Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies

BACKGROUND

Information communication technology (ICT) is a critical enabler of integrated models of community-based primary health care; however, little is known about how existing technologies have been used to support new models of integrated care. To address this gap, we draw on data from an international study of integrated models, exploring how ICT is used to support activities of integrated care and the organizational and environmental barriers and enablers to its adoption.

METHODS

We take an embedded comparative multiple-case study approach using data from a study of implementation of nine models of integrated community-based primary health care, the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study. Six cases from Canada, three each in Ontario and Quebec, and three in New Zealand, were studied. As part of the case studies, interviews were conducted with managers and front-line health care providers from February 2015 to March 2017. A qualitative descriptive approach was used to code data from 137 interviews and generate word tables to guide analysis.

RESULTS

Despite different models and contexts, we found strikingly similar accounts of the types of activities supported through ICT systems in each of the cases. ICT systems were used most frequently to support activities like care coordination by inter-professional teams through information sharing. However, providers were limited in their ability to efficiently share patient data due to data access issues across organizational and professional boundaries and due to system functionality limitations, such as a lack of interoperability.

CONCLUSIONS

Even in innovative models of care, managers and providers in our cases mainly use technology to enable traditional ways of working. Technology limitations prevent more innovative uses of technology that could support disruption necessary to improve care delivery. We argue the barriers to more innovative use of technology are linked to three factors: (1) information access barriers, (2) limited functionality of available technology, and (3) organizational and provider inertia.

Job design, employment practices and well-being: a systematic review of intervention studies

There is inconsistent evidence that deliberate attempts to improve job design realise improvements in well-being. We investigated the role of other employment practices, either as instruments for job redesign or as instruments that augment job redesign. Our primary outcome was well-being. Where studies also assessed performance, we considered performance as an outcome. We reviewed 33 intervention studies. We found that well-being and performance may be improved by: training workers to improve their own jobs; training coupled with job redesign; and system wide approaches that simultaneously enhance job design and a range of other employment practices. We found insufficient evidence to make any firm conclusions concerning the effects of training managers in job redesign and that participatory approaches to improving job design have mixed effects. Successful implementation of interventions was associated with worker involvement and engagement with interventions, managerial commitment to interventions and integration of interventions with other organisational systems. Practitioner Summary: Improvements in well-being and performance may be associated with system-wide approaches that simultaneously enhance job design, introduce a range of other employment practices and focus on worker welfare. Training may have a role in initiating job redesign or augmenting the effects of job design on well-being.

An integrated computer-based procedure for teamwork in digital nuclear power plants

Computer-based procedures (CBPs) are expected to improve operator performance in nuclear power plants (NPPs), but they may reduce the openness of interaction between team members and harm teamwork consequently. To support teamwork in the main control room of an NPP, this study proposed a team-level integrated CBP that presents team members' operation status and execution histories to one another. Through a laboratory experiment, we compared the new integrated design and the existing individual CBP design. Sixty participants, randomly divided into twenty teams of three people each, were assigned to the two conditions to perform simulated emergency operating procedures. The results showed that compared with the existing CBP design, the integrated CBP reduced the effort of team communication and improved team transparency. The results suggest that this novel design is effective to optim team process, but its impact on the behavioural outcomes may be moderated by more factors, such as task duration.

PRACTITIONER SUMMARY

The study proposed and evaluated a team-level integrated computer-based procedure, which present team members' operation status and execution history to one another. The experimental results show that compared with the traditional procedure design, the integrated design reduces the effort of team communication and improves team transparency.

A healthy ticker... or a good heart?

The amount of paperwork requiring completion by NHS professionals has increased over the years. Some employees feel that is driving them away from client care. In this article, one midwife tots up a week's worth of what she describes as 'box-ticking', and asks: what is the effect of this quantifying trend on the quality of care provided for women and families? Does a mark on a page provide a real representation of the interactions that have taken place? Whilst acknowledging that good documentation is an essential part of care, she questions its domination as a reflection of a job well done.

Maintaining the passion for pinards

Throughout my midwifery programme I have developed a passion for the use of pinards; a skill that may be lost within midwifery. It is often acknowledged that the use of pinard stethoscopes prior to the use of electronic devices is best practice (Royal College of Midwives (RCM) 2012), yet it is a practice that seems to be losing its place. This article aims to share some of the benefits of using a pinard and encourages the reader to reflect on their own feelings towards using this tool in practice. I will analyse whether or not there is still a value for pinards following an event I experienced whilst on clinical placement. This reflection uses an adapted version of Driscoll's Model of structured reflection (Driscoll 2000).

Evaluation of second phase insulin secretion with simple surrogates derived from the mixed meal tolerance test in patients with type 2 diabetes

The major contributors to the pathogenesis of type 2 diabetes are impaired insulin action and insulin secretion, including second phase insulin secretion (2nd ISEC). This study aimed to compare surrogates derived from the mixed meal tolerance test (MTT) with 2nd ISEC derived from modified low-dose graded glucose infusion (M-LDGGI) in patients with type 2 diabetes. We were subsequently able to decide which surrogate would be performed easily and accurately. Twenty type 2 diabetes patients were enrolled. They received both MTT and M-LDGGI. The standardized MTT meals were provided at 8:00 A.M. and 12:00 P.M. The M-LDGGI was a simplified version of the Polonsky method; only two 80-min stages of glucose infusion (2 and 6 mg/kg/min) were given. The slopes of the insulin to glucose curve during the test were regarded as the 2nd ISEC. First, we used the area under the insulin curve (AUC(IN)) during MTT to quantify the 2nd ISEC. The best correlated AUC(IN) was from 60-240 min. Second, the slopes between any two time points of the plasma insulin to glucose level (SLOPE(I/G)) were also assessed. The time period best correlated with 2nd ISEC was from 0-120 min (SLOPE₀₋₁₂₀). Finally, the insulin-to-glucose ratio (IGr) of each time point was used to estimate the 2nd ISEC, and the best correlation was observed at 180 min. In conclusion, estimating 2nd ISEC surrogates derived from MTT proved to be possible. The most accurate surrogate is the SLOPE₀₋₁₂₀, while IG(r180) is another less precise but more convenient method.

DAI-10 is as good as DAI-30 in schizophrenia

Drug attitude inventory (DAI-30) is considered to be the best predictor of poor adherence in first-episode schizophrenia. We compared the short version (DAI-10) with DAI-30 in long-term schizophrenia, documented if DAI was associated with poor insight, PANSS and GAF and constructed DAI-10 percentiles. DAI-30 and DAI-10 were homogenous (r = 0.82 and 0.72, respectively) with good test-retest reliability (0.79). The correlation between the DAI versions was high (0.94). Percentile scores of DAI-10 were computed. DAI is an easy-to-use self-report instrument seemingly assessing a unique clinical dimension relevant to non-adherence. DAI-10 might be preferred for its simplicity and good psychometric properties.

Subjective job task analyses for physically demanding occupations: what is best practice?

Workers in physically demanding occupations (PDOs) are frequently subjected to physical selection tests. To avoid legal ramifications, workplaces must be able to show that any personnel selection procedures reflect the inherent requirements of the job. A job task analysis (JTA) is fundamental in determining the work tasks required for employees. To date, there are no published instructions guiding PDO researchers on how to conduct job task analyses. Job task analysis research for non-PDOs offers some insight into the expected reliability and validity of data obtained on the most prevalent task domains in job analysis (importance, frequency, time spent and difficulty). This review critiques such research, and the existing published material on JTA of PDOs, and provides recommendations for future research and practice.

PRACTITIONER SUMMARY

There are no published guidelines for physically demanding occupation (PDO) researchers conducting job task analysis (JTA). Given the legal consequences of improperly conducted JTA, scientifically valid instructions for JTA practitioners are required. This review critiques existing research which analyses reliabilities of JTA data, and provides guidelines for PDO researchers conducting JTA.

Energy

Energy is the capacity to do the things we are capable of and desire to accomplish. Most often this is thought of in terms of PEP--personal energy potential--a reservoir of individual vivacity and zest for work. Like a battery, energy can be conceived of as a resource that is alternatively used and replenished. Transitions between activities, variety of tasks, and choices of what to spend energy on are part of energy management. Energy capacity can be thought of at four levels: (a) so little that harm is caused and extraordinary steps are needed for recovery, (b) a deficit that slightly impairs performance but will recover naturally, (c) the typical range of functioning, and (d) a surplus that may or may not be useful and requires continual investment to maintain. "Flow" is the experience of optimal energy use when challenges balance capacity as a result of imposing order on our environment. There are other energy resources in addition to personal vim. Effective work design reduces demands on energy. Money, office design, and knowledge are excellent substitutes for personal energy.

Clinically lean; "cutting the crap"

Proponents of Lean Philosophy believe that successful businesses must reduce waste in working time and resources to a minimum, and maximise their use in productive work. The productive work of the Acute Medical Unit is to provide effective clinical management to a daily cohort of acutely ill patients. Many Clinicians are cynical about Lean. In this article, Dr Caldwell discusses how many clinicians complain of too much crap in the workplace, which gets in the way of swift, safe high quality clinical care. He argues that "Cutting the Crap" in the Acute Medical Unit is entirely consistent with Lean approaches to management of complex systems.

Research midwives: look at the evidence!

Evidence based practice underpins modern healthcare and includes the use of research knowledge, consideration of an individual's circumstances and their personal preferences. Maternal and child health care interventions aim to prevent disease and disability and promote health and wellbeing. Before interventions are brought into practice the benefits and risks should be adequately evaluated to ensure clinicians and those receiving the interventions fully understand the potential effects. A multidisciplinary team approach to the development of research initiatives is advantageous. The team should include clinicians, researchers and service users working together to answer important clinical questions. It is our view that clinical research midwives are pivotal to the success of maternal and child health improvement initiatives. For example they can help reduce the gap between clinical practice and research by making research understandable to clinicians and applicable to practice by working in partnership with academics.

[Ockham's razor]

The simple management of complexity, allows the definition of learning and of change strategies based on applying smart copying to innovation.

Revisiting the design of minimal and no-preparation veneers: a step-by-step technique

The concept of minimal preparation is more than 25 years old. Interest in conservative treatments is being revisited as dentistry embraces thinner ceramic veneers and adhesive bonding agents that keep preparations in enamel. Experience and professional knowledge help determine appropriate treatments based on patients' clinical situations and esthetic demands. This article reviews the veneer modality, its role as a conservative treatment, and the protocol to be implemented to ensure proper treatment planning and material selection.

Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study

BACKGROUND

Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care.

DESIGN

A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care.

DISCUSSION

A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.

User-agent cooperation in multiagent IVUS image segmentation

Automated interpretation of complex images requires elaborate knowledge and model-based image analysis, but often needs interaction with an expert as well. This research describes expert interaction with a multiagent image interpretation system using only a restricted vocabulary of high-level user interactions. The aim is to minimize inter- and intra-observer variability by keeping the total number of interactions as low and simple as possible. The multiagent image interpretation system has elaborate high-level knowledge-based control over low-level image segmentation algorithms. Agents use contextual knowledge to keep the number of interactions low but, when in doubt, present the user with the most likely interpretation of the situation. The user, in turn, can correct, supplement, and/or confirm the results of image-processing agents. This is done at a very high level of abstraction such that no knowledge of the underlying segmentation methods, parameters or agent functioning is needed. High-level interaction thereby replaces more traditional contour correction methods like inserting points and/or (re)drawing contours. This makes it easier for the user to obtain good results, while inter- and intra-observer variability are kept minimal, since the image segmentation itself remains under control of image-processing agents. The system has been applied to intravascular ultrasound (IVUS) images. Experiments show that with an average of 2-3 high-level user interactions per correction, segmentation results substantially improve while the variation is greatly reduced. The achieved level of accuracy and repeatability is equivalent to that of manual drawing by an expert.

Voice recognition dictation: radiologist as transcriptionist

Continuous voice recognition dictation systems for radiology reporting provide a viable alternative to conventional transcription services with the promise of shorter report turnaround times and increased cost savings. While these benefits may be realized in academic institutions, it is unclear how voice recognition dictation impacts the private practice radiologist who is now faced with the additional task of transcription. In this article, we compare conventional transcription services with a commercially available voice recognition system with the following results: 1) Reports dictated with voice recognition took 50% longer to dictate despite being 24% shorter than those conventionally transcribed, 2) There were 5.1 errors per case, and 90% of all voice recognition dictations contained errors prior to report signoff while 10% of transcribed reports contained errors. 3). After signoff, 35% of VR reports still had errors. Additionally, cost savings using voice recognition systems in non-academic settings may not be realized. Based on average radiologist and transcription salaries, the additional time spent dictating with voice recognition costs an additional $6.10 per case or $76,250.00 yearly. The opportunity costs may be higher. Informally surveyed, all radiologists expressed dissatisfaction with voice recognition with feelings of frustration, and increased fatigue. In summary, in non-academic settings, utilizing radiologists as transcriptionists results in more error ridden radiology reports and increased costs compared with conventional transcription services.

Registered nurses' use of electronic health records: findings from a national survey

OBJECTIVE

(1) To determine the proportion of the registered nurse (RN) workforce that uses a minimally functional electronic health record (EHR) system; (2) to assess the relationship between EHR use and beliefs about quality of care and quality improvement activities; and (3) to determine whether EHR use is associated with less time spent on paperwork and documentation and more time spent in direct patient care.

DESIGN

Data were collected through use of a 6-page survey mailed to a nationally representative sample of RNs. The study is cross-sectional and examines associations between EHR use and measures of quality and time spent on patient care-related tasks.

MEASUREMENTS

A minimally functional EHR was defined as routine use of electronic patient demographics; electronic ordering of tests, procedures, or drugs; electronic clinical and patient notes; electronic access to test results; and electronic decision support. RNs were categorized into those employed in practices or hospitals where 0 functionalities were in routine use, 1 to 4 functionalities were in routine use, or 5 functionalities were in routine use.

RESULTS

Fewer than 1 in 5 RNs work in healthcare settings that have adopted a minimally functional EHR. Use was related to measures of nursing excellence and increased efforts at quality improvement. There were no differences between RNs using an EHR and those not using one on time spent in patient care-related tasks.

CONCLUSION

This study is the first to provide national data on RNs' use of EHRs. It suggests important relationships between EHR use, quality improvement, and nursing excellence.

Technology implementation and workarounds in the nursing home

OBJECTIVE

This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes.

DESIGN

As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings.

MEASUREMENTS

Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks.

RESULTS

Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team.

CONCLUSION

This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.

Accounting for signal loss due to dephasing in the correction of distortions in gradient-echo EPI via nonrigid registration

Gradient-echo (GE) echo planar imaging (EPI) is susceptible to both geometric distortions and signal loss. This paper presents a retrospective correction approach based on nonrigid image registration. A new physics-based intensity correction factor derived to compensate for intravoxel dephasing in GE EPI images is incorporated into a previously reported nonrigid registration algorithm. Intravoxel dephasing causes signal loss and thus intensity attenuation in the images. The new rephasing factor we introduce, which changes the intensity of a voxel in images during the registration, is used to improve the accuracy of the intensity-based nonrigid registration method and mitigate the intensity attenuation effect. Simulation-based experiments are first used to evaluate the method. A magnetic resonance (MR) simulator and a real field map are used to generate a realistic GE EPI image. The geometric distortion computed from the field map is used as the ground truth to which the estimated nonrigid deformation is compared. We then apply the algorithm to a set of real human brain images. The results show that, after registration, alignment between EPI and multi-shot, spin-echo images, which have relatively long acquisition times but negligible distortion, is improved and that signal loss caused by dephasing can be recovered.

How to decide which are the most pertinent overly-represented features during gene set enrichment analysis

Background

The search for enriched features has become widely used to characterize a set of genes or proteins. A key aspect of this technique is its ability to identify correlations amongst heterogeneous data such as Gene Ontology annotations, gene expression data and genome location of genes. Despite the rapid growth of available data, very little has been proposed in terms of formalization and optimization. Additionally, current methods mainly ignore the structure of the data which causes results redundancy. For example, when searching for enrichment in GO terms, genes can be annotated with multiple GO terms and should be propagated to the more general terms in the Gene Ontology. Consequently, the gene sets often overlap partially or totally, and this causes the reported enriched GO terms to be both numerous and redundant, hence, overwhelming the researcher with non-pertinent information. This situation is not unique, it arises whenever some hierarchical clustering is performed (e.g. based on the gene expression profiles), the extreme case being when genes that are neighbors on the chromosomes are considered.

Results

We present a generic framework to efficiently identify the most pertinent over-represented features in a set of genes. We propose a formal representation of gene sets based on the theory of partially ordered sets (posets), and give a formal definition of target set pertinence. Algorithms and compact representations of target sets are provided for the generation and the evaluation of the pertinent target sets. The relevance of our method is illustrated through the search for enriched GO annotations in the proteins involved in a multiprotein complex. The results obtained demonstrate the gain in terms of pertinence (up to 64% redundancy removed), space requirements (up to 73% less storage) and efficiency (up to 98% less comparisons).

Conclusion

The generic framework presented in this article provides a formal approach to adequately represent available data and efficiently search for pertinent over-represented features in a set of genes or proteins. The formalism and the pertinence definition can be directly used by most of the methods and tools currently available for feature enrichment analysis.

The topology of metabolic isotope labeling networks

Background

Metabolic Flux Analysis (MFA) based on isotope labeling experiments (ILEs) is a widely established tool for determining fluxes in metabolic pathways. Isotope labeling networks (ILNs) contain all essential information required to describe the flow of labeled material in an ILE. Whereas recent experimental progress paves the way for high-throughput MFA, large network investigations and exact statistical methods, these developments are still limited by the poor performance of computational routines used for the evaluation and design of ILEs. In this context, the global analysis of ILN topology turns out to be a clue for realizing large speedup factors in all required computational procedures.

Results

With a strong focus on the speedup of algorithms the topology of ILNs is investigated using graph theoretic concepts and algorithms. A rigorous determination of all cyclic and isomorphic subnetworks, accompanied by the global analysis of ILN connectivity is performed. Particularly, it is proven that ILNs always brake up into a large number of small strongly connected components (SCCs) and, moreover, there are natural isomorphisms between many of these SCCs. All presented techniques are universal, i.e. they do not require special assumptions on the network structure, bidirectionality of fluxes, measurement configuration, or label input. The general results are exemplified with a practically relevant metabolic network which describes the central metabolism of E. coli comprising 10390 isotopomer pools.

Conclusion

Exploiting the topological features of ILNs leads to a significant speedup of all universal algorithms for ILE evaluation. It is proven in theory and exemplified with the E. coli example that a speedup factor of about 1000 compared to standard algorithms is achieved. This widely opens the door for new high performance algorithms suitable for high throughput applications and large ILNs. Moreover, for the first time the global topological analysis of ILNs allows to comprehensively describe and understand the general patterns of label flow in complex networks. This is an invaluable tool for the structural design of new experiments and the interpretation of measured data.

Predictors of Adherence to a Skill-Building Intervention in Dementia Caregivers

BACKGROUND

Treatment adherence is a widely recognized problem in health services but understudied in caregiver intervention research. This study examines caregiver sociodemographic and psychological characteristics, patient illness severity, and treatment implementation factors as predictors of caregiver adherence to a skills training intervention to help families manage dementia care problems at home.

METHODS

The sample consisted of 105 caregivers randomized to the Home Environmental Skill-Building Program at the Philadelphia site of the National Institutes of Health (NIH) Resources for Enhancing Alzheimer's Caregiver Health (REACH I). The intervention, implemented by occupational therapists, consisted of education, problem solving, communication, environmental and task simplification techniques, and home modifications. Adherence was measured by a proportion score representing the percentage of strategies used by participants compared to the total number of strategies prescribed during intervention (Strategy Use).

RESULTS

Regression analysis with intraclass correlation adjustment for interventionist effects revealed that caregivers with better physical health (p <.001), greater treatment exposure (p <.001), more problem areas addressed (p =.012), and for whom more active therapeutic techniques (role play) were used (p =.004) demonstrated greater adherence. Other caregiver characteristics, patient cognitive impairment, and troublesome behaviors were not significantly related to caregiver adherence.

CONCLUSIONS

Modifiable caregiver and treatment implementation factors, including active engagement of caregivers, were associated with adherence, whereas patient characteristics were not. Caregivers with poor health may be at risk for not benefiting from intervention, suggesting that efforts, including instruction in preventive care and allocating time to attend to their own health care needs, be directed towards improving their health.

Electronic Templates versus Dictation for the Completion of Mohs Micrographic Surgery Operative Notes

BACKGROUND

Operative notes can be generated electronically by manual input of the entire note, free-form oral dictation, or using either an electronic template or a template for dictation. There are few studies that have directly compared these modalities in terms of speed, accuracy, and completeness.

OBJECTIVE

The objective was to determine whether electronic templates are more efficient and reduce errors compared to free-form oral dictation for the completion of Mohs micrographic surgery operative notes.

METHODS

Operative notes for 110 consecutive Mohs micrographic surgery cases were completed either by oral dictation or by electronic template. The time to dictate or complete the template was recorded for each note. Notes were subsequently edited, recording the number and type of errors as well as the time required to edit each note.

RESULTS

Compared with dictation, operative notes completed with the electronic template had fewer errors (5.8% vs. 81%), took less time to complete (175.5 seconds vs. 240.0 seconds), took less time to review and edit (41.6 seconds vs. 201.1 seconds), and were completed and signed in a more timely fashion (0.115 days vs. 20.7 days).

CONCLUSION

Electronic templates are a more accurate and rapid method compared to free-form oral dictation for the completion of Mohs micrographic surgery operative notes and have the advantage of being immediately available to review and sign.