Ten years ago, two landmark reports were published by the Institute of Medicine on human error in medicine and the quality chasm. It seems appropriate then, that the fourth international conference Information Technology in Health Care, should re-visit these themes now to examine how safer systems can be designed and implemented to improve patient safety. This book presents the proceedings of that conference.
Many policies and programs have been initiated internationally to stimulate the use of electronic health care and record systems. Unfortunately, these do not always run smoothly. For example, a study of electronic prescribing systems in seven western countries showed that the uptake in hospitals was only 20%, and some studies have indicated that electronic systems may even introduce more errors instead of reducing them.
Of the 28 submitted papers presented here, seven deal with patient safety, eight address various topics of system design, six cover the subject of implementation and four explore patient involvement. The remaining three papers cover the theme of the conference in a broader perspective.
Offering insights into how improved design and implementation will advance patient safety, this book will be of interest to a wide range of professionals involved in all aspects of electronic health care.
This volume presents the papers from the fourth International Conference on Information Technology in Health Care: Socio-technical Approaches held in Aalborg, Denmark in June 2010.
In 2001 the first conference was held in Rotterdam, The Netherlands with the theme: Sociotechnical' approaches that consider ‘social’ and ‘technical’ aspects as inextricably intertwined, and as equally important in information systems design, implementation and evaluation.
The second conference was held in 2004 in Portland, Oregon, USA. The theme here was: To err is system.
Sydney in Australia was the venue for the third conference with the theme: The ability to design, implement and evaluate safe, useable and effective systems within complex health care organizations.
The theme for this conference was “Designing and Implementing Health IT: from safe systems to patient safety”. The contributions have reflected on a number of important issues. How are the mutual adaptations of technology and work practice during implementation reflected in design and redesign? How are the successful implementations carried out as a process of organizational change? How does a socio-technical understanding improve the design and implementation of safe systems and thus contribute to the agenda of patient safety?
The contributions demonstrate how the health informatics community has contributed to the performance of significant research and to translating research findings to develop health care delivery and improve patient safety.
The editors want to thank Marianne Sørensen, Aalborg University for keeping track of all the contributions and ensuring they found their way to the final proceedings. We also want to thank all the reviewers for their excellent work in providing constructive feedback to the authors. This valuable input has significantly improved the quality of many papers. We also want to acknowledge the sponsorship of the conference by Det Obelske Familiefond, the Mayor of Aalborg and of Aalborg University.
In this introduction we summarize the contributions to the Fourth International Conference Information Technology in Health Care: Socio-technical Approaches. We argue that putting to use information systems in health care is a difficult and winding road. Systems may even compromise instead of improving patient safety. Designing and implementing systems requires a thorough understanding of the context in which technology is being used. But this understanding should also lead to better design and implementation methods. Therefore this conference wishes to address the challenges of safe systems and patient safety, ten years after the publication of the landmark reports on human error and quality of health care by the Institute of Medicine.
While healthcare information technology (HIT) offers extraordinary promise of clinical improvement and greater efficiencies, the realization of the promise must confront and overcome a number of challenges caused by incomplete and inappropriate software design. In this paper, we review several types of HIT design and workflow decisions that limit the value and utility of HIT in electronic health (medical) record (EHR/EMR), computerized physician order entry (CPOE), and electronic medication administration record (eMAR) systems. While remedies for problems of design or workflow may be either easy or difficult, , the industry creates additional barriers in the contractual relationships it creates between itself (HIT vendors) and the clinical facilities (hospitals, clinics, and physician offices) that purchase its systems. We suggest that the structure of those relationships may retard the progress and responsiveness of HIT.
Since 2001 when the systematic analysis of serious patient safety incidents was implemented, a number of root cause analyses have been completed. Common to these is that the medication of the patient has been problematic and has had serious consequences for the patient. In the analyses the events causing the patient safety incidents are described in detail, the causes are identified and a plan of actions is created.
Participatory design includes engaging in large-scale information-systems development where participatory design approaches have been applied throughout design and organizational implementation. The keynote suggest to extend the iterative prototyping approach by (1) emphasizing participatory design experiments and pilot implementations as transcending traditional prototyping by evaluating fully integrated systems exposed to real work practices; (2) incorporating improvisational change management including anticipated, emergent, and opportunity-based change; and (3) extending initial design and development into a sustained and ongoing implementation that constitutes an overall technology-driven organizational change. This sustained participatory design and implementation approach is exemplified through a large-scale project in the Danish healthcare sector.
This paper discusses a conceptual approach to the study of the implementation of ICTs in healthcare organizations. The paper uses some fundamental concepts from sociotechnical studies to address the complex process of change – the changing – that accompanies ICT innovations. The paper argues for the importance of the perspective of changing as a way to account for the dynamics as technology and people, organizations and institutions co-constitutively work-out their future together.
This paper discusses two approaches to “the sociotechnical”, one coming from the Tavistock tradition and the other from actor network theory. These two differ in important ways and from the latter it follows that what patient safety means must be scrutinized and unpacked. The paper thus rudimentarily discusses central contributions to the problematization of patient safety. Last, it is argued that patient safety does not exist apart from the sociotechnical practices that seek to accomplish it, but is constructed in and through them, which is why it is pertinent to reflect on how those practices constructs what comes to qualify as patient safety.
The article deals with architecture and EHRs on a conceptual and philosophical level. Architecture is seen as the essential human expression of being, exemplified through the thoughts and writings of the German architect Gottfried Semper, the American architect Philip Johnson and the German philosopher Martin Heidegger. It is the assumption of the article that the current versions of EHR architectures are the result of a technical and systemic perspective on architecture, as opposed to the thoughts of Semper, Johnson and Heidegger. The article has a value-based and phronetic approach to the topic field, and claims that construction of EHRs should be a matter of concern, and not, as it is for now, a matter of fact.
Despite a wealth of research on user participation, few studies offer insights into how to involve multi-organizational users in agile development methods. This paper is a case study of user involvement in developing a system for electronic laboratory requisitions using agile methodologies in a multi-organizational context. Building on an interpretive approach, we illuminate questions such as: How does collaboration between users and developers evolve and how might it be improved? What key motivational aspects are at play when users volunteer and continue contributing in the face of considerable added burdens? The study highlights how agile methods in themselves appear to facilitate mutually motivating collaboration between user groups and developers. Lessons learned for leveraging the advantages of agile development processes include acknowledging the substantial and ongoing contributions of users and their roles as co-designers of the system.
This paper reports preliminary findings from an ongoing research project on the development of IT support for communication and information sharing across institutional and professional boundaries within the Danish healthcare system. The project focuses on the treatment of patients with implanted ICDs (implantable cardioverter-defibrillator). These are chronic patients who usually see several different healthcare providers on a regular basis. The main findings so far are: (1) Most of the data produced and recorded as part of the care process are context-specific and often difficult to interpret unless you are an expert on the subject. Sharing these types of data across institutional and professional boundaries is not feasible. (2) Yet, it appears that a small subset of data can make sense across the different contexts and be of use to others. These data are good candidates for sharing. (3) In addition, there appears to be a need for creating new types of data specifically designed to meet the coordination needs across different contexts and expert domains. (4) The dilemma is, however, that the production of these new types of data must not require too much extra work.
James T. Tufano, James D. Ralston, Peter Tarczy-Hornoch, Robert J. Reid
59 - 65
This paper describes one organization's interpretation of the Patient-Centered Medical Home concept and the healthcare delivery system that has emerged from their participatory redesign initiative. Group Health, a large integrated healthcare system based in Seattle, Washington, USA initiated a Patient-Centered Medical Home care delivery system transformation in January 2007. Current theories and evidence about the Patient-Centered Medical Home (PCMH), the Chronic Care Model, and effective primary care were interpreted via a facilitated group process and translated into a core set of 5 system design principles. These design principles guided all subsequent system transformation activities. The central organizing principle is supporting and sustaining the patient-primary care physician relationship. The emergent PCMH healthcare delivery system comprises both opportunistic point-of-care and outreach components, many of which leverage and enhance the organization's health information and communication technologies.
Since 2001, patients in Norway with long-term, complex needs for care have had a legal right to an “individual care plan”, intended to increase efficiency and quality in health and social services, as well as patient involvement. Commonly, a responsible group is established to manage the planning process. A web-based application was developed and tested for three years in groups including both patients and professionals. Data were collected through questionnaires, interviews, project documentation and field notes. The findings showed that iterative testing improved usability. Participants expressed confidence in the online access and their enhanced control of planning and documentation. Testing in real-life environments added valuable and unforeseen information. It also showed that technical and organizational aspects influenced each other, and should not be considered separately. Despite the successful testing and improvement of the application, some participants and groups did not feel comfortable using it. Further research will be undertaken to address barriers to participation.
Lone Stub Petersen, Charlotte D. Bjoernes, Pernille Bertelsen
72 - 78
A well-known challenge in system development is the aspect of user participation. In this paper we shift perspective from how to involve users in system development to how project managers with a clinical background, but without technical system knowledge, can involve system developers in IT projects. Using data from the development of an online patient book (an ICT application for clinical practice), we analyze challenges using the concept of language-games. We conclude that further research and development of participatory and communicative methods to involve system developers in IT projects, based in a clinical context, is needed.
The need for improving dementia care has driven the development of the clinical decision support system DMSS (Dementia Management and Support System). A sociotechnical approach to design and development has been applied, with an activity-centered methodology and user participation throughout the process. Prototypes have been developed based on the characteristics of clinical practice and domain knowledge, while clinical practice has been subjected to different efforts for development such as education and organizational change. This paper addresses the lessons learned and role and impact DMSS has had, and is expected to have on the clinical assessment of dementia in different clinics in Sweden, South Korea and Japan. Furthermore, it will be described in what way the development of DMSS and the development of dementia care in these three areas are interlinked. Results indicate that the most important contribution of DMSS at the point of care, is the educational support that DMSS provides, part from the tailored explanatory support related to a patient case. This effect was partly manifested in a change of routines in the encounter with patients.
Torbjørg Meum, Gro Wangensteen, Harald Igesund, Gunnar Ellingsen, Eric Monteiro
85 - 90
This paper explores how nursing classification has been adopted and used in a local clinical practice. The study is inspired by the socio-technical approach to information system and illustrates some of the enabling and constraining properties of standardization. Findings from the study show how international standards have been embedded into local practice. At the same time, the use of locally developed standards has increased and many of these are similar to the international classification. This indicates that we need to move beyond the dichotomous perspective on nurses' use of classification and strive for more flexible solutions.
Socio-technical approaches have established that ICT-supported standardization of healthcare work is difficult, if not impossible. We argue that standardization is neither straightforward nor uncontroversial, but discuss an interpretative case study where standardization of nursing work – to an interesting degree – has been achieved. Our case suggests that co-constructing of the standards is essential to standardization in practice. This is partly imposed from the top, and partly accomplished through the active involvement and ingenuity of users.
The radiology department at a Danish regional university hospital implemented integrated RIS/PACS. In the process, it became clear that some aspects of the changes had been ignored and that the impact on the organization would be substantial. With that in mind this study was planned, and an interdisciplinary working group was appointed and tasked with implementing activities to improve the organizational environment and atmosphere in the department. One activity aimed at formulating a vision/activity plan by using café seminars to involve all employees. The plan for implementation included 35 activities to support the realization of the vision. Bottom-up organizational development does work – provided that responsibility for the process is delegated.
Referrals are requests for medical examination and evaluation by a specialist, outpatient clinic or a hospital. The referral can be sent from a GP, specialist or from one hospital to another. The referral transfers fully or partly the responsibility for further treatment of the patient. The diffusion of electronic referrals in the health sector has been slow in many countries despite the fact that EHR-systems, referral standards and technical infrastructure are available. This paper addresses shortcomings that have been seen in the Norwegian deployment process, and how collaboration can support, and be supported by, the involved actors in different organizations. Special attention is paid to how GPs that work in part time positions as practice consultants in Hospitals can act as boundary spanners in order to improve the collaborating actors understanding of each other's needs and work processes. Practice consultant should also be used actively in design of ICT-systems that support collaboration across organizational boarders in health care.
Several studies stressed that the introduction of CPOE applications deteriorates the doctor-nurse communication. But there are many factors that might influence communication behaviors, as for example the way these communications are organized. The present study aims at showing that the impact of a CPOE system on the cooperative activities can be controlled given that a good understanding of the cooperative workflows support the implementation. By analyzing the doctors-nurses communications during the medication use process, the study demonstrates that the technical system has no impact on the cooperative activities within a given organization. CPOE does not induce differences in the dialogs' durations and contents.
Users gave us 104 different reasons for the failure of implementing an EPR in a surgical clinic. We classify the reasons with the issue order model, where the first issue level is for simple and technical issues, the second one for more complex and combined issues, and the third one for political or ideological issues. However, what appears as a first order issue to a manager might be seen as an insurmountable third order issue for a worker and vice versa. The issues are interrelated, and solving one issue might have a substantial influence on other issues. Also, the issues seemed to accumulate and concentrate on points. The analysis helps focus on key problems, with consideration to related issues.
Developing countries represent the fastest growing mobile markets in the world. For people with no computing access, a mobile will be their first computing device. Mobile technologies offer a significant potential to strengthen health systems in developing countries with respect to community based monitoring, reporting, feedback to service providers, and strengthening communication and coordination between different health functionaries, medical officers and the community. However, there are various challenges in realizing this potential including technological such as lack of power, social, institutional and use issues. In this paper a case study from India on mobile health implementation and use will be reported. An underlying principle guiding this paper is to see mobile technology not as a “stand alone device” but potentially an integral component of an integrated mobile supported health information infrastructure.
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