Context is key in the design, implementation and evaluation of health information technology. Healthcare systems around the world are in transition; adopting technologies to deal with the problems of aging populations, increased numbers of chronically ill patients and limited resources. But a 'one size fits all' approach is not the answer, and may limit those local healthcare system innovations that are so crucial to the development of health informatics. Even the most advanced systems will fail to achieve the desired outcomes if context is not taken into account.
This book presents the proceedings of the Context Sensitive Health Informatics (CSHI) conference, held in Curitiba, Brazil, in August 2015. Context sensitive health informatics is about health information technologies and their environments, and the 26 papers included here examine how health informatics systems are developed, implemented and evaluated in a complex environment of many places, many users, many uses and in many contexts. The book is divided into four themes: different users in different contexts; evaluating for context through usability testing and ensuring patient safety; organizational and social issues in different places; and understanding different contexts using theory.
This overview of the research and experience critical to ensuring the successful introduction and adaptation of healthcare systems to new countries, contexts and healthcare settings will be of interest to all those involved in improving the quality of healthcare worldwide.
Christian Nøhr, Elizabeth M. Borycki, Andre W. Kushniruk, Craig E. Kuziemsky
1 - 6
Context is a key issue when designing, implementing, and evaluating health information technology. Advanced and well-designed systems may not achieve desired outcomes because of complex contextual issues, and unintended consequences are often reported in the literature. The conference introduced in this article integrates sociotechnical and human factors based theories and methods for analysis and evaluation of complex health information technologies in diverse environments demanding high context sensitivity.
Tariq Andersen, Finn Kensing, Lisbeth Kjellberg, Jonas Moll
9 - 14
This paper presents three distinct challenges to research and development (R&D) of marketable eHealth systems and suggests strategies to mitigate them. The eHealth system in question is designed to improve self-care and collaboration between remotely monitored heart failure patients and clinicians. By way of introspection and reflection on a current and a previous project, the authors propose solutions for mitigating the central challenges.
National e-Prescription services are becoming more common in Europe. While enhancing communication between levels of health care, few solutions have demonstrated enhanced quality of care and patient safety benefits. The article presents the results of a project to map the user needs the Estonian national e-prescription service. A survey was conducted among primary care physicians (PCPs) to inquire about their needs in the medication management process. The results showed that PCPs lacked a medication management tool to support patient care across different care settings. A mockup for the national service was developed based on the survey results. The medication management tool features a visual presentation of a patient's medication list and includes decision support functions for allergies and potential interactions. This mockup will be used to further investigate the needs of PCPs as well as other care providers in the medication management process.
Janessa Griffith, Helen Monkman, Elizabeth Borycki, Andre Kushniruk
20 - 25
The overuse of diagnostic imaging (DI) services, which is estimated to be 30% in Canada, can expose patients to unnecessary radiation, and strain human and financial resources. This study explored the DI ordering practices of physicians in Canada through semi-structured interviews to gain a deeper understanding of the factors contributing to the overuse of DI services. The majority of participants (n=11; 91%) described feeling pressured by patients to order DI services in circumstances that were unwarranted. The results are followed by a discussion about ways technology (such as a decision support system) could aid in facilitating a dialogue between physicians and patients about when and when not to order DI.
Derived from overlapping concepts in consumer health, a consumer health information system refers to any of the broad range of applications, tools, and educational resources developed to empower consumers with knowledge, techniques, and strategies, to manage their own health. As consumer health information systems become increasingly popular, it is important to explore the factors that impact their adoption and success. Accumulating evidence indicates a relationship between usability and consumers' eHealth Literacy skills and the demands consumer HISs place on their skills. Here, we present a new model called the Consumer Health Information System Adoption Model, which depicts both consumer eHealth literacy skills and system demands on eHealth literacy as moderators with the potential to affect the strength of relationship between usefulness and usability (predictors of usage) and adoption, value, and successful use (actual usage outcomes). Strategies for aligning these two moderating factors are described.
Terje Solvoll, Adrienne Hanenburg, Alain Giordanego, Gunnar Hartvigsen
32 - 38
CallMeSmart is a context aware communication system for hospitals. The system is being used by nurses and the physicians at the Oncology department, University Hospital of North Norway. CallMeSmart has been designed to increase the efficiency of communication between the nurse-physician and physician-physician. In this study, we have looked at the communication pathways between nurse-nurse and patient-nurse: how nurses define a preference of calling somebody, how alarms and tasks are prioritized, and how this could be implemented into the CallMeSmart system to improve the system for the nurses. This paper discusses how the communication pathways of the patient alarm system can be improved for health care actors in hospitals by revealing the communication patterns according to an alarm between those actors. We address the communication pattern between nurses, other health care actors, patients and the devices used, and discuss possible improvements of this communication.
Elizabeth Cummings, Elizabeth M. Borycki, Inge Madsen
39 - 44
Whilst there is a strong interest in nursing informatics in the graduate nurse population, nursing informatics has been slow to be incorporated into the undergraduate nursing curriculum. Nursing schools in Australia, Canada, and Denmark are all currently involved in redeveloping their curricula to include nursing informatics in a meaningful way. This paper provides a brief historical description of the uptake of nursing informatics in each of the three countries and discusses the required future directions and strategies towards incorporating nursing informatics into the undergraduate curriculum.
Elizabeth M. Borycki, Esther Sangster-Gormley, Rita Schreiber, April Feddema, Janessa Griffith, Mindy Swamy
45 - 51
A survey was conducted in the province of British Columba, Canada with nurse practitioners (NP). This paper reports on the quantitative and qualitative findings of the survey questions specifically focused on NP perceptions of the clinical impacts associated with using electronic medical records (EMRs) in a primary care setting. Findings suggest that although NPs perceived EMRs to improve the overall quality of clinical decisions, challenges remain in terms of tailoring the design of EMRs to address NP needs.
Romaric Marcilly, Linda W. Peute, Marie-Catherine Beuscart-Zephir, Monique W. Jaspers
55 - 60
In a Health Information Technology (HIT) regulatory context in which the usability of this technology is more and more a critical issue, there is an increasing need for evidence based usability practice. However, a clear definition of evidence based usability practice and how to achieve it is still lacking. This paper underlines the need for evidence based HIT design and provides a definition of evidence based usability practice as the conscientious, explicit and judicious use of current best evidence in making decisions in design of interactive systems in health by applying usability engineering and usability design principles that have proven their value in practice. Current issues that hamper evidence based usability practice are highlighted and steps needed to achieve evidence are presented.
Blake Lesselroth, Kathleen Adams, Stephanie Tallett, Scott Ragland, Victoria Church, Elizabeth M. Borycki, Andre Kushniruk
61 - 67
Internationally, major efforts are underway to improve medication safety and reduce medication errors during transitions of care. One strategy that has emerged to improve data accuracy and close information gaps is the introduction of software applications and workflow models that allow patients to review, enter, and modify their own patient data (e.g. information about medications they are taking). Evaluating the quality and effectiveness of such patient-facing healthcare applications is critical, especially when this approach is applied to high-stakes clinical tasks such as medication reconciliation. In this paper we describe an approach that has been used to assess the usability of a patient-facing medication reconciliation and allergy review (MRAR) kiosk. The phases involved are described along with implications and challenges of carrying out this work.
Usability has been identified as a key issue in health informatics. Worldwide numerous projects have been carried out in an attempt to increase and optimize health system usability. Usability testing, involving observing end users interacting with systems, has been widely applied and numerous publications have appeared describing such studies. However, to date, fewer works have been published describing methodological approaches to analyzing the rich data stream that results from usability testing. This includes analysis of video, audio and screen recordings. In this paper we describe our work in the development and application of a coding scheme for analyzing the usability of health information systems. The phases involved in such analyses are described.
Mette Kjer Kaltoft, Jesper Bo Nielsen, Glenn Salkeld, Jack Dowie
74 - 79
In this protocol for a pilot study we seek to establish the feasibility of using a web-based survey to simultaneously supply healthcare organisations and agencies with feedback on a key aspect of the care experience they provide and increase the generic health decision literacy of the individuals responding. The focus is on the person's involvement in decision making, an aspect of care which is seriously under-represented in current surveys if one adopts the perspective of person-centred care. By engaging with an instrument to assess decision quality the person can, in the one action, provide a retrospective evaluation of a past decision making experience in a specific provider context and enhance their competency in future decision making in any setting. We see this as an exercise in context-sensitive educational health informatics.
Clément Wawrzyniak, Marie-Catherine Beuscart-Zephir, Romaric Marcilly, Laura Douze, Jean-Baptiste Beuscart, Dominique Lecoutre, François Puisieux, Sylvia Pelayo
80 - 85
Background: Medication Review (MRev) has been implemented in many hospitals to improve patient safety and well-being. However, it seems sometimes difficult to implement, maintain and systematize this process, especially when key-elements are absent. This study focuses on the analysis of a MRev process implemented in an Acute Geriatric Unit (AGU) which, at the time of the study, had no Computerized Physician Order Entry (CPOE) and no sufficient staff to - normally - support the process.
Objective: This study describes the MRev process as existing in the AGU with a particular focus on the preparatory MRev meeting phase and presents our recommendations to maintain and optimize it.
Methods: Human Factor experts have collected and analyzed data during MRev process by interviews, shadowing observations and video recording from April to October 2014 at Lille University Hospital.
Results: MRev process consists of three phases (meeting preparation, MRev meeting and patient discharge) and includes seven main tasks for which actors, documented supports, outcomes and difficulties are identified. Although allocating a fulltime pharmacist for the AGU would solve several problems, the main realistic recommendations concern training for junior and senior actors according to their roles and the improvement of some tasks processes.
Conclusion: Despite less than optimal conditions as compared to those recommended by the literature, the observed AGU performs an efficient review based on well designed tools and processes.
As the deployment of health information technology progresses, issues of usability and safety, including the possibility of technology-induced errors have come to the fore. Increased complexity of care delivery models and emergent conditions such as the Ebola scare in the US point to the difficulty of design that allows for human cognitive limits while meeting complex needs. We previously described a modular composable approach to health information systems, which gives the end-user some control of design and allows for creation of systems meeting myriad and varied needs. Here we discuss how the different drag/drop interaction paradigm has implications for health IT safety via several mechanisms. These include display fragmentation and the need to changeably prioritize information elements, interruptions, fit to tasks and contexts, and rapid changeability allowing low-cost readjustments when lack of fit is found.
Data quality was placed as a major reason for the low utility of patient safety event reporting systems. A pressing need in improving data quality has advanced recent research focus in data entry associated with human factors. The debate on structured data entry or unstructured data entry reveals not only a trade-off problem among data accuracy, completeness, and timeliness, but also a technical gap on text mining. The present study suggested a text classification method, k-nearest neighbor (KNN), for predicting subject categories as in our proposed reporting system. Our results demonstrated the feasibility of KNN classifier used for text classification and indicated the advantage of such an application to raise data quality and clinical decision support in reporting patient safety events.
Heloá Costa Borim, Lilian Mie Mukai, Lucas Emanuel Silva E Oliveira, Vagner José Lopes, Claudia Maria Cabral Moro
100 - 104
There are different methods to evaluate Health Information Systems (HIS), such as Quality Evaluation of software products, human factors, and socio-technical approaches. This work aims to identify the main aspects used to evaluate HIS, and whether there are relationships between issues considered in assessment of software quality and the ones applied specific to the health domain. This was an exploratory study that included a literature search related to HIS evaluation and software quality analyses applying the norms of the International Organization for Standardization (ISO/IEC), to identify aspects and features applied during the assessment process. The result is a proposal of an evaluation method based on the integration of these two evaluative approaches, combining or complementing the considered aspects. The method was applied to an evaluation of a natural language processing system to identify continuity of care in discharge summaries.
Implementing team based workflows can be complex because of the scope of providers involved and the extent of information exchange and communication that needs to occur. While a workflow may represent the ideal structure of communication that needs to occur, information issues and contextual factors may impact how the workflow is implemented in practice. Understanding these issues will help us better design systems to support team based workflows. In this paper we use a case study of palliative sedation therapy (PST) to model a PST workflow and then use it to identify purposes of communication, information issues and contextual factors that impact them. We then suggest how our findings could inform health information technology (HIT) design to support team based communication workflows.
Monika A. Johansen, Åse-Merete Pedersen, Gunnar Ellingsen
114 - 119
This study aimed to investigate the quality-assurance work conducted by medical transcriptionists in the production of medical records, and the implications of these findings when designing a structured electronic patient record (EPR) system in which physicians are supposed to write documentation themselves. Both qualitative and quantitative methods were applied. Qualitative data were collected through informal discussions and focus-group interviews. Quantitative data were collected through the medical transcriptionists' daily recordings of their quality-assurance work. The results show the many essential quality-assurance tasks conducted by medical transcriptionists and the extent of this work. Each medical transcriptionist performs an average of more than six corrections per day, and approximately one of three dictations are corrected. We suggest that these correction and quality-assurance tasks need to be compensated for when designing and developing new structured EPRs. Some quality-assurance tasks may also advantageously be performed by secretaries in the future.
David R. Kaufman, Stephanie K. Furniss, Maria Adela Grando, David W. Larson, Matthew M. Burton
120 - 125
Failure to understand clinical workflow across electronic health record (EHR) tasks is a significant contributor to usability problems. In this paper, we employed sequential data analysis methods with the aim of characterizing patterns of 5 clinicians' information-gathering across 66 patients. Two analyses were conducted. The first one characterized the most common sequential patterns as reflected in the screen transitions. The second analysis was designed to mine and quantify the frequency of sequence occurrence. We observed 27 screen-transition patterns that were employed from 2 to 7 times. Documents/Images and Intake/Output screens were viewed for nearly all patients indicating the importance of these information sources. In some cases, they were viewed more than once which may show that users are following inefficient patterns in the information gathering process. New quantitative methods of analysis as applied to interaction data can yield critical insights in robust designs that better support clinical workflow.
A mobile learning paradox exists in Australian healthcare settings. Although it is increasingly acknowledged that timely, easy, and convenient access to health information using mobile learning technologies can enhance care and improve patient outcomes, currently there is an inability for nurses to access information at the point of care. Rapid growth in the use of mobile technology has created challenges for learning and teaching in the workplace. Easy access to educational resources via mobile devices challenges traditional strategies of knowledge and skill acquisition. Redesign of learning and teaching in the undergraduate curriculum and the development of policies to support the use of mobile learning at point of care is overdue. This study explored mobile learning opportunities used by clinical supervisors in tertiary and community-based facilities in two Australian States. Individual, organisation and systems level governance were sub-themes of professionalism that emerged as the main theme and impacts on learning and teaching in situ in healthcare environments. It is imperative healthcare work redesign includes learning and teaching that supports professional identity formation of students during work integrated learning.
Focus within eHealth research is often on development and implementation. However, the role of information systems maintenance and management is often neglected. In order for the IT department to accommodate the needs of the hospitals and continuous change of organization and practice there is a need for developing an understanding of the complex relationship between the IT department and clinical practice. In this paper the concept of redesign is used to deepen our understanding of IT related organizational change in healthcare organizations. In the paper I argue that the IT department is a central partner, steward and power in organizational change and learning in hospitals as the IT department serve both as a barrier and a catalyst of change and flexibility in the organization through management of information systems maintenance and redesign. Therefore it is important to consider and secure appropriate forms for stewarding redesign and learning in cooperation between the health care organizations and the IT department.
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