnographic study with observations and semi-structured interviews was conducted and analyzed through categorization and iterative coding.

RESULTS

Several digital-analog workarounds are employed for documentation and a shared server functions as a shadow system to support workflows in ways the HIS cannot. For collaborative documentation, all (official and informal) information sources were used simultaneously as part of an interconnected boundary infrastructure.

CONCLUSION

Formal and informal IT systems are interconnected across different organizational levels and provide insights into unmet information requirements, effective and problematic work practices, and how to address them to improve system functioning. An integrated perspective on boundary infrastructures, workarounds, and shadow systems may advance system analysis, providing a more comprehensive picture of IT requirements than any concept alone.

APPLICATION

Workarounds and shadow systems highlight that HIS should support systemic and local needs. Customized interfaces in HIS to support search, access, and exchange of relevant data might help to mitigate current shortcomings.

Unscheduled Emergency Department Revisits Within 48 Hours of Discharge

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

Designing a comprehensive minimum dataset for patients with COVID-19 in Iranian hospital information systems

BACKGROUND

The Minimum Data Set (MDS) plays a vital role in data exchange, collection and quality improvement. In the context of the COVID-19 pandemic, there is a need for a tailored MDS that aligns with the specific information needs of the Iranian community and integrates seamlessly into the country's Hospital Information Systems (HIS).

OBJECTIVE

The study aimed to develop a comprehensive MDS for COVID-19 patients in Iran, with objectives to identify essential data elements and integrate the MDS into HIS, enhancing data exchange and supporting decision-making.

METHOD

This study employed a comparative-descriptive approach to design COVID-19 patient data elements based on World Health Organisation and Centers for Disease Control and Prevention guidelines. The Delphi technique involved 35 experts in two rounds for checklist refinement. The finalised MDS consisted of 9 main terms and 80 sub-terms, analysed using descriptive statistics and IBM SPSS software.

RESULTS

Of 35 experts involved with the study, 69% were male and 31% female, and Health Information Management experts were the majority (34%). The refined MDS for COVID-19 in Iran comprises 50 data elements, while 30 elements were excluded. The MDS includes 8 main terms and 80 sub-terms, with unanimous approval for identity, underlying disease, and treatment sections.

CONCLUSION

The customised MDS for COVID-19 patients in Iran addresses data collection challenges and supports effective disease prevention and management. By providing comprehensive and reliable information, the MDS enhances healthcare quality, facilitates timely access to medical records, and fosters integrated health services.

Understanding the role and impact of electronic health records in labor and delivery nursing practice: A scoping review protocol

Background

Electronic health records have a significant impact on nursing practice, particularly in specializations such as labor and delivery, or acute care maternity nursing practice. Although primary studies on the use of electronic health records in labor and delivery have been done, no reviews on this topic exist. Moreover, the topic of labor and delivery nurses' organizing work in the electronic health record-enabled context has not been addressed.

Objective

To (a) synthesize research on electronic health record use in labor and delivery nursing and (b) map how labor and delivery nursing organizing work is transformed by the electronic health record (as described in the reviewed studies).

Methods

The scoping review will be guided by a modified methodology based on selected recommendations from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews. A comprehensive search will be conducted in the following databases: CINAHL Complete, MEDLINE, Academic Search Complete, Web of Science, Scopus and Dissertations and Theses Abstracts and Indexes. Included sources will be primary research, dissertations, or theses that address the use of electronic health records in labor and delivery nursing practice in countries with high levels of electronic health record adoption. Data extracted from included sources will be analyzed thematically. Further analysis will theorize labor and delivery nurses' organizing work in the context of electronic health record use by utilizing concepts from Davina Allen's Translational Mobilization Theory. Findings will be presented in tabular and descriptive formats.

Conclusion

The findings of this review will help understand transformations of nursing practice in the electronic health record-enabled labor and delivery context and identify areas of future research. We will propose an extension of the Translational Mobilization Theory and theorize nurses' organizing work involving the use of the electronic health record.

Implementing Clinical Information Systems in Sub-Saharan Africa: Report and Lessons Learned From the MatLook Project in Cameroon

BACKGROUND

Yaoundé Central Hospital (YCH), located in the capital of Cameroon, is one of the leading referral hospitals in Cameroon. The hospital has several departments, including the Department of Gynecology-Obstetrics (hereinafter referred to as "the Maternity"). This clinical department has faced numerous problems with clinical information management, including the lack of high-quality and reliable clinical information, lack of access to this information, and poor use of this information.

OBJECTIVE

We aim to improve the management of clinical information generated at the Maternity at YCH and to describe the challenges, success factors, and lessons learned during its implementation and use.

METHODS

Based on an open-source hospital information system (HIS), this intervention implemented a clinical information system (CIS) at the Maternity at YCH and was carried out using the HERMES model-the first part aimed to cover outpatient consultations, billing, and cash management of the Maternity. Geneva University Hospitals supported this project, and several outcomes were measured at the end. The following outcomes were assessed: project management, technical and organizational aspects, leadership, change management, user training, and system use.

IMPLEMENTATION (RESULTS)

The first part of the project was completed, and the CIS was deployed in the Maternity at YCH. The main technical activities were adapting the open-source HIS to manage outpatient consultations and develop integrated billing and cash management software. In addition to technical aspects, we implemented several other activities. They consisted of the implementation of appropriate project governance or management, improvement of the organizational processes at the Maternity, promotion of the local digital health leadership and performance of change management, and implementation of the training and support of users. Despite barriers encountered during the project, the 6-month evaluation showed that the CIS was effectively used during the first 6 months.

CONCLUSIONS

Implementation of the HIS or CIS is feasible in a resource-limited setting such as Cameroon. The CIS was implemented based on good practices at the Maternity at YCH. This project had successes but also many challenges. Beyond project management and technical and financial aspects, the other main problems of implementing health information systems or HISs in Africa lie in digital health leadership, governance, and change management. This digital health leadership, governance, and change management should prioritize data as a tool for improving productivity and managing health institutions, and promote a data culture among health professionals to support a change in mindset and the acquisition of information management skills. Moreover, in countries with a highly centralized political system like ours, a high-level strategic and political anchor for such projects is often necessary to guarantee their success.

Implementing AI Models for Prognostic Predictions in High-Risk Burn Patients

BACKGROUND AND OBJECTIVES

Burn injuries range from minor medical issues to severe, life-threatening conditions. The severity and location of the burn dictate its treatment; while minor burns might be treatable at home, severe burns necessitate medical intervention, sometimes in specialized burn centers with extended follow-up care. This study aims to leverage artificial intelligence (AI)/machine learning (ML) to forecast potential adverse effects in burn patients.

METHODS

This retrospective analysis considered burn patients admitted to Chi Mei Medical Center from 2010 to 2019. The study employed 14 features, comprising supplementary information like prior comorbidities and laboratory results, for building models for predicting graft surgery, a prolonged hospital stay, and overall adverse effects. Overall, 70% of the data set trained the AI models, with the remaining 30% reserved for testing. Three ML algorithms of random forest, LightGBM, and logistic regression were employed with evaluation metrics of accuracy, sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC).

RESULTS

In this research, out of 224 patients assessed, the random forest model yielded the highest AUC for predictions related to prolonged hospital stays (>14 days) at 81.1%, followed by the XGBoost (79.9%) and LightGBM (79.5%) models. Besides, the random forest model of the need for a skin graft showed the highest AUC (78.8%), while the random forest model and XGBoost model of the occurrence of adverse complications both demonstrated the highest AUC (87.2%) as well. Based on the best models with the highest AUC values, an AI prediction system is designed and integrated into hospital information systems to assist physicians in the decision-making process.

CONCLUSIONS

AI techniques showcased exceptional capabilities for predicting a prolonged hospital stay, the need for a skin graft, and the occurrence of overall adverse complications for burn patients. The insights from our study fuel optimism for the inception of a novel predictive model that can seamlessly meld with hospital information systems, enhancing clinical decisions and bolstering physician-patient dialogues.

[Access to neonatal healthcare services: analysis of displacement networks between municipalities in the State of Paraná, Brazil]

This study aimed to characterize hospitalizations of residents in Paraná State, Brazil, that occurred during the neonatal period in a municipality different from their place of residence from 2008 to 2019, and to describe displacement networks for the first and last biennium of the series, corresponding to periods before and after initiatives to regionalize health services in the state. Admissions of children aged from 0 to 27 days were obtained from the Hospital Information System of the Brazilian National Unified Health System (SIH-SUS) database. For each biennium and health region, the proportion of admissions that occurred outside the municipality of residence, the weighted average distance traveled, and indicators of health and service provision were calculated. Mixed models were fitted to evaluate the biennial trend of the indicators and to investigate factors associated with the neonatal mortality rate (NMR). In total, 76,438 hospitalizations were selected, ranging from 9,030 in 2008-2009 to 17,076 in 2018-2019. The comparison of the networks obtained for 2008-2009 and 2018-2019 revealed an increase in the number of frequent destinations and in the proportion of displacements within the same health region. A decreasing trend was observed for distance, the proportion of live births with 5-minute Apgar ≤ 7, and for NMR. In the adjusted analysis for NMR, besides the biennial effect (-0.64; 95%CI: -0.95; -0.28), only the proportion of live birth with gestational age < 28 weeks showed statistical significance (4.26; 95%CI: 1.29; 7.06). The demand for neonatal hospital care increased over the study period. The displacement networks suggest a positive impact of regionalization, although investment in regions with the potential to become healthcare centers is necessary.

Designing a minimum data set of laboratory data for the electronic summary sheet of pediatric ward in Iran: A cross-sectional study

Background and Aim

Iranian hospitals are provided with hospital information systems (HISs) from different vendors, which make it hardly possible to summarize laboratory data in an consistent manner. Therefore, there is a need to design a minimum data set of laboratory data that will define standard criteria and reduce potential medical errors. The purpose of this study was to design a minimum data set (MDS) of laboratory data for an electronic summary sheet to be used in the pediatric ward of Iranian hospitals.

Methods

This study consists of three phases. In the first phase, out of 3997 medical records from the pediatric ward, 604 summary sheets were chosen as sample. The laboratory data of these sheets were examined and the recorded tests were categorized. In the second phase, based on the types of diagnosis we developed a list of tests. Then we asked the physicians of the ward to select which ones should be documented for each patient's diagnosis. In the third phase, the tests that were reported in 21%-80% of the records, and were verified by the same percentage of physicians, were evaluated by the experts' panel.

Results

In the first phase, 10,224 laboratory data were extracted. Of these, 144 data elements reported in more than 80% of the records, and more than 80% of experts approved them to be included in the MDS for patients' summary sheet. After data elements were investigated in the experts' panel, 292 items were chosen for the final list of the data set.

Conclusions

This MDS was designed such that, if implemented in hospital information systems, it could automatically enable registering data in the summary sheet when patient's diagnosis is registered.

Continuity of Patient Information to Palliative Care

The purpose of this study was to describe the sharing of knowledge and information to palliative care in terms of information content, information structure and information quality by means of Advance Care Planning (ACP). This study used a descriptive qualitative study design. Purposively selected nurses, physicians and social workers working in palliative care in Finland took part in thematic interviews in five hospitals in three hospital districts in 2019. The data (n = 33) were analyzed by means of content analysis. The results demonstrate the evidence-based practices of ACP in terms of information content, structure and quality. The results of this study can be utilized in the development of sharing knowledge and information and as the basis in the development of an ACP instrument.

The Reasons for Physicians and Pharmacists' Acceptance of Clinical Support Systems in Saudi Arabia

This research aims to identify the technological and non-technological factors influencing user acceptance of the CDSS in a group of healthcare facilities in Saudi Arabia. The study proposes an integrated model that indicates the factors to be considered when designing and evaluating CDSS. This model is developed by integrating factors from the "Fit between Individuals, Task, and Technology" (FITT) framework into the three domains of the human, organization, and technology-fit (HOT-fit) model. The resulting FITT-HOT-fit integrated model was tested using a quantitative approach to evaluate the currently implemented CDSS as a part of Hospital Information System BESTCare 2.0 in the Saudi Ministry of National Guard Health Affairs. For data collection, a survey questionnaire was conducted at all Ministry of National Guard Health Affairs hospitals. Then, the collected survey data were analyzed using Structural Equation Modeling (SEM). This analysis included measurement instrument reliability, discriminant validity, convergent validity, and hypothesis testing. Moreover, a CDSS usage data sample was extracted from the data warehouse to be analyzed as an additional data source. The results of the hypotheses test show that usability, availability, and medical history accessibility are critical factors influencing user acceptance of CDSS. This study provides prudence about healthcare facilities and their higher management to adopt CDSS.

Usefulness of the Hospital Information System for maternal mortality surveillance in Brazil

OBJECTIVE

To evaluate the capability of hospital records in the Hospital Information System (SIH) to add valuable and complementary information to the Mortality Information System (SIM) in studies on maternal mortality. We calculated and compared the maternal mortality ratio from the SIH and SIM databases, by age group and region, to highlight differences between groups and assess the coverage of maternal deaths using SIH compared with SIM.

METHODS

Obstetric hospitalizations were defined based on three sources (codes ICD-10 in diagnoses; procedures; billing information). Hospital and SIM mortality ratios were calculated by dividing maternal deaths in hospitals affiliated to the Unified Brazilian Health System (SUS) per live births (SINASC) in the same hospitals.

RESULTS

In 2019, we identified 2,497,957 obstetric admissions, 0.04% (946) with in-hospital mortality as outcome. The presence of three criteria identified 98% of obstetric hospitalizations and 83% of obstetric hospitalizations with death as outcome. The comparison of mortality ratios between SIH (45.5 MMR; 95%CI 42.7 - 48.5) and SIM (49.7 MMR; 95%CI 46.7 - 52.8) was not statistically significant (p-value: 0.053).

CONCLUSION

The analysis of SIH was able to provide additional information for the monitoring and surveillance of maternal health in Brazil. Although there are differences between the mortality rates, the SIH, as a complementary information system to the SIM, may be valid in studies on maternal mortality and morbidity.

Feasibility of a Hospital Information System for a Military Public Organization in the Light of the Multi-Criteria Analysis

The healthcare environment presents a large volume of personal and sensitive patient data that needs to be available and secure. Information and communication technology brings a new reality to healthcare, promoting improvements, agility and integration. Regarding high-level and complex decision-making scenarios, the Brazilian Navy (BN), concerning its healthcare field, is seeking to provide better management of its respective processes in its hospital facilities, allowing accurate control of preventive and curative medicine to members who work or have served there in past years. The study addresses the understanding, structure and clarifying variables related to the feasibility of technological updating and installing of a Hospital Information System (HIS) for BN. In this scenario, through interviews and analysis of military organization business processes, criteria and alternatives were established based on multi-criteria methodology as a decision aid. As methodological support for research and data processing, THOR 2 and PROMETHEE-SAPEVO-M1 methods were approached, both based on the scenarios of outranking alternatives based on the preferences established by the stakeholders in the problem. As a result of the methodological implementation, we compare the two implemented methods in this context, exposing the Commercial Software Purchase and Adoption of Free Software, integrated into Customization by the Marine Studies Foundation, as favorable actions to be adopted concerning HIS feasibility. This finding generates a comprehensive discussion regarding the BN perspective and changes in internal development in the military environment, prospecting alignment to the culture of private organizations in Information Technology for healthcare management. In the end, we present some conclusions concerning the study, exploring the main points of the decision-making analysis and for future research.

Health Information Systems: Past, Present, Future - Revisited

BACKGROUND

Health information systems (HIS) represent an essential part of the infrastructure for the delivery of good health care.

OBJECTIVES

To present the author's personal views on HIS developments over the last decades and on the opportunities and priorities for future HIS developments.

METHODS

Reflecting on his views, the author identified relevant semantic dimensions, which are denoted as development paths, and searched for appropriate periods to characterize HIS development leaps.

RESULTS

HIS developments were divided into the periods past (1961-2016), present (2017-2022), and future (the next decades). Eight development paths for HIS were considered as being relevant to presenting the author's views: life situations related to health care, entities for health care, health care facilities, settings of health care, data to be processed, features for functions, architectures of HIS, and management of HIS. For each of these paths, the past and present states as well as challenges and opportunities for future HIS developments were outlined.

DISCUSSION AND CONCLUSIONS

The presented views on HIS developments and the selected development paths and periods are by nature subjective 'avant la lettre'. The views were, however, formed over almost half a century during which the author has been engaged with HIS developments, and thus may be worth reporting and discussion. If past is prologue, the tremendous HIS developments in the past and in the present may predict a similar development intensity in the future. Present HIS are significantly better than HIS of the past, however they leave room for continued improvement with an end of HIS developments far from sight.

Enhanced Communication for Interhospital Transfers Increases Preparedness in an Academic Tertiary Care Center

OBJECTIVES

This quality improvement project sought to enhance clinical information sharing for interhospital transfers to an inpatient hepatology service comprised of internal medicine resident frontline providers (housestaff) with the specific aims of making housestaff aware of 100% of incoming transfers and providing timely access to clinical summaries.

INTERVENTIONS

In February 2020, an email notification system to senior medicine residents responsible for patient triage shared planned arrival time for patients pending transfer. In July 2020, a clinical data repository ("Transfer Log") updated daily by accepting providers (attending physicians and subspecialty fellows) became available to senior medicine residents responsible for triage.

METHODS

Likert scale surveys were administered to housestaff before email intervention (pre) and after transfer log intervention (post). The time from patient arrival to team assignment (TTA) in the electronic medical record was used as a proxy for time to patient assessment and was measured pre- and postinterventions; >2 hours to TTA was considered an extreme delay.

RESULTS

Housestaff reported frequency of access to clinical information as follows: preinterventions 4/31 (13%) sometimes/very often and 27/31 (87%) never/rarely; postinterventions 11/26 (42%) sometimes/very often and 15/26 (58%) never/rarely (p = 0.02). Preinterventions 12/39 (31%) felt "not at all prepared" versus 27/39 (69%) "somewhat" or "adequately"; postinterventions 2/24 (8%) felt "not at all prepared" versus 22/24 (92%) somewhat/adequately prepared (p = 0.06). There was a significant difference in mean TTA between pre- and posttransfer log groups (62 vs. 40 minutes, p = 0.01) and a significant reduction in patients with extreme delays in TTA post-email (18/180 pre-email vs. 7/174 post-email, p = 0.04).

CONCLUSION

Early notification and increased access to clinical information were associated with better sense of preparedness for admitting housestaff, reduction in TTA, and reduced frequency of extreme delays in team assignment.

Type and Number of Errors of the Iranian Electronic Health Record (SEPAS) in Hospitals Affiliated with Mashhad University of Medical Sciences

This study aims to identify the type and number of errors in the Iranian Electronic Health Record System (SEPAS) in hospitals affiliated with Mashhad University of Medical Sciences (MUMS). A cross-sectional analytical study was conducted to specify the errors done by SEPAS in the first half of 2019, based on the type and number of errors in 26 hospitals affiliated with MUMS that were connected to the SEPAS system. SEPAS system errors were classified into four categories: identity errors, clinical errors, administrative-financial and technical errors. The most important errors that occurred in the SEPAS system included non-authentication errors in Hospital Information System (HIS), non-service records, and invalid national code, respectively. Therefore, hospital administrators and information system developers must make an effort to prevent such errors.

Admission and Discharge Following Ambulance Transport to the Emergency Department

Emergency ambulance use is deemed necessary for the transport of acutely ill patients to hospital emergency departments (ED). However, some patients are discharged as they present low acuity or chronic problems and should receive primary healthcare services, while the most severely ill are admitted. In the present study, we examined the descriptive epidemiology of ambulance transports for emergencies in the ED by utilizing the data of the information systems of a public tertiary general hospital in Greece. More than half of the patients transferred to the ED by an ambulance were finally admitted to the hospital (52.25%), whereas only one-third (33.74%) of those transferred by other means. A statistically significant association was detected between ambulance use and hospital admission. Age was also statistically significantly higher in the ambulance group. Higher mean values of creatinine, CRP, LDH, urea, white-blood-cell count, and neutrophils were detected in the ambulance group, in contrast to hemoglobin and lymphocyte count which were higher in the non-ambulance group.

Lean management for improving hospital waiting times-Case study of a Vietnamese public/general hospital emergency department

INTRODUCTION

Emergency departments (EDs) at public hospitals in Vietnam typically face problems with overcrowding, as well as being populated by a wide variety of illnesses, resulting in increasing dissatisfaction from patients. To alleviate these problems, we used the increasingly popular value-stream mapping (VSM) and lean strategy approaches to (1) evaluate the current patient flow in EDs; (2) identify and eliminate the non-valued-added components; and (3) modify the existing process in order to improve waiting times.

METHODS

Data from a total of 742 patients who presented at the ED of 108 Military Central Hospital in Hanoi, Vietnam, were collected. A VSM was developed where improvement possibilities were identified and attempts to eliminate non-value-added activities were made. A range of issues that were considered as a resource waste were highlighted, which led to a re-design process focusing on prioritizing blood tests and ultrasound procedures. On the administrative side, various measures were considered, including streamlining communication with medical departments, using QR codes for healthcare insurance payments, and efficient management of X-ray and CT scan online results.

RESULTS

By implementing a lean approach, the following reductions in delay and waiting time were incurred: (1) pre-operative test results (for patients requiring medical procedures/operations) by 33.3% (from 134.4 to 89.4 min); (2) vascular interventions by 10.4% (from 54.6 to 48.9 min); and (3) admission to other hospital departments by 49.5% (from 118.3 to 59.8 min). Additionally, prior to the implementation of the lean strategy approach, only 22.9% of patients or their proxies (family members or friends), who responded to the survey, expressed satisfaction with the ED services. This percentage increased to 76.5% following the curtailment of non-value-added activities. Through statistical inferential test analyses, it can be confidently concluded that applying lean strategy and tools can improve patient flow in public/general hospital EDs and achieve better staff coordination within the various clinical and administrative hospital departments. To the authors' knowledge, such analysis in a Vietnamese hospital's ED context has not been previously undertaken.

Design, development, and evaluation of an interactive training simulator for teaching hospital information systems

BACKGROUND

In their apprenticeship program, health information technology (HIT) students are deprived of the ample opportunity to work with the hospital information system (HIS). This study aimed to design an interactive simulator for the HIS training and evaluate its effects on the informatics skills of HIT students.

MATERIALS AND METHODS

This study was conducted on 16 Bachelor of Science students of HIT at Kashan University of Medical Sciences in 2019. After the functionalities and features of the simulator were determined based on similar existing simulators, expert opinions were received to simulate eight important processes of admission, discharge, and transfer module in HIS. The scores of students' skills and time taken to perform the processes were recorded and analyzed before and after the educational intervention. After they were trained by the simulator, the students filled out a usability evaluation questionnaire. The data were then analyzed in SPSS version 21.

RESULTS

The simulators of health information systems were characterized by interactivity, multimedia applications, practice exercises, tests, and feedback. After the students were trained by the developed simulator, their skills scores improved significantly in 75% (6/8) of the processes, and the timespans of all processes decreased significantly (P < 0.05). The usability evaluation indicated the usability of the simulator was at a "good" level.

CONCLUSIONS

According to the study results, using the simulator improves the informatics skills of HIT students in working with HIS. It is recommended that this method also be used in other apprenticeship programs to teach health information systems.

Digitization of Measurement-Based Care Pathways in Mental Health Through REDCap and Electronic Health Record Integration: Development and Usability Study

Background

The delivery of standardized self-report assessments is essential for measurement-based care in mental health. Paper-based methods of measurement-based care data collection may result in transcription errors, missing data, and other data quality issues when entered into patient electronic health records (EHRs).

Objective

This study aims to help address these issues by using a dedicated instance of REDCap (Research Electronic Data Capture; Vanderbilt University)—a free, widely used electronic data capture platform—that was established to enable the deployment of digitized self-assessments in clinical care pathways to inform clinical decision making.

Methods

REDCap was integrated with the primary clinical information system to facilitate the real-time transfer of discrete data and PDF reports from REDCap into the EHR. Both technical and administrative components were required for complete implementation. A technology acceptance survey was also administered to capture physicians’ and clinicians’ attitudes toward the new system.

Results

The integration of REDCap with the EHR transitioned clinical workflows from paper-based methods of data collection to electronic data collection. This resulted in significant time savings, improved data quality, and valuable real-time information delivery. The digitization of self-report assessments at each appointment contributed to the clinic-wide implementation of the major depressive disorder integrated care pathway. This digital transformation facilitated a 4-fold increase in the physician adoption of this integrated care pathway workflow and a 3-fold increase in patient enrollment, resulting in an overall significant increase in major depressive disorder integrated care pathway capacity. Physicians’ and clinicians’ attitudes were overall positive, with almost all respondents agreeing that the system was useful to their work.

Conclusions

REDCap provided an intuitive patient interface for collecting self-report measures and accessing results in real time to inform clinical decisions and an extensible backend for system integration. The approach scaled effectively and expanded to high-impact clinics throughout the hospital, allowing for the broad deployment of complex workflows and standardized assessments, which led to the accumulation of harmonized data across clinics and care pathways. REDCap is a flexible tool that can be effectively leveraged to facilitate the automatic transfer of self-report data to the EHR; however, thoughtful governance is required to complement the technical implementation to ensure that data standardization, data quality, patient safety, and privacy are maintained.

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.

The Contributing Factors to Nurses' Behavioral Intention to Use Hospital Information Technologies in Ghana

Background

Medical care facilities in both developed and developing countries around the world continue to invest in hospital information technologies (HITs). Nevertheless, it has been discovered that user acceptance of these technologies is one of the imperative issues during their implementation and management in developing countries such as Ghana.

Purpose

Notably, the technology acceptance assessment of nurses is a timely one since they play a very important role in the medical sector. Based on the model of “Unified Theory of Acceptance and Use of Technology,” this study explored the factors that affect Ghanaian nurses’ acceptance of HIT.

Design/Method/Approach: A descriptive nonexperimental research design was employed in this study to recruit 660 nurses (404 females and 256 males) from 3 teaching and 2 regional hospitals in Ghana. A standardized electronic platform questionnaire (based on the Unified Theory of Acceptance and Use of Technology model) was designed on smartphones and was self-administered, while the data collected were analyzed via the SmartPLS Structural Equation Modeling path analysis. The “Social Influence” (t  = 3.656, p < .001), “Attitude towards the Use of Technology” (t = 5.861, p < .001), and “Facilitating Conditions” (t = 2.616, p < .001) were the main predictors of the nurses’ behavioral intention to use HIT. The effects of the aforementioned constructs explained 60.7% (R²= 0.607) of the variance in the nurses’ intentions to use the HIT systems.

Conclusions

Precisely, HIT systems are essential in the quality and the enhancement of nursing services provision and in the effectiveness of the performance of nursing staff. This study, therefore, offers a piece of empirical evidence for hospital administrators in developing countries especially Ghana, to assess the success probability of new HITs before and after their implementation.

Developing a national minimum data set for hospital information systems in the Islamic Republic of Iran

Background

Standardized data collection supports disease information management and leads to better quality of care. The Islamic Republic of Iran lacks a standard data set for data collection in hospitals.

Aims

The aim of this study was to design a minimum data set for hospital information systems in the Islamic Republic of Iran.

Methods

This study was conducted in 2015. Data sets of other countries, hospital records, hospital information systems and electronic health record systems in the Islamic Republic of Iran were reviewed for data elements for the minimum data set. Data elements were collected using a data extraction form and were categorized into similar classes, which were divided into administrative and clinical sections. The list of data elements was reviewed by experts in technical offices of the Iranian Ministry of Health and Medical Education, and a minimum data set was drawn up.

Results

There were nine and 18 data classes in the administrative and clinical sections with a total of 166 and 684 data elements respectively. After review by the expert panel, 159 administrative and 621 clinical data elements were retained as the minimum data set for the Iranian hospital information system.

Conclusion

Our dataset can be used by the Iranian health ministry, hospital information system companies and health surveillance centres for more efficient management of health data.

A Late Attempt to Involve End Users in the Design of Medication-Related Alerts: Survey Study

Background

When users of electronic medical records (EMRs) are presented with large numbers of irrelevant computerized alerts, they experience alert fatigue, begin to ignore alert information, and override alerts without processing or heeding alert recommendations. Anecdotally, doctors at our study site were dissatisfied with the medication-related alerts being generated, both in terms of volume being experienced and clinical relevance.

Objective

This study aimed to involve end users in the redesign of medication-related alerts in a hospital EMR, 4 years post implementation.

Methods

This work was undertaken at a private not-for-profit teaching hospital in Sydney, Australia. Since EMR implementation in 2015, the organization elected to implement all medication-related alert types available in the system for prescribers: allergy and intolerance alerts, therapeutic duplication alerts, pregnancy alerts, and drug-drug interaction alerts. The EMR included no medication administration alerts for nurses. To obtain feedback on current alerts and suggestions for redesign, a Web-based survey was distributed to all doctors and nurses at the site via hospital mailing lists.

Results

Despite a general dissatisfaction with alerts, very few end users completed the survey. In total, only 3.37% (36/1066) of doctors and 14.5% (60/411) of nurses took part. Approximately 90% (30/33) of doctors who responded held the view that too many alerts were triggered in the EMR. Doctors suggested that most alerts be removed and that alerts be more specific and less sensitive. In contrast, 97% (58/60) of the nurse respondents indicated that they would like to receive medication administration alerts in the EMR. Most nurses indicated that they would like to receive all the alert types available at all severity levels.

Conclusions

Attempting to engage with end users several years post implementation was challenging. Involving users so late in the implementation process may lead to clinicians viewing the provision of feedback to be futile. Seeking user feedback on usefulness, volume, and design of alerts is extremely valuable; however, we suggest this is undertaken early, preferably before system implementation.

Designing and evaluating functional laboratory information system requirements integrated to hospital information systems

RATIONALE, AIMS, AND OBJECTIVES

Laboratory information sub-systems play an important role in diagnosis and treatment of patients. This study aimed to determine functional requirements of users and assess the existence of these requirements in the laboratory information system.

METHOD

This descriptive cross-sectional study was conducted in 2016 in two phases. The first phase was done through three stages. First, based on an unsystematic review of related literature, an outline of functional laboratory information system requirements was identified. In the second stage, these requirements were identified in group meetings in the form of a semi-structured questionnaire and given to experts. Then, modified Delphi technique was used to reach agreement on each item. Then, based on experts' comments, the final version of the questionnaire was presented including 61 closed-ended items using Likert scale and an open-ended item. It was surveyed by 50 experts using Delphi technique. Responses were scored, and the requirements whose mean final score was 3 and above were finally confirmed. In the second phase, based on the confirmed requirements, a checklist comprising 68 requirements was prepared and adopted hospital information systems were evaluated through researcher observation. Data were analysed using descriptive statistics.

RESULTS

The final list of functional laboratory information system requirements was prepared with 68 items. The results of the evaluation revealed that confirmed requirements existed in 58.8% of hospital information systems.

CONCLUSION

Laboratory information system requirements were designed with 68 items. Evaluation results showed that the systems were moderate in terms of compliance with the requirements.

Suicidal and self-harm presentations to Emergency Departments: The challenges of identification through diagnostic codes and presenting complaints

BACKGROUND

The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce.

OBJECTIVE

To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia.

METHOD

All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard).

RESULTS

A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%).

CONCLUSION

Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.

Utilisation of hospital information systems for medical research in Saudi Arabia: A mixed-method exploration of the views of healthcare and IT professionals involved in hospital database management systems

BACKGROUND

Although in recent times the Saudi government has paid much attention to the adaptation of hospital information systems (HIS) and electronic medical records (EMR), the importance of utilising HIS to enhance medical research has been neglected.

OBJECTIVE

We aimed to (i) investigate the current state of medical research in Saudi Arabia, (ii) identify possible issues that hinder improvement of medical research and (iii) identify possible solutions to enhance the role of HIS in medical research in Saudi Arabia.

METHOD

We used a questionnaire and structured interview approach. Questionnaires were distributed to Saudi healthcare professionals. One hundred responses to our questionnaire were captured by the online Google Form designed specifically for our survey. Structured interviews with two IT professionals were conducted regarding technical aspects of their hospital data management systems.

RESULTS

Six themes contributing to the inefficacy of HIS in medical research in Saudi Arabia emerged from the data: incorrect datasets, difficult data collection and storage, poor data analytics, a lack of system interoperability across different HIS for universal access and negative perception of the usefulness of HIS for medical research.

CONCLUSION AND IMPLICATIONS

Our findings suggest (i) cloud-based HIS would support efficient, reliable and integrated data collection and storage across all hospitals in Saudi Arabia; (ii) EMR data sources should be seamlessly linked to avoid incomplete, fragmented or erroneous EMR in Saudi Arabia; and (iii) collaboration between all hospitals in Saudi Arabia to adopt a uniform standard to support interoperability and improve data exchange and integration is necessary.

Inpatient Communication Networks: Leveraging Secure Text-Messaging Platforms to Gain Insight into Inpatient Communication Systems

OBJECTIVE

This study attempts to characterize the inpatient communication network within a quaternary pediatric academic medical center by applying network analysis methods to secure text-messaging data.

METHODS

We used network graphing and statistical software to create network models of an inpatient communication system with secure text-messaging data from physicians, nurses, and other ancillary staff in an academic medical center. Descriptive statistics about the network, users within the network, and visualizations informed the team's understanding of the network and its components.

RESULTS

Analysis of messages exchanged over approximately 23 days revealed a large, scale-free network with 4,442 nodes and 59,913 edges. Quantitative description of user behavior (messages sent and received) and network metrics (i.e., importance of nodes within a network) revealed several operational and clinical roles both sending and receiving > 1,000 messages over this time period. While some of these nodes represented expected "dispatcher" roles in our inpatient system, others occupied important frontline clinical roles responsible for bedside clinical care.

CONCLUSION

Quantitative and network analysis of secure text-messaging logs revealed several key operational and clinical roles at risk for alert fatigue and information overload. This analysis also revealed a communication network highly reliant on these key roles, meaning disruption to these individuals or their workflows could lead to dysfunction of the communication network. While secure text-messaging applications play increasingly important roles in facilitating inpatient communication, little is understood about the impact these systems have on health care providers. Developing methods to understand and optimize communication between inpatient providers might help operational and clinical leaders to proactively prevent poorly understood pitfalls associated with these systems and build resilient and effective communication structures.

A Mobile Phone App for Bedside Nursing Care: Design and Development Using an Adapted Software Development Life Cycle Model

Background

Nurses are increasingly spending time on computers, and providing them with a tailored tool to access clinical information and perform documentation at the bedside could help to improve their efficiency. Designing an app to support nurses’ work at the bedside is a challenging task, given the complexity of the care process.

Objective

This study aimed to present the design, development, and testing of a smartphone app for nurses guided by an adapted software development life cycle model that takes into consideration the complexity and constraints of a health care setting.

Methods

The model drives us through an iterative development process intersected by 3 stages of formative evaluation of growing ecological validity.

Results

The initial requirements identification stage included 11 participants who helped us select the most important functionalities to integrate into the tool. Starting with a usability evaluation allowed for the identification of design issues that could have caused misuse. Then, making on-site evaluations under the supervision of an investigator helped to understand the adequacy of the tool with limited risks. Finally, the on-site evaluation allowed us to validate the acceptance of the app by caregivers.

Conclusions

The interpretation of the collected evaluation confirms the necessary involvement of end users early in the process to help address the heterogeneity of the nursing workflow processes in the different wards. We also highlight the delicate balance between high-security measures to protect access to patient data and maintaining ease of access for efficiency and usability. Although a close collaboration with clinicians throughout the entire project facilitated the development of a tailored solution, it was also important to involve all stakeholders, in particular, the information technology (IT) security officers.

Healthcare practitioner behaviours that influence unsafe use of hospital information systems

This study aims to investigate healthcare practitioner behaviour in adopting Health Information Systems which could affect patients' safety and quality of health. A qualitative study was conducted based on a semi-structured interview protocol on 31 medical doctors in three Malaysian government hospitals implementing the Total Hospital Information Systems. The period of study was between March and May 2015. A thematic qualitative analysis was performed on the resultant data to categorize them into relevant themes. Four themes emerged as healthcare practitioners' behaviours that influence the unsafe use of Hospital Information Systems. The themes include (1) carelessness, (2) workarounds, (3) noncompliance to procedure, and (4) copy and paste habit. By addressing these behaviours, the hospital management could further improve patient safety and the quality of patient care.

Sociotechnical factors influencing unsafe use of hospital information systems: A qualitative study in Malaysian government hospitals

The objective of this study is to identify factors influencing unsafe use of hospital information systems in Malaysian government hospitals. Semi-structured interviews with 31 medical doctors in three Malaysian government hospitals implementing total hospital information systems were conducted between March and May 2015. A thematic qualitative analysis was performed on the resultant data to deduce the relevant themes. A total of five themes emerged as the factors influencing unsafe use of a hospital information system: (1) knowledge, (2) system quality, (3) task stressor, (4) organization resources, and (5) teamwork. These qualitative findings highlight that factors influencing unsafe use of a hospital information system originate from multidimensional sociotechnical aspects. Unsafe use of a hospital information system could possibly lead to the incidence of errors and thus raises safety risks to the patients. Hence, multiple interventions (e.g. technology systems and teamwork) are required in shaping high-quality hospital information system use.

Secondary use of hospital information system data for safe bedside radiography in terms of patient factors

OBJECTIVE:

The purpose of this study was to use patient data gathered by a hospital information system (HIS) to improve the safe performance of bedside radiography.

METHOD:

Hierarchical cluster analysis was used to investigate the factors of hospitalised patients who had undergone radiography in the X-ray room or at the bedside. Logistic regression analysis was then performed to quantify patient factors and calculate the probability of undergoing general radiography or bedside radiography.

RESULTS:

Patients were grouped into six clusters by hierarchical cluster analysis on the basis of their factors. We found a remarkable difference between clusters for the ratio of bedside radiography. Results indicated that "types of transportation" and "level of mobility" related to the ratio of bedside radiography. Logistic regression analysis of the associations between the probability of undergoing bedside radiography and patient factors indicated that type of transportation and level of mobility were highly correlated with bedside radiography or general radiography.

CONCLUSION:

Our results suggested that the secondary use of HIS data for the quantitative evaluation of patient factors and implementation of those quantitative values in medical records may be useful for the safe performance of bedside radiography as well as providing a method of decision support for doctors to order bedside radiography.

Utilising Information of the Case Fee Catalogue to Enhance 30-Day Readmission Prediction in the German DRG System

Unplanned hospital readmissions are a burden to the healthcare system and to the patients. To lower the readmission rates, machine learning approaches can be used to create predictive models, with the intention to provide actionable information for caregivers. According to the German Diagnosis Related Groups (G-DRG) system, for every stay in a German hospital, data are collected for the subsequent reimbursement calculations. After statistical evaluation, these data are summarised in the yearly updated Case Fee Catalogue, which not only contains the weights for the reimbursement calculations, but also the expected length of stay values. The aim of the present paper was to evaluate potential enhancements of the prediction accuracy of our 30-day readmission prediction model by utilising additional information from the Case Fee Catalogue. A bagged ensemble of 25 regression trees was applied to §21 datasets from five independent German hospitals from 2013 to 2017, resulting in 422,597 cases. The overall model showed an area under the receiver operating characteristics curve of 0.812. Three of the top five features ranked by out of bag feature importance emerged from the Case Fee Catalogue. We conclude, that additional information from the Case Fee Catalogue can enhance the accuracy of 30-day readmission prediction.

Prediction of Readmissions in the German DRG System Based on §21 Datasets

Hospital readmissions receive increasing interest, since they are burdensome for patients and costly for healthcare providers. For the calculation of reimbursement fees, in Germany there is the German-Diagnosis Related Groups (G-DRG) system. For every hospital stay, data are collected as a so-called "case", as the basis for the subsequent reimbursement calculations ("§21 dataset"). Merging rules lead to a loss of information in §21 datasets. We applied machine learning to §21 datasets and evaluated the influence of case merging for the resulting accuracy of readmission risk prediction. Data from 478,966 cases were analysed by applying a random forest. Many cases with readmissions within 30 days had been merged and thus their prediction required additional data. Using 10-fold cross validation, the prediction for readmissions within 31-60 days showed no notable difference in the area under the ROC curves comparing unedited §21 datasets with §21 datasets with restored original cases. The achieved AUC values of 0.69 lie in a similar range as the values of comparable state-of-the-art models. We conclude that dealing with merged cases, i.e. adding data, is required for 30-day-readmission prediction, whereas un-merging brings no improvement for the readmission prediction of period beyond 30 days.

Comparing Inpatient Satisfaction Collected via a Web-Based Questionnaire Self-Completion and Through a Telephone Interview: An Ancillary Study of the SENTIPAT Randomized Controlled Trial

Background

Assessing the satisfaction of patients about the health care they have received is relatively common nowadays. In France, the satisfaction questionnaire, I-Satis, is deployed in each institution admitting inpatients. Internet self-completion and telephone interview are the two modes of administration for collecting inpatient satisfaction that have never been compared in a multicenter randomized experiment involving a substantial number of patients.

Objective

The objective of this study was to compare two modes of survey administration for collecting inpatient satisfaction: Internet self-completion and telephone interview.

Methods

In the multicenter SENTIPAT (acronym for the concept of sentinel patients, ie, patients who would voluntarily report their health evolution on a dedicated website) randomized controlled trial, patients who were discharged from the hospital to home and had an Internet connection at home were enrolled between February 2013 and September 2014. They were randomized to either self-complete a set of questionnaires using a dedicated website or to provide answers to the same questionnaires administered during a telephone interview. As recommended by French authorities, the analysis of I-Satis satisfaction questionnaire involved all inpatients with a length of stay (LOS), including at least two nights. Participation rates, questionnaire consistency (measured using Cronbach alpha coefficient), and satisfaction scores were compared in the two groups.

Results

A total of 1680 eligible patients were randomized to the Internet group (n=840) or the telephone group (n=840). The analysis of I-Satis concerned 392 and 389 patients fulfilling the minimum LOS required in the Internet and telephone group, respectively. There were 39.3% (154/392) and 88.4% (344/389) responders in the Internet and telephone group, respectively (P<.001), with similar baseline variables. Internal consistency of the global satisfaction score was higher (P=.03) in the Internet group (Cronbach alpha estimate=.89; 95% CI 0.86-0.91) than in the telephone group (Cronbach alpha estimate=.84; 95% CI 0.79-0.87). The mean global satisfaction score was lower (P=.03) in the Internet group (68.9; 95% CI 66.4-71.4) than in the telephone group (72.1; 95% CI 70.4-74.6), with a corresponding effect size of the difference at −0.253.

Conclusions

The lower response rate issued from Internet administration should be balanced with a likely improved quality in satisfaction estimates, when compared with telephone administration, for which an interviewer effect cannot be excluded.

Trial Registration

Clinicaltrials.gov NCT01769261 ; http://clinicaltrials.gov/ct2/show/NCT01769261 (Archived by WebCite at http://www.webcitation.org/6ZDF5lA41)

Maturity of hospital information systems: Most important influencing factors

Maturity models facilitate organizational management, including information systems management, with hospital organizations no exception. This article puts forth a study carried out with a group of experts in the field of hospital information systems management with a view to identifying the main influencing factors to be included in an encompassing maturity model for hospital information systems management. This study is based on the results of a literature review, which identified maturity models in the health field and relevant influencing factors. The development of this model is justified to the extent that the available maturity models for the hospital information systems management field reveal multiple limitations, including lack of detail, absence of tools to determine their maturity and lack of characterization for stages of maturity structured by different influencing factors.

Web-Based Medical Appointment Systems: A Systematic Review

Background

Health care is changing with a new emphasis on patient-centeredness. Fundamental to this transformation is the increasing recognition of patients' role in health care delivery and design. Medical appointment scheduling, as the starting point of most non-urgent health care services, is undergoing major developments to support active involvement of patients. By using the Internet as a medium, patients are given more freedom in decision making about their preferences for the appointments and have improved access.

Objective

The purpose of this study was to identify the benefits and barriers to implement Web-based medical scheduling discussed in the literature as well as the unmet needs under the current health care environment.

Methods

In February 2017, MEDLINE was searched through PubMed to identify articles relating to the impacts of Web-based appointment scheduling.

Results

A total of 36 articles discussing 21 Web-based appointment systems were selected for this review. Most of the practices have positive changes in some metrics after adopting Web-based scheduling, such as reduced no-show rate, decreased staff labor, decreased waiting time, and improved satisfaction, and so on. Cost, flexibility, safety, and integrity are major reasons discouraging providers from switching to Web-based scheduling. Patients’ reluctance to adopt Web-based appointment scheduling is mainly influenced by their past experiences using computers and the Internet as well as their communication preferences.

Conclusions

Overall, the literature suggests a growing trend for the adoption of Web-based appointment systems. The findings of this review suggest that there are benefits to a variety of patient outcomes from Web-based scheduling interventions with the need for further studies.

Indirect effect of management support on users' compliance behaviour towards information security policies

BACKGROUND

Health information systems are innovative products designed to improve the delivery of effective healthcare, but they are also vulnerable to breaches of information security, including unauthorised access, use, disclosure, disruption, modification or destruction, and duplication of passwords. Greater openness and multi-connectedness between heterogeneous stakeholders within health networks increase the security risk.

OBJECTIVE

The focus of this research was on the indirect effects of management support (MS) on user compliance behaviour (UCB) towards information security policies (ISPs) among health professionals in selected Malaysian public hospitals. The aim was to identify significant factors and provide a clearer understanding of the nature of compliance behaviour in the health sector environment.

METHOD

Using a survey design and stratified random sampling method, self-administered questionnaires were distributed to 454 healthcare professionals in three hospitals. Drawing on theories of planned behaviour, perceived behavioural control (self-efficacy (SE) and MS components) and the trust factor, an information system security policies compliance model was developed to test three related constructs (MS, SE and perceived trust (PT)) and their relationship to UCB towards ISPs.

RESULTS

Results showed a 52.8% variation in UCB through significant factors. Partial least squares structural equation modelling demonstrated that all factors were significant and that MS had an indirect effect on UCB through both PT and SE among respondents to this study.

CONCLUSION

The research model based on the theory of planned behaviour in combination with other human and organisational factors has made a useful contribution towards explaining compliance behaviour in relation to organisational ISPs, with trust being the most significant factor. In adopting a multidimensional approach to management-user interactions via multidisciplinary concepts and theories to evaluate the association between the integrated management-user values and the nature of compliance towards ISPs among selected health professionals, this study has made a unique contribution to the literature.

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review

OBJECTIVE

Infobuttons appear as small icons adjacent to electronic health record (EHR) data (e.g., medications, diagnoses, or test results) that, when clicked, access online knowledge resources tailored to the patient, care setting, or task. Infobuttons are required for "Meaningful Use" certification of US EHRs. We sought to evaluate infobuttons' impact on clinical practice and identify features associated with improved outcomes.

METHODS

We conducted a systematic review, searching MEDLINE, EMBASE, and other databases from inception to July 6, 2015. We included and cataloged all original research in any language describing implementation of infobuttons or other context-sensitive links. Studies evaluating clinical implementations with outcomes of usage or impact were reviewed in greater detail. Reviewers worked in duplicate to select articles, evaluate quality, and abstract information.

RESULTS

Of 599 potential articles, 77 described infobutton implementation. The 17 studies meriting detailed review, including 3 randomized trials, yielded the following findings. Infobutton usage frequency ranged from 0.3 to 7.4 uses per month per potential user. Usage appeared to be influenced by EHR task. Five studies found that infobuttons are used less often than non-context-sensitive links (proportionate usage 0.20-0.34). In 3 studies, users answered their clinical question in > 69% of infobutton sessions. Seven studies evaluated alternative approaches to infobutton design and implementation. No studies isolated the impact of infobuttons on objectively measured patient outcomes.

CONCLUSIONS

Weak evidence suggests that infobuttons can help providers answer clinical questions. Research on optimal infobutton design and implementation, and on the impact on patient outcomes and provider behaviors, is needed.

Support for Sustainable Use of Personal Health Records: Understanding the Needs of Users as a First Step Towards Patient-Driven Mobile Health

Background

The tethering of a personal health record (PHR) to an electronic medical record (EMR) may serve as a catalyst in accelerating the distribution of integrated PHRs. Creating shared health records for patients and their health care professionals using self-administered functions of EMR-tethered PHRs is crucial to support sustainable use of the system.

Objective

This study assesses the factors related to active use of a self-administered function (Health Notes) in an EMR-tethered PHR (Health4U) in a tertiary academic hospital.

Methods

This research is a cross-sectional study conducted in a tertiary academic hospital in South Korea. The enrollees included adults aged 19 years and older with experience accessing Health4U in the 13-month period after June 2013. The primary outcome was the adoption of Health Notes in accordance with the number of chronic diseases. Socio-demographic variables were included as confounding factors.

Results

Subjects 71 years of age and older were less likely to become active users of Health Notes than those 30 years and younger. Moreover, compared with men, women had 44% and 40% lower tendencies to become Health Notes users and active users, respectively. Those who accessed the desktop page and/or mobile page had higher tendencies to become users of Health Notes. We found a consistent increase in the odds ratio as the number of chronic diseases increased in the active users. When considering specific diseases, patients who had cancer or chronic kidney disease had higher tendencies to become users of Health Notes.

Conclusions

Patients with a greater number of chronic diseases tended to use PHR more actively, and used the self-administered function. Women and the elderly may have lower tendencies to actively use PHR. Therefore, items specific to the health of each demographic—women, the elderly, and those with chronic diseases—should be carefully considered to support sustainable use of PHRs.

Estimating Sample Size for a Feasibility Study of Computer-Assisted Input Support to EDC

The aim of this study was to to estimate the sample size for the assumed feasibility study of the computer-assisted input support on a clinica trial. More than 1,500 observations were required for the feasibility study with assumed settings. Further study was required for more efficient research design.

A Novel Survey to Examine the Relationship between Health IT Adoption and Nurse-Physician Communication

BACKGROUND

As EHR adoption in US hospitals becomes ubiquitous, a wide range of IT options are theoretically available to facilitate physician-nurse communication, but we know little about the adoption rate of specific technologies or the impact of their use.

OBJECTIVES

To measure adoption of hardware, software, and telephony relevant to nurse-physician communication in US hospitals. To assess the relationship between non-IT communication practices and hardware, software, and telephony adoption. To identify hospital characteristics associated with greater adoption of hardware, software, telephony, and non-IT communication practices.

METHODS

We conducted a survey of 105 hospitals in the National Nursing Practice Network. The survey captured adoption of hardware, software, and telephony to support nurse-physician communication, along with non-IT communication practices. We calculated descriptive statistics and then created four indices, one for each category, by scoring degree of adoption of technologies or practices within each category. Next, we examined correlations between the three technology indices and the non-IT communication practices index. We used multivariate OLS regression to assess whether certain types of hospitals had higher index scores.

RESULTS

The majority of hospitals surveyed have a range of hardware, software, and telephony tools available to support nurse-physician communication; we found substantial heterogeneity across hospitals in non-IT communication practices. More intensive non-IT communication was associated with greater adoption of software (r=0.31, p=0.01), but was not correlated with hardware or telephony. Medium-sized hospitals had lower adoption of software (r =-1.14,p=0.04) in comparison to small hospitals, while federally-owned hospitals had lower software (r=-2.57, p=0.02) and hardware adoption (r=-1.63, p=0.01).

CONCLUSIONS

The positive relationship between non-IT communication and level of software adoption suggests that there is a complementary, rather than substitutive, relationship. Our results suggest that some technologies with the potential to further enhance communication, such as CPOE and secure messaging, are not being utilized to their full potential in many hospitals.

Mortality and potential years of life lost by road traffic injuries in Brazil, 2013

OBJECTIVE

To estimate the potential years of life lost by road traffic injuries three years after the beginning of the Decade of Action for Traffic Safety.

METHODS

We analyzed the data of the Sistema de Informações sobre Mortalidade (SIM - Mortality Information System) related to road traffic injuries, in 2013. We estimated the crude and standardized mortality rates for Brazil and geographic regions. We calculated, for the Country, the proportional mortality according to age groups, education level, race/skin color, and type or quality of the victim while user of the public highway. We estimated the potential years of life lost according to sex.

RESULTS

The mortality rate in 2013 was of 21.0 deaths per 100,000 inhabitants for the Country. The Midwest region presented the highest rate (29.9 deaths per 100,000 inhabitants). Most of the deaths by road traffic injuries took place with males (34.9 deaths per 100,000 males). More than half of the people who have died because of road traffic injuries were of black race/skin color, young adults (24.2%), individuals with low schooling (24.0%), and motorcyclists (28.5%). The mortality rate in the triennium 2011-2013 decreased 4.1%, but increased among motorcyclists. Across the Country, more than a million of potential years of life were lost, in 2013, because of road traffic injuries, especially in the age group of 20 to 29 years.

CONCLUSIONS

The impact of the high mortality rate is of over a million of potential years of life lost by road traffic injuries, especially among adults in productive age (early mortality), in only one year, representing extreme social cost arising from a cause of death that could be prevented. Despite the reduction of mortality by road traffic injuries from 2011 to 2013, the mortality rates increased among motorcyclists.

OBJETIVO

Estimar os anos potenciais de vida perdidos por acidente de transporte terrestre após três anos do início da Década de Ação pela Segurança no Trânsito.

MÉTODOS

Foram analisados os dados do Sistema de Informações sobre Mortalidade correspondentes aos acidentes de transporte terrestre, em 2013. Foram calculadas as taxas de mortalidade bruta e padronizada para o Brasil e regiões geográficas. Foi calculada, para o País, a mortalidade proporcional segundo faixas etárias, escolaridade, raça/cor da pele e tipo ou qualidade da vítima enquanto usuária da via pública. Foram estimados os anos potenciais de vida perdidos segundo sexo.

RESULTADOS

A taxa de mortalidade, em 2013, foi de 21,0 óbitos por 100 mil habitantes para o País. A região Centro-Oeste apresentou a taxa mais elevada (29,9 óbitos por 100 mil habitantes). A maioria dos óbitos por acidentes de transporte terrestre foi observada no sexo masculino (34,9 óbitos por 100 mil homens). Mais da metade das pessoas que faleceram em decorrência de acidentes de transporte terrestre eram da raça/cor da pele negra, adultos jovens (24,2%), indivíduos com baixa escolaridade (24,0%) e motociclistas (28,5%). A taxa de mortalidade, no triênio 2011 a 2013, apresentou redução de 4,1%, mas aumentou entre os motociclistas. Em todo o País, mais de um milhão de anos potenciais de vida foram perdidos, em 2013, devido aos acidentes de transporte terrestre, especialmente na faixa etária de 20 a 29 anos.

CONCLUSÕES

O impacto da alta taxa de mortalidade é de mais de um milhão de anos potenciais de vida perdidos por acidentes de transporte terrestre, principalmente entre adultos em idade produtiva (mortalidade precoce), em apenas um ano, representando extremo custo social decorrente de uma causa de óbito que poderia ser prevenida. Apesar da redução da mortalidade por acidentes de transporte terrestre de 2011 a 2013, as taxas de mortalidade aumentaram entre os motociclistas.

The design and application of an e-health readiness assessment tool

BACKGROUND

To date, several models have been developed to evaluate e-health readiness in healthcare organisations; however, no specific tool has been designed to assess or measure e-health readiness.

OBJECTIVE

The aim of this research was to design an e-health readiness assessment tool and to apply this tool to two Iranian hospitals to assess their readiness for the implementation of e-health.

METHOD

The study, which was undertaken in 2012, consisted of three phases: (i) review of existing models of e-health; (ii) design of an e-health readiness assessment tool; and (iii) trial of the assessment tool in two Iranian hospitals. Phase 1 consisted of a literature review that informed the development of the tool. In phase 2, we developed an e-health readiness assessment tool with feedback using two questionnaires from 40 employees from two teaching hospitals in Iran. In phase 3, we applied the tool to the same two Iranian teaching hospitals. Participants who completed the questionnaires were from management, health information technology, medical and nursing backgrounds and were familiar with e-health. A purposive sampling method was used to invite them to take part in the study. Data from the questionnaires were analysed using factor analysis and descriptive statistics.

RESULTS

Five dimensions and twenty-one indices were selected to be included in the e-health readiness tool. The 5 dimensions and their relative importance were e-health readiness (16%), information and communication technology (ICT) functions (15%), environmental readiness (20%), human resources readiness (29%) and ICT readiness (20%). The total e-health readiness scores for hospital A and hospital B were 0.22 and 0.4, respectively (a score of 1 is the ideal).

CONCLUSION

It is important to assess the e-health readiness of hospitals to save time and money and be able to better prepare for ICT implementations. The e-health readiness assessment tool provides a relatively simple method for assessing hospitals and provides essential information to assist healthcare facilities focus preparations and planning for e-health implementations.

Learning from defects using a comprehensive management system for incident reports in critical care

Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.

Analysis of Nursing Clinical Decision Support Requests and Strategic Plan in a Large Academic Health System

OBJECTIVES

To understand requests for nursing Clinical Decision Support (CDS) interventions at a large integrated health system undergoing vendor-based EHR implementation. In addition, to establish a process to guide both short-term implementation and long-term strategic goals to meet nursing CDS needs.

MATERIALS AND METHODS

We conducted an environmental scan to understand current state of nursing CDS over three months. The environmental scan consisted of a literature review and an analysis of CDS requests received from across our health system. We identified existing high priority CDS and paper-based tools used in nursing practice at our health system that guide decision-making.

RESULTS

A total of 46 nursing CDS requests were received. Fifty-six percent (n=26) were specific to a clinical specialty; 22 percent (n=10) were focused on facilitating clinical consults in the inpatient setting. "Risk Assessments/Risk Reduction/Promotion of Healthy Habits" (n=23) was the most requested High Priority Category received for nursing CDS. A continuum of types of nursing CDS needs emerged using the Data-Information-Knowledge-Wisdom Conceptual Framework: 1) facilitating data capture, 2) meeting information needs, 3) guiding knowledge-based decision making, and 4) exposing analytics for wisdom-based clinical interpretation by the nurse.

CONCLUSION

Identifying and prioritizing paper-based tools that can be modified into electronic CDS is a challenge. CDS strategy is an evolving process that relies on close collaboration and engagement with clinical sites for short-term implementation and should be incorporated into a long-term strategic plan that can be optimized and achieved overtime. The Data-Information-Knowledge-Wisdom Conceptual Framework in conjunction with the High Priority Categories established may be a useful tool to guide a strategic approach for meeting short-term nursing CDS needs and aligning with the organizational strategic plan.

Factors Affecting Successful Implementation of Hospital Information Systems

BACKGROUND

Today, the use of information systems in health environments, like any other fields, is necessary and organizational managers are convinced to use these systems. However, managers' satisfaction is not the only factor in successfully implementing these systems and failed information technology projects (IT) are reported despite the consent of the directors. Therefore, this study aims to determine the factors affecting the successful implementation of a hospital information system.

METHODS

The study was carried out as a descriptive method in 20 clinical hospitals that the hospital information system (HIS) was conducted in them. The clinical and paraclinical users of mentioned hospitals are the study group. 400 people were chosen as samples in scientific method and the data was collected using a questionnaire consisted of three main human, managerial and organizational, and technological factors, by questionnaire and interview. Then the data was scored in Likert scale (score of 1 to 5) and were analyzed using the SPSS software.

RESULTS

About 75 percent of the population were female, with average work experience of 10 years and the mean age was 30 years. The human factors affecting the success of hospital information system implementation achieved the mean score of 3.5, both organizational and managerial factors 2.9 and technological factors the mean of 3.

CONCLUSION

Human factors including computer skills, perceiving usefulness and perceiving the ease of a hospital information system use are more effective on the acceptance and successful implementation of hospital information systems; then the technological factors play a greater role. It is recommended that for the successful implementation of hospital information systems, most of these factors to be considered.

Interactive tools for inpatient medication tracking: a multi-phase study with cardiothoracic surgery patients

OBJECTIVE

Prior studies of computing applications that support patients' medication knowledge and self-management offer valuable insights into effective application design, but do not address inpatient settings. This study is the first to explore the design and usefulness of patient-facing tools supporting inpatient medication management and tracking.

MATERIALS AND METHODS

We designed myNYP Inpatient, a custom personal health record application, through an iterative, user-centered approach. Medication-tracking tools in myNYP Inpatient include interactive views of home and hospital medication data and features for commenting on these data. In a two-phase pilot study, patients used the tools during cardiothoracic postoperative care at Columbia University Medical Center. In Phase One, we provided 20 patients with the application for 24-48 h and conducted a closing interview after this period. In Phase Two, we conducted semi-structured interviews with 12 patients and 5 clinical pharmacists who evaluated refinements to the tools based on the feedback received during Phase One.

RESULTS

Patients reported that the medication-tracking tools were useful. During Phase One, 14 of the 20 participants used the tools actively, to review medication lists and log comments and questions about their medications. Patients' interview responses and audit logs revealed that they made frequent use of the hospital medications feature and found electronic reporting of questions and comments useful. We also uncovered important considerations for subsequent design of such tools. In Phase Two, the patients and pharmacists participating in the study confirmed the usability and usefulness of the refined tools.

CONCLUSIONS

Inpatient medication-tracking tools, when designed to meet patients' needs, can play an important role in fostering patient participation in their own care and patient-provider communication during a hospital stay.

Building Data-Driven Pathways From Routinely Collected Hospital Data: A Case Study on Prostate Cancer

BACKGROUND

Routinely collected data in hospitals is complex, typically heterogeneous, and scattered across multiple Hospital Information Systems (HIS). This big data, created as a byproduct of health care activities, has the potential to provide a better understanding of diseases, unearth hidden patterns, and improve services and cost. The extent and uses of such data rely on its quality, which is not consistently checked, nor fully understood. Nevertheless, using routine data for the construction of data-driven clinical pathways, describing processes and trends, is a key topic receiving increasing attention in the literature. Traditional algorithms do not cope well with unstructured processes or data, and do not produce clinically meaningful visualizations. Supporting systems that provide additional information, context, and quality assurance inspection are needed.

OBJECTIVE

The objective of the study is to explore how routine hospital data can be used to develop data-driven pathways that describe the journeys that patients take through care, and their potential uses in biomedical research; it proposes a framework for the construction, quality assessment, and visualization of patient pathways for clinical studies and decision support using a case study on prostate cancer.

METHODS

Data pertaining to prostate cancer patients were extracted from a large UK hospital from eight different HIS, validated, and complemented with information from the local cancer registry. Data-driven pathways were built for each of the 1904 patients and an expert knowledge base, containing rules on the prostate cancer biomarker, was used to assess the completeness and utility of the pathways for a specific clinical study. Software components were built to provide meaningful visualizations for the constructed pathways.

RESULTS

The proposed framework and pathway formalism enable the summarization, visualization, and querying of complex patient-centric clinical information, as well as the computation of quality indicators and dimensions. A novel graphical representation of the pathways allows the synthesis of such information.

CONCLUSIONS

Clinical pathways built from routinely collected hospital data can unearth information about patients and diseases that may otherwise be unavailable or overlooked in hospitals. Data-driven clinical pathways allow for heterogeneous data (ie, semistructured and unstructured data) to be collated over a unified data model and for data quality dimensions to be assessed. This work has enabled further research on prostate cancer and its biomarkers, and on the development and application of methods to mine, compare, analyze, and visualize pathways constructed from routine data. This is an important development for the reuse of big data in hospitals.

Comparing Patients' Opinions on the Hospital Discharge Process Collected With a Self-Reported Questionnaire Completed Via the Internet or Through a Telephone Survey: An Ancillary Study of the SENTIPAT Randomized Controlled Trial

BACKGROUND

Hospital discharge, a critical stage in the hospital-to-home transition of patient care, is a complex process with potential dysfunctions having an impact on patients' health on their return home. No study has yet reported the feasibility and usefulness of an information system that would directly collect and transmit, via the Internet, volunteer patients' opinions on their satisfaction concerning the organization of hospital discharge.

OBJECTIVE

Our primary objective was to compare patients' opinions on the discharge process collected with 2 different methods: self-questionnaire completed on a dedicated website versus a telephone interview. The secondary goal was to estimate patient satisfaction.

METHODS

We created a questionnaire to examine hospital discharge according to 3 dimensions: discharge logistics organization, preplanned posthospital continuity-of-care organization, and patients' impressions at the time of discharge. A satisfaction score (between 0 and 1) for each of those dimensions and an associated total score were calculated. Taking advantage of the randomized SENTIPAT trial that questioned patients recruited at hospital discharge about the evolution of their health after returning home and randomly assigned them to complete a self-questionnaire directly online or during a telephone interview, we conducted an ancillary study comparing satisfaction with the organization of hospital discharge for these 2 patient groups. The questionnaire was proposed to 1141 patients included in the trial who were hospitalized for ≥2 days, among whom 867 eligible patients had access to the Internet at home and were randomized to the Internet or telephone group.

RESULTS

Of the 1141 patients included, 755 (66.17%) completed the questionnaire. The response rates for the Internet (39.1%, 168/430) and telephone groups (87.2%, 381/437) differed significantly (P<.001), but their total satisfaction scores did not (P=.08) nor did the satisfaction subscores (P=.58 for discharge logistics organization, P=.12 for preplanned posthospital continuity-of-care organization, and P=.35 for patients' impressions at the time of discharge). The total satisfaction score (median 0.83, IQR 0.72-0.92) indicated the patients' high satisfaction.

CONCLUSIONS

The direct transmission of personal health data via the Internet requires patients' active participation and those planning surveys in the domain explored in this study should anticipate a lower response rate than that issued from a similar survey conducted by telephone interviews. Nevertheless, collecting patients' opinions on their hospital discharge via the Internet proved operational; study results indicate that conducting such surveys via the Internet yields similar estimates to those obtained via a telephone survey. The results support the establishment of a permanent dedicated website that could also be used to obtain users' opinions on other aspects of their hospital stay and follow-up.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01769261; http://clinicaltrials.gov/ct2/show/NCT01769261 (Archived by WebCite at http://www.webcitation.org/6ZDF5bdQb).

Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review

BACKGROUND

Although timely treatment of sepsis improves outcomes, delays in administering evidence-based therapies are common.

PURPOSE

To determine whether automated real-time electronic sepsis alerts can: (1) accurately identify sepsis and (2) improve process measures and outcomes.

DATA SOURCES

We systematically searched MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from database inception through June 27, 2014.

STUDY SELECTION

Included studies that empirically evaluated 1 or both of the prespecified objectives.

DATA EXTRACTION

Two independent reviewers extracted data and assessed the risk of bias. Diagnostic accuracy of sepsis identification was measured by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR). Effectiveness was assessed by changes in sepsis care process measures and outcomes.

DATA SYNTHESIS

Of 1293 citations, 8 studies met inclusion criteria, 5 for the identification of sepsis (n = 35,423) and 5 for the effectiveness of sepsis alerts (n = 6894). Though definition of sepsis alert thresholds varied, most included systemic inflammatory response syndrome criteria ± evidence of shock. Diagnostic accuracy varied greatly, with PPV ranging from 20.5% to 53.8%, NPV 76.5% to 99.7%, LR+ 1.2 to 145.8, and LR- 0.06 to 0.86. There was modest evidence for improvement in process measures (ie, antibiotic escalation), but only among patients in non-critical care settings; there were no corresponding improvements in mortality or length of stay. Minimal data were reported on potential harms due to false positive alerts.

CONCLUSIONS

Automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and do not improve mortality or length of stay.