Ebook: Context Sensitive Health Informatics: Sustainability in Dynamic Ecosystems

This volume presents the papers of the International Conference on “Context Sensitive Health Informatics” held at Lille University in August 2019.

Context Sensitive Health Informatics is about health information technologies and their environments. Environments may be people in different roles such as citizens, patients, users, designers, and evaluators, but also non-human constructs such as organizations, work practices, guidelines and protocols, buildings and markets.

The conference is endorsed by and organized/supported by the International Medical Informatics Association (IMIA) working groups “Human Factors Engineering for Healthcare Informatics” and “Organizational and Social Issues”, and by the European Federation for Medical Informatics (EFMI), especially the working group “Human and Organizational Factors in Medical Informatics”.

The CSHI 2019 conference is sponsored by Lille University, Lille Academic Hospital, the Federative Research Structure for Health Technology” (SFR-TS), the research team 2694, I-site ULNE, and Inserm.

The editors want to thank the sponsors and the local organizing committee for making it possible to have the conference in Lille.

We would also like to thank Pierre-François Gautier for setting up the conference web site and Linda Peute for designing the logo of the conference. Finally, we want to thank the Scientific Program Committee for their efforts to establish the content of the conference and all the reviewers for providing constructive feedback to the authors. Their excellent work has significantly improved the quality of many papers.

Romaric Marcilly

Christian Nøhr

Craig Kuziemsky

Sylvia Pelayo

May 2019

The digital transformation of health care delivery remains an elusive work in progress. Contextual variation continues to be a significant barrier to the development of sustainable health information systems. In this paper we characterize health informaticians as modern alchemists and use this characterization to describe informatics progress in addressing four key healthcare challenges. We highlight the need for informaticians to be diligent and loyal to basic methodological principles while also appreciating the role that contextual variation plays in informatics research. We also emphasize that meaningful health systems transformation takes time. The insight presented in this paper helps informaticians in our quest to develop sustainable health information systems.

In this paper we elaborate a preliminary framework to fill this gap and describe the potential contributions of HFE to improve digital health interventions, at the macro, meso and micro level of a health system. Researchers present a practical approach, integrated with some limited reflections on methodological aspects, recently covered in a position paper [8], while previously in conference series and handbooks. This paper presents a HFES perspective on digital health – from the macro, meso and micro level to improve patient safety and delivery of quality care. Experts in HFE can play a key role in creating evidence for an ethical and effective design of digital health intervention and providing support to their implementation and evaluation at the macro, meso and micro level. This framework may help to integrate HFE at the different levels of the system and following the tracks of organization, technology and human factors.

Developing structures and processes for continuous sociotechnical system design is key to sustaining human factors (HF) knowledge in the context of rapid health care changes and technological innovations. Two research studies illustrate how to embed HF in organizational learning processes and structures. We need to develop innovative HF methods for continuous sociotechnical system design.

To improve patient safety, hospital organisations are encouraged to run their operations in line with high reliability organisations’ collective mindfulness principles and practices. For the same safety goals, they also implement health information technology (IT). However, little is known about whether, or how, health IT can impact organisational mindfulness, and thereby safety. We propose that research in this area can be approached through a simple framework of overarching, umbrella questions, then carefully translated into nuanced context-specific questions and study designs. The framework and approach we propose provides a structure for comparing results from studies of collective mindfulness and health IT, across different clinical contexts and IT applications.

This paper presents preliminary results from a larger project led with the French company Auxivia. The latter offers a smart drinking glass (SDG), supporting monitoring daily water intakes of elderly people and helping identify residents to encourage. Contexts and work organizations can deeply differ from a nursing home to another and can impact the use of the SDG. Based on a comparison between two nursing homes, we unveil the impact of both work organizations on the integration of technology requirements. We discuss the results by providing recommendations to improve the integration of SDGs in various work organizations.

The responsibilities for delivery of care in Sweden is divided between the regions and the municipalities. The regions run the hospitals and the primary care centres (PCCs) whereas the municipalities are responsible for homecare nursing and nursing homes. The homecare nurses and the doctors they need to seek advice from, thus belong to different organizations/contexts. As more patients with multi- and long-term illnesses are taken care of in their homes the workload of the homecare nurses has increased. A new healthcare agreement has thus been signed between a region in South Sweden and its municipalities. The healthcare agreement states that doctors from the PCCs are to form mobile teams together with the homecare nurses. This paper reports from a pre-study investigating how the agreement, in terms of translation sociology, is interpreted in four of the municipalities. The aim of the research project as a whole is to develop digital support systems for the mobile teams.

Community Health Workers (CHW) perform important healthcare and health promotion in many low and middle income countries. They are increasingly supported in their work by the use of mHealth. This study aims to explore how mHealth services can support the everyday work for CHWs when delivering home care in rural areas in South Africa. A single case study was performed, mapping CHWs workflow and investigating where and when CHW can be supported by mHealth services. Despite the very positive feedback from the CHWs and the fact that the studied mHealth solutions appears to support the majority of the important activities in the CHWs work process, the application is no longer in use. Financial and strategic decisions are behind the discontinuation of the project, further stressing the importance of taking all socio-technical dimensions into account when evaluating success or failure of implementation projects.

With an ageing population and limited resources in healthcare, many high-income countries such as Sweden see an increase in homecare and mobile work for healthcare professionals. In this case study, we explore how mHealth services can support the everyday work for healthcare professionals when delivering home care in rural areas in Sweden. The studied mHealth application had failed to be adopted among district nurses, despite a great expressed need for mobile tools. The results indicate that the mHealth solution did not live up the healthcare professionals’ expectations in terms of providing the same functions as the regular electronic health record systems, and with poor integration into the existing eco-system of eHealth applications. In conclusion, in order for a mHealth application to be successfully implemented in a context where many digital services are already in use, it is not enough to support important activities in the current workflow. The mHealth application will need to be carefully integrated into the existing eco-system of healthcare applications to increase the chances of adoption.

Policy makers and health system managers in many countries are advocating the deployment of inter-operable health information technology systems, spanning organisations in a health economy, believing that they will be clinically effective. The case for investments has not, however, been made to date. This paper presents early results from a systematic review of the effects of inter-operable systems on patient safety. The review uses the realist synthesis method, which focuses on evidence about the decisions and actions that link interventions and outcomes, as well as the evidence about those outcomes. The evidence base is sufficient to identify plausible arguments for investments in inter-operable systems. This said, there is limited empirical evidence about each of the steps in the sequences of events. We comment on implications for the design of sustainable socio-technical solutions. We suggest that current gaps in the evidence base are in areas where informatics field methods can make a valuable contribution to our understanding of the role of inter-operable systems in patient safety.

Many Electronic Health Record (EHRs) data displays are insensitive to their settings, contexts, and to clinicians’ needs. Yet, the contexts in which the data are displayed critically affect EHR usability and patient safety. Medication prescribing is a complex task; especially sensitive to contextual variation in EHR displays as vast variations in formats and logic are often unnecessarily confusing, leading to unwanted cognitive burdens and medical errors. With examples of EHR screenshots, we illustrate contextual variations in medication and allergy displays across different EHR systems and implementations—noting often seemingly haphazard differences that can lead to misunderstandings and misinterpretations.

There has been an acknowledged need for the integration of health technologies such as the electronic health record system (EHR) into health professional education. At the University of Victoria we have been experimenting with different models, architectures and applications of educational EHRs in the context of training health informatics, medical, and nursing students who will ultimately use this technology in their daily practice upon graduation. Our initial work involved the development of a Web-based portal that contained a number of open source EHRs and is described in this paper. In addition to the technical side, considerations around pedagogy and how best to integrate such technology into the classroom and educational experience are discussed. Finally, challenges and lessons learned from our decade of work in this area are discussed.

The usability of healthcare information technology has become a major issue in health informatics. There have been many reports of systems that have been deemed unusable by end users such as clinicians and a growing body of usability studies have been reported in the literature. The issue of how to fruitfully analyze and code usability study data in a meaningful way that can lead to optimized and more efficient systems has remained to be fully detailed. In this paper we describe our work in developing and organizing a principled video coding scheme that builds from our previous work in a couple of areas. We include video coding categories we have developed for understanding problems and issues with human-computer interaction. In addition, we integrate this coding scheme with categories we have used to characterize human cognition, such as clinical reasoning and decision making, in isolation of technology use. The resultant new scheme thus incorporates coding categories that can used to evaluate both usability issues (applying categories from human-computer interaction) and human cognition, in order to assess the impact of technology on clinical reasoning and decision making.

We report from the initial steps of a collaboration project between two post-doctoral projects, both using a qualitative action research approach to address challenges related to shifting from a free text to a structured EPR system constituting important preconditions for establishing advanced decision support and reuse of healthcare data. We have started to explore three areas that may influence this process related to: 1) Legislative challenges of getting access to all relevant healthcare data. 2) Challenges of exchanging data between silo systems and open platform systems. 3) Replacing a free text silo EPR with an open platform system – and the practical challenges of defining the content of the context sensitive structured EPR. Hence, we ask the following research questions: How to address challenges related to the shift from free text to structured EPR systems? How will the need for semantic interoperability between different EPRs influence the goal of advanced clinical decision support? Empirically, we draw on the regional FRESK program (2017–2022), in the North Norwegian Health Region, which includes implementing both a new regional open platform based EPR system, and a proprietary medical chart system.

As hospitals transition from paper to electronic medication charts, an opportunity exists to ‘nudge’ prescribers to document medication indications by making this data-entry field mandatory. The aim of this study was to explore hospital doctors’ perceptions of mandatory documentation of indications in an electronic medication management (EMM) system. Ten junior doctors took part in brief semi-structured interviews. Participants identified improved communication among staff as a key benefit of indication documentation. Recording indications was also seen to act as a prompt for medication review. Despite these benefits, indication documentation for all medications would be challenging to implement in practice. Users of the EMM system (i.e. junior doctors) explained that they are time poor and are often tasked with transcribing medication orders into the electronic system with limited knowledge of why medications are being prescribed. Determining the indication for use would require additional time and effort, and prescribers reported a high risk of working around the system if indication documentation was made mandatory.

Medication errors are preventable adverse events or unsafe conditions caused by inappropriate uses of medication. To collect data of patient safety events (PSE) and to analyze the root causes of PSE, reporting systems have been implemented in healthcare settings and patient safety organizations (PSO). However, the poor data quality of reports impedes the reporting and root cause analysis (RCA) of PSE. Incomplete or missing data is the most prevalent problem in event reports. To assess the data quality of PSE reports, we used an adapted taxonomy as the data evaluation model to evaluate the quality of narrative reports collected by a PSO. Sample reports were extracted based on eight error types and scored by experts. Most structured fields in the reports were ignored by reporters. In contrast, the narrative parts of the reports contain rich and valuable information. The evaluation results show that the adapted taxonomy is a promising tool for report quality assessment and improvement.

Medication errors are associated with adverse health outcomes and may prolong hospital stays and increase societal costs. Safety initiatives to reduce adverse health outcomes should be based on reliable information of current shortcomings. The aim of this study was to identify barriers to medication error reporting in a hospital and to describe heath personnel’s views of the safety culture. Seven interviews with health personnel (two doctors, four nurses and one pharmacist) were conducted November 2016–January 2017 at the University Hospital of North Norway. Nurses, more frequently than doctors, reported medication errors and discussed reported errors at staff meetings. Doctors preferred to solve the problem directly, for example writing a new medication order, rather than writing a report when a medication error had been identified. There was variation between the wards regarding the perception of support, confidence in and focus on error reporting, which indicates different safety cultures within the hospital. Identified barriers to medication error reporting included lack of time, and the impression that the reporting system is complicated and not user-friendly. Staff also reported inadequate training using the system, which could contribute to the perception that the system is inaccessible. Hospital management should take actions to improve the safety culture throughout the hospital based on the barriers identified in this study. This could include stronger focus on the importance of reporting medication errors, a transparent review process and clearly communicated actions.

This study aimed to develop a classification scheme for retrieving information from incident reports of medication errors. This 15-category classification scheme captures minimal medication-incident related information from incident reports and thus serves as an information model for automatic information retrieval solution. The automatic solution uses recent advances in artificial intelligence methods to learn from incident report resources and is promising to the prevention of adverse drug events and promotion of safety in medical care.

Health care is in dramatic transformation due to the rapid development and massive implementation of (high- and low-tech) technologies. But not all transformations are as intended. Research in health transformation has disclosed new sources of risk and unpredictability, which require more research and organizational adjustment, i.e. learning. However, unintended consequences and effects occur at different levels of interaction and collaboration, requiring corresponding adjustment and learning strategies. – On the background of an ethnographic study of support-work in surgery in different Danish hospitals, this paper analyses cognitive-socio-technical health care practices as learning ecologies, giving special attention to the intentional and unintentional roles of technologies herein and their context dependency. The paper argues for an increased awareness of support at different contextual levels of use, presenting three examples from the study as learning cases. The three cases exemplify instances of disruption of the workflow and the collaboration among clinicians. They display how these instances are taken as challenges requiring learning at different levels in order to live up to the overall purpose, which is to reestablish safety – in the team and for the patient.

Patient-centred care and the empowerment of patients through shared clinical decision-making is a key goal of healthcare systems internationally. The Emergency Department is one of the first opportunities for shared decision-making to occur, with information exchanged between patient and clinician, between clinical disciplines, across the continuum of care, and between clinicians and ancillary departments including radiology and pathology laboratories. The successful development and implementation of sustainable health information technology (HIT) to support shared decision-making in Emergency care requires an understanding of the factors affecting this context. From a purposive, maximum variation sample of clinicians and a convenience sample of patients across three metropolitan and regional Emergency Departments in Australia, we identified three divergent discourses from an in-depth qualitative exploration of issues around shared decision-making. This allowed us to identify unanticipated factors affecting patient-centred care to inform context-sensitive implementation of HIT in the Emergency Department.