Ebook: Improving Usability, Safety and Patient Outcomes with Health Information Technology

Health information technologies (IT) are revolutionizing and streamlining healthcare and their uptake is rising dramatically. The variety and range of technologies and software applications is considerable and there is increasing demand for implementation of health IT in hospitals, clinics, homes and in the virtual space of mHealth, pervasive healthcare and social media. However, to effectively implement these technologies scientific research and industrial and governmental supports must be strongly in place in order to transform health care and build capacity at the regional, national and global levels.

The conference will take a multi-perspective view about what is needed in order to move technology along to real sustained and widespread use in moving research findings and approaches into practice. Solutions range from improvements in usability and training, to need for new and improved design of information systems, user interfaces and interoperable solutions, to governmental policy, mandates, initiatives and need for regulation. In addition, greater interaction will be needed among industrial, governmental and academic partners.

We believe that the knowledge and insights gained from the ITCH 2019 conference will stimulate fruitful discussions and collaborations among the participants in ways that can bridge research and practice to improve the usability, safety and patient outcomes through innovative and responsible application of health IT solutions.

Francis Lau PhD, Professor

School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada

Opioid-related harm is a major public health concern in Canada and abroad. There is a growing market of mobile apps that focus on preventing and managing opioid-related harm. The use of mobile health technologies is a promising intervention that can assist with addressing the problem. The aim of this paper is to examine the current state of the mobile app market with respect to prevention and management of opioid-related harm. This will involve a review currently available opioid apps for the major operating systems (iOS, Android, Windows CE and BlackBerry OS) and examine the number of released apps, service providers, operating systems, target user groups, purpose of app, range of features, location, use of evidence, interface, languages, cost and licensing model, and user ratings.

Long wait times for elective services are seen as one of the major challenges for Canadian healthcare. Canadians report that they wait longer for specialists than citizens in other countries. The main reason for this is that the referral process is poorly coordinated and leads to delays in care. Electronic referral (eReferral) is seen as a potential means of improving the referral process and enabling faster access to care. There is the potential for national implementation of eReferral in Canada to help achieve this aim. However, existing initiatives have encountered challenges with user adoption and users have continued to use fax. A validated tool was used to survey both users of fax as well as users of eReferral. These two groups of users were then compared. Most family physicians using fax were satisfied overall with the process. This highlighted how challenging any change of this engrained technology will be. There were, however, some significant areas were eReferral was superior to fax. This included response time, the overall quality of referral information, completeness of the information, the timeliness of the information, and the format and layout. There is an opportunity to leverage these findings to support the adoption of eReferral and help reduce wait times.

With the emerging use of speech technology in consumer goods, we experimented with the application of conversational agents for the communication of health information relating to HPV vaccine. Research have stated that one-to-one contact between providers and patients have a variety of positive influences on patients' perception towards vaccines, even leading to uptake, compared to paper-based methods. We implemented a Wizard of Oz experiment that counsels adults with children (n=18) on the HPV vaccine, using an iPad tablet and dialogue script developed by public health collaborators, and for early testing of a prospective conversational agent in this area. Our early results show that non-vaccine hesitant parents believed that agent was easy to use and had capabilities needed, despite the desire for additional features. Our future work will involve developing a dialogue engine to provide automated dialogue interaction and future improvements and experimentation for the speech interface.

Early implementation of electronic health records and patient portals had great promise of addressing the widening disparities in health. However, recent research has found that not only are these disparities persisting, but the differences in health outcomes between populations are increasing. Addressing this gap specific to ehealth calls for attention to health equity. Health equity approaches reveal the systematic and societal structures that contribute to preventable and unjust outcomes for different populations. To conceptualize and apply a health equity approach within ehealth, we propose the eHealth Equity Framework (eHEF). Derived from the World Health Organization's conceptual framework for actions on the social determinants of health, eHEF can be useful for public health practitioners, researchers, policymakers and information technology designers to keep health equity agenda at the forefront of all stages of health information technology lifecycle.

The increased demand of clinical data for the conduct of clinical and translational research incentivized repurposing of the University of Arkansas for Medical Sciences' enterprise data warehouse (EDW) to meet researchers' data needs. The EDW was renamed the Arkansas Clinical Data Repository (AR-CDR), underwent content enhancements, and deployed a self-service cohort estimation tool in late of 2016. In an effort to increase adoption of the AR-CDR, a team of physician informaticist and information technology professionals conducted various informational sessions across the UAMS campus to increase awareness of the AR-CDR and the informatics capabilities. The restructuring of the data warehouse resulted in four-fold utilization increase of the AR-CDR data services in 2017. To assess acceptance rates of the AR-CDR and quantify outcomes of services provided, Everett Rogers' diffusion of innovation (DOI) framework was applied, and a survey was distributed. Results show the factors that had impact on increased adoption were: presence of physician informaticist to mediate interactions between researchers and analysts, data quality, communication with and engagement of researchers, and the AR-CDR's team responsiveness and customer service mindset.

Patient portals are becoming increasingly available at medical institutions, worldwide. Reporting of patient portal adoption strategies is scarce. A multi-institutional health network in Toronto, Canada is seeing great success with its portal adoption by patients, with an annual adoption rate of almost 65%. In the literature, annually adoption rates in Canada range between 5% and 10%. This significant difference and high adoption is attributed to a multifactorial approach that includes a dedicated operations team to engage with patients and staff, a co-design approach for portal development and more recently, new data-driven strategies to affirm and recommend promotion approaches. Advanced data mining and analytics are promising tools to help improve the adoption rate. This paper will describe five analytics tools used to describe and potentially improve patient portal adoption rates.

Oncology, telehealth nursing practice is growing. There has been an increased use of telehealth systems to support patients living with cancer in the community. In this study we explore the impact of integrating electronic symptom management guidelines (eSMGs) and electronic health records (EHRs) upon oncology, telehealth nursing practice. Ten nurses participated in clinical simulations and post-clinical simulation interviews. Participants' identified that several factors that influenced the use of SMGs including nursing experience and experience in using the eSMGs.

The objective of this study is to understand how the reason for use (RFU) or the indication for medications are used, its effects on the decision-making process, the implications, and the willingness among prescribers, pharmacists, and patients to share RFU information. Methods, semi-structured interviews were conducted to retrieve the information needed from a total of 60 participants. Results, pharmacists, prescribers, and patients generally have positive opinions about including RFU information in their communications. Conclusion, there is a general agreement among participants that sharing RFU information will improve patient safety.

This paper describes a method by which the Web Ontology Language (OWL) can be used to specify a highly structured health record, following internationally recognised standards such as ISO 13606 and HL7 CDA. The structured record is coded using schemes such as SNOMED, ICD or LOINC, with the coding applied statically, on the basis of the predefined structure, or dynamically, on the basis of data values entered in the health record. The highly structured, coded record can then be linked with external knowledge sources which are themselves coded using the Resource Description Framework. These methods have been used to implement dynamic decision support in the open source cityEHR health records system. The effectiveness of the decision support depends on the scope and quality of the clinical coding and the sophistication of the algorithm used to match the structured record with knowledge sources.

Many health care providers have opened their EHR systems to patients in order to increase information sharing and patient participation. Accessing to EHR has offered the promises of improving patient understanding, engagement, and outcomes. Although patients generally appreciate the access to their health records, currently, most EHR systems are used as data storage and communication tools and their potential for promoting productive patient engagement have not fully developed. There is a need to develop and incorporate effective health literacy tools into EHR patient portals, helping patients interpret their health data, understand their medical conditions and treatment plans, make informed decisions, and take proper actions. We will examine the challenges that patients face in using EHR portals, then provide two innovative health literacy solutions for facilitating productive patient engagement: (a) an embedded semantic medical search engine that provides reliable and contextualized health information support, and (b) an integrated AI voice chatbot that answers patients' questions and provides on-demand self-care advice. Other approaches that can add benefits to patients in the context of using EHR will also be described.

The lack of standardized descriptors of behavior change facilitators in mobile health apps makes it difficult for clinicians and consumers to quickly evaluate the potential of a mobile health app. The Behavior Change Technique Taxonomy (BCTT) was developed to evaluate health interventions for the presence of behavior change techniques. This paper describes the methods used and methodological results in applying the BCTT to commercially available mobile health apps in the respiratory and sleep domains.

Patient empowerment is a buzzword that has gained much currency in recent years. It is defined as a process that helps people gain control over their own lives and increases their capacity to act on issues that they themselves define as important. This paper outlines the problems faced by the current medical model of patient empowerment and proposes a unique framework for patient empowerment that provides guidance on how health technology supports or detracts from empowering patients and families. The paper provides an ethical lens for physicians, policymakers, patients, and families in the health care system to consider the central role of the principles of autonomy and justice in patient empowerment. This paper also discusses how technology can be used to further patient empowerment and patient-centeredness of health care systems.

Technological interventions aimed at addressing medication non-adherence have shown some promise but do not deliver the full potential of an Internet of Things based Adherence Decision Support (ADS) system due, in part, to a lack high-resolution definition and measure of adherence. This paper presents a novel methodology and pilot study aimed at collecting data to support an AI-based measure of adherence. The pilot study results demonstrate the viability of the methodology and that a full-scale study could provide meaningful data to support to an AI-based ADS system.

Electronic Forms (E-Forms) for data capture are vital for most health information systems in public health and clinical research. Standardized electronic forms ensure accurate data collection, consistent form rendering, easy maintainability, and interoperability. Adopting an innovation research method we explore the challenges of standardized data capture in healthcare and offer a pragmatic solution. We appraise existing standards and software to propose the list of requirements for an ideal E-form framework. Our proposed solution leverages FHIR specification and existing open-source software tools. We discuss how our open-source solution can be extended collaboratively and discuss its value using InterRAI instruments as examples.

Death, as a biological phenomenon, is well understood and a commonly employed endpoint for clinical trials. However, death identification and adjudication may be difficult for pragmatic clinical trials (PCT) that rely upon electronic health record and patient reported data. We propose a novel death identification and verification approach that is being used in the ToRsemide compArisoN with furoSemide FOR Management of Heart Failure (TRANSFORM-HF) PCT. We describe our hybrid approach that includes gathering information from clinical trial sites, a centralized call center, and National Death Index searches. Our methods detail how a possible death is triggered from each of these components and the types of information we require to verify a triggered death. Our different trigger/verification elements collectively define the TRANSFORM-HF PCT's definition of a death event.

Clinical trials conducted for regulatory approval may include outcomes that are informative but not routinely collected in clinical practice. This situation can be problematic when pragmatic clinical trials (PCT) seek to use electronic health record (EHR) data to test the effectiveness of medical products and services in actual practice settings. We use TIMI bleeding events to illustrate how a complex clinical trial endpoint can be implemented using EHR data. While we were able to demonstrate that our EHR-defined bleeding events were associated with differences in patient clinical outcomes, we are not confident that these measurements could be replicated in other locations with consistent reliability and validity. We believe the development of PCT endpoint definitions is an important issue that should be addressed by medical and informatics professional societies, regulators and the medical products industry.

The Integrated Funding Model (IFM) is designed to measure the impact of a bundled model of health care for patients with Congestive Heart Failure (CHF) for a period of 60 days post discharge. CHF is a primary reason for patient admissions. The goal of this study is to gain insight into the effectiveness of the IFM pathway intervention on health care outcomes for persons living with CHF, using Health data Analytics.

The aim of this systematic review is to summarize studies in different settings that used Information and Communication Technologies (ICT) to address intimate partner violence (IPV). We've conducted a systematic review using PRISMA guidelines using the following databases: PubMed, CINAHL, PsycINFO, and Web of Science. Inclusion criteria were ICT-based interventions addressing IPV, focused on women. 21 studies were identified in which ICT was found to be a suitable low-cost option for screening and disclosure of IPV, as well as for preventing IPV. More research is needed to use ICT for prevention and treatment of IPV, taking consideration new ICT environments such as virtual communities.

Patient portals provide patients with electronic access to their health records. Since there has been limited use of patient portals in mental health settings, there is a lack of research regarding the usability of the technology amongst this patient population. The purpose of this study was to assess the usability of a mental health patient portal, and to provide the study site with design recommendations. Ten (n=10) participants completed a guided user interface assessment on laptops and tablet devices, along with a structured questionnaire. Findings revealed a number of modifiable aspects of the portal design to improve the usability of the technology for the end user.

The availability of research and outcomes data is the primary limitation to evidence-based practice. Today, only a fraction of clinical decisions are based upon evidence derived from randomized control trials (RCTs), the gold-standard of knowledge discovery. At the same time, clinical trial complexity has steadily increased as has the effort required at clinical investigational sites. Direct use of electronic health record (EHR) data for clinical trials has the potential to address some of these needs, improving data quality and reducing cost.

Data standards are now required for many submissions to the United States Food and Drug Administration (FDA). The required standard for submission of clinical data is the Clinical Data Interchange Standards Consortium (CDISC) Submission Data Tabulation Model (SDTM). Currently, 45 business rules and 115 associated validation rules exist for SDTM data. However, such rules have not yet been developed for therapeutic area data standards developed under the last reauthorization of the Prescription Drug User Fee Act (PDUFA V). The objective of this effort was to develop data validation rules for new therapeutic area data standards in four mental health domains, assess the metadata required to associate such rules with standard data elements, and assess the level of data validation possible for therapeutic area data elements.

Telenursing triage and advice services are continuing to expand both nationally and internationally. A primary role of telehealth nursing triage is to channel patients or clients towards appropriate levels of care, thereby reducing healthcare costs and freeing up resources.

Purpose: The objective of this research is to: (a) present an overview of the current research, (b) describe the extent to which telenursing services are fulfilling this role, (c) identify gaps in the literature and (d) propose future research directions.

Methods: The report consists of a scoping review of current literature based on the framework suggested by Arkseyand O'Malley (2005).

Results: Although the available research spans a variety of jurisdictions, which makes comparison difficult, there is some evidence that suggests telenursing services empower clients to access levels of care in keeping with the severity of their symptoms, as well as enabling clients to engage in self-care when appropriate. This in turn leads to cost savings for the broader health care system.

Conclusion: More evaluation of telenursing programs is needed to identify consistent savings. Health outcomes should be a part of the research.

Health care organizations are investing in system solutions that can be leveraged across the continuum of care (i.e. electronic medical records (EMR's); electronic health records (EHR's); health information exchanges (HIE's) and patient portals. The importance of these systems and how they have evolved over the past 30 years has been well researched. The value and benefits of these systems are therefore well known; however, it is estimated that most projects are typically 100% over budget and a year behind schedule [1, p. 2]. In this paper the authors examine what literature is available on agile project management methodologies in health care settings. A scoping review of the literature available specifically on agile methods use in implementing systems within health care was undertaken. Findings revealed there is very little literature available on agile project management methodologies used in health care IT systems implementations. The authors identify there is a strong need for research to look into project management methodologies and identify areas in the project lifecycle, where change is needed to increase clinical systems adoption.

In descriptions of digital health the role of human agency and the work of managing and governing health information and communication technology is often invisible. This paper reports preliminary results of a scoping review of the literature and a national workforce census, undertaken as part of a research program to shed light on the responsibilities and the contributions of the health information workforce. The global literature is not a good indicator of the actual proportion of health informaticians, health information managers, health librarians or other health professionals who are engaged in health information work in Australia. While the research interest in health information work of all descriptions is increasing, the practice of health information work is neither highly skilled nor easily identifiable in findings of an Australian census. Reforming this workforce may be a key to translating digital health rhetoric into measurable improvements in health system performance.