Ebook: Investing in E-Health: People, Knowledge and Technology for a Healthy Future

Around the world the healthcare industry is embracing information technology (IT). Historically the use of IT was administrative, financial, or statistical. Now it is transforming the way healthcare does business from the bedside, into primary care and patient and carer information management. As a part of this exciting change the Health Informatics Society of Australia, with the active support and involvement of the Australasian College of Health Informatics, is excited and proud to be active contributors to extending knowledge and understanding of these changes and the opportunities associated with them. The Australian National Health Informatics Conference (HIC) series of meetings is the largest national event of this type in Australia, with a dedicated scientific stream on health informatics. HIC provides a valued platform for academic and research contributions and interchange as well as industry updates and innovations.

The HIC 2014 theme of ‘Investing in e-health: People, knowledge and technology for a healthy future’ emphasises the journey being made in healthcare. As healthcare organisations and government projects look to information technology to capitalise and enhance healthcare the need for investment is clear, but where to invest, how to define success and understand opportunities and risks in this time of change are key issues. These investments extend past the technology required to provide infrastructure for the future. Investment is also required to enable the building of people, skills, careers, and professions to support and develop this infrastructure in a cost effective and clinically safe manner and lead change management. This e-health enabled healthcare environment offers faster and more wide reaching knowledge acquisition and best practice improvement, as well as improved healthcare.

Decisions made about investment in e-health need to consider what the successful outcomes would look like, rather than just considering a single project in isolation. Success can be seen as delivering

1. future focused infrastructure, scalable and adaptable to changing needs

2. capacity and capability building amongst our healthcare workforce, to enable them to meet the challenges of this information centric world and certainly doing no harm (preferably making care, or the care system better). It is also vital that systems enable secondary use of clinical data for biomedical research, public health and health policy. This necessitates a more active role from individuals in maintaining their health, facilitated by innovative technologies.

Questions arise such as: What investments will give the best short and long term outcomes, what activities could be undertaken, what works and what does not are all considered by papers in this volume. Papers represent experiences in Australia and New Zealand and further afield. As always, it is the strength of HIC that a wide diversity of work is presented and that a set of papers has been collected here that ranges from deeply theoretical to intensely practical. The careful reader will be rewarded with exposure to much diversity, and many elements of contemporary health informatics research endeavours.

The double blind peer review process established for HIC 2011 in a previous volume has been continued and augmented. All papers were reviewed by 3 experts in the field of health informatics, selected as prominent academics and industry specialists. The assistance of the Australasian College of Health Informatics in supporting this process through the voluntary efforts of a number of their Fellows is gratefully acknowledged, as is the similar contribution made by many senior members of the Health Informatics Society of Australia. This phase of reviewing resulted in the provisional acceptance of 28 from a much expanded submission field of 42. The Scientific Program Committee then undertook a validation process for all such papers that were resubmitted in amended form, to ensure that reviewers' recommendations were appropriately addressed or rebutted.

Heather Grain

Fernando Martin-Sanchez

Louise K. Schaper

Most studies evaluating the effect of computerised alerts embedded in electronic medication management systems (eMMS) on prescribing behavior demonstrate positive and often substantial effects. But many studies also report that doctors override computerised alerts, sometimes up to 95% of the time. Alert fatigue, due to excessive numbers of alerts being presented, is the primary reason for alerts being overridden. This paper summarises and sythesises a program of research undertaken to determine whether doctors working in a teaching hospital in Sydney, Australia, were experiencing alert fatigue, and to identify and implement strategies for alleviating alert fatigue. We synthesise several published studies adopting a variety of data collection methods (observation of prescribers as they interact with the eMMS, interviews with users, review of alerts generated in eMMS, and a Delphi technique) to present four key lessons learnt. These are: 1) the fewer alerts the better; 2) context of use matters; 3) people use systems in unexpected ways; and 4) user feedback is invaluable.

With the ageing of our society and the increasing pressure on health and aged care services, the need for technological solutions to help older people stay in their own home for as long as possible is becoming increasingly important. To create information and communications technology (ICT) that will fit with the way older people live their lives and wish to use technology, necessitates their involvement in the design and development process. This paper will highlight some of the issues when designing for and with older people, and highlights the need for more research on how to involve older persons as stakeholders when designing technology for their use, as well as the need for easily accessible guidelines for how to do this.

The quality of data in public health information systems can be ensured by effective data quality assessment. In order to conduct effective data quality assessment, measurable data attributes have to be precisely defined. Then reliable and valid measurement methods for data attributes have to be used to measure each attribute. We conducted a systematic review of data quality assessment methods for public health using major databases and well-known institutional websites. 35 studies were eligible for inclusion in the study. A total of 49 attributes of data quality were identified from the literature. Completeness, accuracy and timeliness were the three most frequently assessed attributes of data quality. Most studies directly examined data values. This is complemented by exploring either data users' perception or documentation quality. However, there are limitations of current data quality assessment methods: a lack of consensus on attributes measured; inconsistent definition of the data quality attributes; a lack of mixed methods for assessing data quality; and inadequate attention to reliability and validity. Removal of these limitations is an opportunity for further improvement.

This paper presents research undertaken as part of a larger research project to examine the factors that influence midwives when entering perinatal data. A grounded theory methodology was used to undertake qualitative interviews with 15 participants from 12 different hospitals across Queensland, Australia using three different systems for perinatal data collection. The findings surrounding accountability are presented revealing that a shift in governance relating to responsibility and accountability is not occurring in midwifery units across Queensland. Without assignation of responsibility for entries and accountability for mistakes or omissions, perinatal data records can be left incomplete or inaccurate. Increasing use of electronic health records and creation of digital hospitals indicates these issues are highly relevant in planning for these services.

This article focuses on a framework that will investigate the integration of two disparate methodologies: patient journey modelling and visual multi-agent simulation, and its impact on the speed and quality of knowledge translation to healthcare stakeholders. Literature describes patient journey modelling and visual simulation as discrete activities. This paper suggests that their combination and their impact on translating knowledge to practitioners are greater than the sum of the two technologies. The test-bed is ambulatory care and the goal is to determine if this approach can improve health services delivery, workflow, and patient outcomes and satisfaction. The multidisciplinary research team is comprised of expertise in patient journey modelling, simulation, and knowledge translation.

The attempts to train nurses to effectively use information systems have had mixed results. One problem is that training materials are not adequately designed to guide trainees to gradually learn to use a system without experiencing a heavy cognitive load. This is because training design often does not take into consideration a learner's cognitive ability to absorb new information in a short training period. Given the high cost and difficulty of organising training in healthcare organisations, there is an urgent need for information system trainers to be aware of how cognitive overload or information overload affect a trainee's capability to acquire new knowledge and skills, and what instructional techniques can be used to facilitate effective learning.

This paper introduces the concept of cognitive load and how it affects nurses when learning to use a new health information system. This is followed by the relevant strategies for instructional design, underpinned by the principles of cognitive load theory, which may be helpful for the development of effective instructional materials and activities for training nurses to use information systems.

This study conducts a systematic literature review on the application of the three-dimensional virtual worlds (3DVW) in healthcare context. During the past decade, 3DVWs have emerged as a cutting edge technology that has much to offer to the healthcare sector. Our systematic review began with an initial set of 1088 studies published from 1990 to 2013 which have used 3DVWs for the healthcare specific purposes. We found a variety of areas of application for the 3DVWs in healthcare, and categorised them into the following categories: education, treatment, evaluation, lifestyle and simulation. The presented big picture of application areas of 3DVWs in this study can be very valuable and insightful for the researchers and healthcare community.

There has been limited uptake of electronic health records (EHR) by allied health professionals. Yet, not much attention has been given to their information needs. For EHR to work for these health professionals, it is essential to understand their current practice of information management and their perceptions towards EHR. A qualitative interview study was thus conducted with four managers in four allied health practices in Sydney to understand their perceptions for the adoption and use of a new Australian e-health standards compliant EHR system. We found that these allied health professionals were highly confident with the use of electronic information system and were enthusiastically expecting the introduction of the EHR system to support their information management and practice. A number of issues related to the use of EHR in practice for small, independent allied health practices were also discussed. It appears that allied health professionals today are information technology (IT) savvy and ready to adopt EHR. EHR for allied health practices in Australia are long overdue. The health informatics community can no longer ignore the need and want of allied health professionals for EHR that are tailored and built to support their information and practice management.

Introduced with a promise to reduce overcrowding in the Emergency Department (ED) and the associated morbidity and mortality linked to bed access difficulties, the National Emergency Access Target (NEAT) is now over halfway through transitionary arrangements towards a target of 90% of patients that visit a hospital ED being admitted or discharged within 4 hours. Facilitation and reward funding has ensured hospitals around the country are remodelling workflows to ensure compliance. Recent reports however show that the majority of hospitals are still far from being able to meet this target. We investigate the NEAT journey of 30 Queensland hospitals over the past two years and compare this performance to a previous study that investigated the 4 hour ED discharge performance of these hospitals at various times of day and under varying occupancy conditions. Our findings reveal that, while most hospitals have made significant improvements to their 4 hour discharge performance in 2013, the underlying flow patterns and periods of poor NEAT compliance remain largely unchanged. The work identifies areas for targeted improvement to inform system redesign and workflow planning.

Background: There are many factors affecting health professionals' willingness to engage in e-health. One of these factors is whether health professionals perceive themselves to be able to learn new skills, and have the confidence in mastering these new Information and Communication Technology (ICT) skills. Objective: This study examined how health students' confidence and perceived ability for learning new ICT skills affect their attitude towards engaging in e-health. Methods: A survey was conducted to explore students' attitude towards using e-health and their perceived self-efficacy and confidence to learn new ICT skills. Multiple regression analysis was used to examine the relationship between confidence and self-efficacy, and attitude towards engaging in e-health controlling for participants' age, gender, and prior IT learning experience. Results: The three scales measuring attitude, confidence and self-efficacy showed good internal consistency with respective Cronbach's Alpha scores of 0.835, 0.761 and 0.762. Multiple regression analysis showed a significant relationship between confidence, self-efficacy and prior IT learning experiences with attitude towards e-health after adjusting for the effect of each other (F_3,350=17.20,p<0.001). Conclusion: Self-efficacy and confidence in learning new ICT skills together with previous ICT training either at or outside their university studies are significant factors associated with students' attitude towards using e-health. Enhancing students' level of self-efficacy in learning new ICT skills may be the key to the success of implementation of e-health initiatives.

Much clinical information is computerised and doctors' use of mobile devices such as iPad tablets to access this information is expanding rapidly. This study investigated the use of iPads during ward rounds and their usefulness in providing access to information during ward rounds. Ten teams of doctors at a large teaching hospital were given iPads for ten weeks and were observed on ward rounds for 77.3 hours as they interacted with 525 patients. Use of iPads and other information technology devices to access clinical information was recorded. The majority of clinical information was accessed using iPads (56.2%), followed by computers-on-wheels (35.8%), stationary PCs (7.9%) and smartphones (0.1%). Despite having read-only access on iPads, doctors were generally happy using iPads on ward rounds. These findings provide evidence of the value of iPads as a tool to access information at the point of care.

Electronic ordering systems have the potential to enhance the efficient utilisation of pathology services. The aim of this study was to assess the effect of electronic pathology ordering on repeat test ordering for paediatric patients (ages 0 to 18 years) who were in intensive care units (ICUs) and non-ICU wards. The dataset described 85,728 pathology tests ordered for 5,073 children before and after the implementation of electronic ordering. This study showed that, for children in ICUs, the repeat test order rate was significantly lower for electronic orders than for paper-based orders. Similarly, the rate of repeat tests ordered within short intervals (up to 23-hours), for children older than one-year in non-ICU wards, was lower for electronic ordering than for paper ordering. The proportion of repeat tests occurring within one-hour of the previous test was consistently lower for tests ordered using electronic ordering than it was for tests ordered using the paper based system for patients older than one-year in all wards and for patients under one-year in ICUs. These results suggest that features of the electronic system, including alerts about previously ordered tests and the availability of information about previous orders, can help clinicians to identify and reduce unnecessary repeat tests.

Online social networking (OSN) provides a new way for health professionals to communicate, collaborate and share ideas with each other for informal learning on a massive scale. It has important implications for ongoing efforts to support Continuing Professional Development (CPD) in the health professions. However, the challenge of analysing the data generated in OSNs makes it difficult to understand whether and how they are useful for CPD. This paper presents a conceptual model for using mixed methods to study data from OSNs to examine the efficacy of OSN in supporting informal learning of health professionals. It is expected that using this model with the dataset generated in OSNs for informal learning will produce new and important insights into how well this innovation in CPD is serving professionals and the healthcare system.

General practices in Australia recognise the importance of comprehensive protective security measures. Some elements of information security governance are incorporated into recommended standards, however the governance component of information security is still insufficiently addressed in practice. The International Organistion for Standardisation (ISO) released a new global standard in May 2013 entitled, ISO/IEC 27014:2013 Information technology – Security techniques – Governance of information security. This standard, applicable to organisations of all sizes, offers a framework against which to assess and implement the governance components of information security. The standard demonstrates the relationship between governance and the management of information security, provides strategic principles and processes, and forms the basis for establishing a positive information security culture. An analysis interpretation of this standard for use in Australian general practice was performed. This work is unique as such interpretation for the Australian healthcare environment has not been undertaken before. It demonstrates an application of the standard at a strategic level to inform existing development of an information security governance framework.

Work on building a strong research base, a skilled workforce and an accredited learning and development system in Australian Health Informatics is not mature. This paper aims to explore how such work is supported at a fundamental level, that is, within formal systems for identifying fields of research, occupation and education in Australia. The researchers examined the treatment of Health Informatics and related terms in a range of relevant Australian standards. We found that Health Informatics has somewhat inappropriate recognition in the formal systems defining research in Australia, a tenuous presence in those describing education, and none in those describing occupations. We argue that our findings provide the evidence base for decisive action to benefit not only individuals but also the wider Australian community.

Digital technology provides opportunities for using mobile learning strategies in healthcare environments. To realise the vision of the National Workforce Development Strategy there needs to be innovation of health professionals to further develop knowledge and skills of clinical supervisors to access and gain an understanding of the value of mobile learning at the workplace. The use of digital technology by clinical supervisors was explored in 2012 as part of a teaching development grant to evaluate the use of Web 2.0 technology to develop a community of practice about clinical supervision. Prior to developing the virtual network of clinical supervisors, feedback about the use of Web 2.0 technology by clinicians was sought via an online survey. Over 90% of respondents used social media, 85% understood what a blog and wiki were and approximately half of the respondents used smart phones. More than one-third indicated they would participate in a virtual community of practice and would like to receive information about clinical facilitation at least once per week. Findings indicate both inhibitors and opportunities for workforce development within healthcare environments that need to be addressed. Support of graduate-ready nurses can be achieved through an integrated outlook that enables health professionals within organisations to undertake mobile learning in situ. A flexible and collaborative approach to continuing professional development within organisations could enhance practice development and could positively impact on workforce development.

Workplaces are being transformed by technological change. There is great potential for innovation at educational institutions and in the workplace. Creative and effective use of information communication technology in learning and teaching and for continuing professional development of health professionals is imperative. To determine the usability of a virtual community of practice for clinical supervisors, an online survey was administered prior to attendance at professional development workshops. Clinical supervisors were targeted because they were senior nurse leaders and could promote and model the use of the virtual network within their organisations. Survey findings indicated that a community of practice would be useful for communication about clinical supervision and obtaining information from the University. However, respondents were less certain they would share information by actively contributing to the public mobile learning resources. This study indicates there is considerable potential to build capacity of healthcare professionals through workforce development. Support for clinical supervisors to understand and use mobile learning strategies for continuing professional development and promote life-long learning can assist with realising the vision of the National Workforce Development Strategy.

Chronic pain is a burden on an individual, social and economic level. Growing published research outlines various innovative online solutions aimed at addressing this issue, including interactive patient websites. This paper presents expert insights regarding an existing interactive chronic pain website, ‘ONESELF’, operating in Switzerland. Based on their experience, members of the research team involved in the ‘ONESELF’ project were asked to reflect about what they understood to be key considerations salient to designing and implementing such interventions. Thematic analysis uncovered five main themes that these experts used to interpret what worked, when and why in ‘ONESELF’ design and implementation: health literacy, Internet literacy, access to healthcare, adherence and attrition, and health outcomes. These findings may serves as a base to assist Australian health researchers and practitioners working toward developing effective interactive patient websites for people with chronic pain.

When modelling and simulating healthcare related processes, free-text data is often the only possible source of information. This data may contain vocabulary variations such as mistyped, misspelled and/or abbreviated words. This paper describes a semi-automated approach to free-text normalisation based on a combination of commonly used techniques and local expertise of medical oncology nurses. The approach emphasises the effectiveness of the vocabulary creation process through an interactive software application. When local knowledge is successfully captured, normalisation of large data sets can be done very rapidly with a high accuracy rate achieved. Furthermore, the techniques for localised normalisation can have significant benefits to free-text parsing accuracy when data is aggregated from multiple sites (hospitals). This research may lead to increased understanding of issues associated with chemotherapy related free-text data which in turn may impact patient treatment safety.

Disease surveillance systems can be extremely valuable tools and a critical step in system implementation is data collection. In order to obtain quality data efficiently and align the public health business process, Epidemiologic Dynamic Data Collection platform (EDDC) was developed and applied in China. We describe the design of EDDC and assess the platform from six dimensions (service, system, information, use, users and benefit) under the DeLone and McLean Information System Success Model. Objective indicators were extracted from each dimension with the aim of describing the system in detail. The characteristics of functions, performances, usages and benefits of EDDC were reflected under the analysis framework. The limitations and future directions of EDDC are offered for wide use in public health data collection.

Residential aged care homes have, or are in the process of implementing, electronic health record (EHR) systems to improve quality of care and reduce cost. For the system to deliver benefits, it must support nursing tasks and be seamlessly integrated into the nursing workflow. To identify whether and how an EHR system can do this most effectively, direct observation was conducted in a residential aged care home on nurses' use of EHR for wound care. The work processes of wound care and its documentation were investigated. Problems in the use of EHR were identified: 1) functional deficiencies of the EHR system which included a lack of functions to remind nurses of the existence of a wound chart, unavailability of an existent function when needed and a lack of sufficient detail in the information provided; 2) a lack of mobile devices to allow nurses to access the EHR system at the point-of-care, resulting in nurses using paper for point-of-care documentation. The findings suggest that continuous improvement in both the EHR system and its management is required to achieve integration of people, task, process and technology for the optimal benefits of EHR.

Healthcare systems are increasingly adapting to address the issues associated with population ageing. The shift to chronic diseases and a rise in neuroepidemiological conditions, associated with rising life expectancies, means that continued change and accommodation will be required of our health and social support systems. Current social policy environments developed out of early approaches to state-supported health and welfare service provision, most now a century or more old. A feature of these systems has often been a formal separation between them, into silos, that does not and cannot effectively address the issues raised by a growing population of older people. This is especially true in the context of community-based care where the majority of older people currently live and where governments hope to keep more elderly people living into the future. This objective will require a far more sophisticated and responsive approach to the health information environment than is currently the case. One strategy for improving this scenario is the development of augmented and virtual environments that collect and analyse real-time data on which health professionals and support staff can act in a timely manner. In this paper we explore some aspects of a virtualised aged care system and provide some examples of how this would enhance our current strategies for aged care.

Digital activity trackers are becoming increasingly more widespread and affordable, providing new opportunities to support participatory e-health programs in which participants take an active role. However, there is limited knowledge of how to deploy these activity trackers within these programs. In response, we conducted a 7-month study with 212 employees using a wireless activity tracker to log step count. Our results suggest that these devices can support improving physical activity levels and consequently reduce diabetes risk factors. Furthermore, the intervention seems more effective for people with higher risk factors. With our work we aim to contribute to a better understanding of the issues and challenges involved in the design of participatory e-health programs that include activity trackers.

Introduction: The benefits of CPOE are many and have been recognised in the literature as important components for improving patient safety and clinician performance. However, there remain concerns about adverse effects CPOE systems may have on the medication order process and workflow processes. This study explores the perception of nurses regarding the CPOE support on nurse physician communication in the medication order process. Methods: A survey was developed measuring perceptions of CPOE features on workflow and nurse physician communication on a Likert scale. Results: The majority of nurses felt that CPOE features supported the medication order process and perceived proper nurse physician communication. Conclusions: CPOE characteristics supported medication order processes and nurse physician communication although nurses reported additional work was required for follow up of physicians. Additional studies utilising in depth methods are recommended to fully understand medication order processes with further CPOE implementation.