Ebook: Building Capacity for Health Informatics in the Future

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

This year, the conference will take on a multi-perspective view about what capacity is needed in order to move health IT along to achieve real, sustained and widespread use. The solutions can 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. There is also a need for greater interaction and collaboration among industrial, governmental and academic partners. The papers in this proceedings reflect the innovative ways with which the healthcare community have come together to build health informatics capacity for the future. In particular, the papers have been carefully selected to ensure there is a balance of scientific rigor, practice relevance, and tangible impacts in terms of productivity, access, empowerment and outcomes.

It is our hope that the knowledgeinsights gained from the ITCH 2017 conference can stimulate fruitful discussions and collaborations among the participants to build the next generation of health informatics capacity that is in great demand to bring about positive change in healthcare in Canada and other countries.

Francis Lau

School of Health Information Science

University of Victoria

Victoria, British Columbia

Canada

Health care continue to lag behind other industries, such as retail and financial services, in the use of decision-support-like tools. Amazon is particularly prolific in the use of advanced predictive and prescriptive analytics to assist its customers to purchase more, while increasing satisfaction, retention, repeat-purchases and loyalty. How can we do the same in health care? In this paper, we explore various elements of the Amazon website and Amazon's data science and big data practices to gather inspiration for re-designing clinical decision support in the health care sector. For each Amazon element we identified, we present one or more clinical applications to help us better understand where Amazon's

This paper explains the benefits model developed and deployed by the connecting South West Ontario (cSWO) program. The cSWO approach is founded on the principles of enabling clinical and organizational value and the recognition that enabling requires a collaborative approach that can include several perspectives. We describe our approach which is aimed at creating a four-part harmony between change management and adoption, best practice research and quality indicators, data analytics and clinical value production.

Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well

The translation of successful behavior change interventions to new delivery mechanisms requires an understanding of the underlying concepts that led to its success. This has particular relevance when converting in-person interventions into remote technological applications. The active ingredients that may have been successful in the “live” application can appear differently in a technological application. The communication module within a multi-user telehealth kiosk will be used as an example of how behavior change techniques from a “live” intervention may be represented in an information technology-delivered intervention.

Background: Mobile audience response systems (mARS) are electronic systems allowing speakers to ask questions and audience members to respond anonymously and immediately on a screen which enables learners to view their peers' responses as well as their own. mARS encourages increased interaction and active learning.

Objectives: This study aims to examine the perceptions of audience members and speakers towards the implementation of mARS at a national medical conference.

Methods: mARS was implemented at the CSO Annual Meeting in Winnipeg 2015. Eleven presenters agreed to participate in the mARS trial. Both audience and presenters received instructions. Five-point Likert questions and short answer questions were emailed to all conference attendees and the data was evaluated.

Results: Twenty-seven participants responded, 23 audience members and 4 instructors. Overall, responders indicated improved attention, involvement, engagement and recognition of audience's understanding of topics with the use of mARS. mARS was perceived as easy to use, with clear instructions, and the majority of respondents expressed an interest in using mARS in more presentations and in future national medical conferences. Most respondents preferred lectures with mARS over lectures without mARS. Some negative feedback on mARS involved dissatisfaction with how some presenters implemented mARS into the workshops.

Conclusion: Overall mARS was perceived positively with the majority of respondents wanting mARS implemented in more national medical conferences. Future studies should look at how mARS can be used as an educational tool to help improve patient outcomes.

Background & Objectives: Legacy laboratory test codes make it difficult to use clinical datasets for meaningful translational research, where populations are followed for disease risk and outcomes over many years. The Health Informatics Centre (HIC) at the University of Dundee hosts continuous biochemistry data from the clinical laboratories in Tayside and Fife dating back as far as 1987. However, the HIC-managed biochemistry dataset is coupled with incoherent sample types and unstandardised legacy local test codes, which increases the complexity of using the dataset for reasonable population health outcomes. The objective of this study was to map the legacy local test codes to the Scottish 5-byte Version 2 Read Codes using biochemistry data extracted from the repository of the Scottish Care Information (SCI) Store.

Methods: Data mapping methodology was used to map legacy local test codes from clinical biochemistry laboratories within Tayside and Fife to the Scottish 5-byte Version 2 Read Codes.

Results: The methodology resulted in the mapping of 485 legacy laboratory test codes, spanning 25 years, to 124 Read Codes.

Conclusion: The data mapping methodology not only facilitated the restructuring of the HIC-managed biochemistry dataset to support easier cohort identification and selection, but it also made it easier for the standardised local laboratory test codes, in the Scottish 5-byte Version 2 Read Codes, to be mapped to other health data standards such as Clinical Terms Version 3 (CTV3); LOINC; and SNOMED CT.

Mobile phones are used in conjunction with mobile eHealth software applications. These mobile software applications can be used to access, review and document clinical information. The objective of this research was to explore the relationship between mobile phones, usability and safety. Clinical simulations and semi-structured interviews were used to investigate this relationship. The findings revealed that mobile phones may lead to specific types of usability issues that may introduce some types of errors.

Health information technologies (HIT) promised to streamline and modernize healthcare processes. However, a growing body of research has indicated that if such technologies are not designed, implemented or maintained properly this may lead to an increased incidence of new types of errors which the authors have referred to as “technology-induced errors”. In this paper, framework is presented that can be used to manage HIT risk. The framework considers the reduction of technology-induced errors at different stages by managing risks associated with the implementation of HIT. Frameworks that allow health information technology managers to employ proactive and preventative approaches that can be used to manage the risks associated with technology-induced errors are critical to improving HIT safety and managing risk associated with implementing new technologies.

mHealth apps are not being used. Over 45,000 mhealth apps are languishing in mobile app stores. We evaluated over 200 diabetes mobile apps found in the Apple and Google app stores using a framework that we recently published. None of the apps met all 15 criteria identified by our framework. The largest number of apps fell into the category of Type 1 diabetes blood sugar and medication trackers. Other types of apps included educational apps such as recipe apps, guideline dissemination apps, simple diabetes education apps, etc. There is a need for more Type 2 apps and for all types of apps that are better integrated into EMRs for more holistic care that can be prescribed by clinicians and monitored and supported by the health care team.

British Columbia's health care system is facing challenges related to rural access to care and an ever increasing demand for services. These variables are compounded by the anticipated needs of an aging population that can expect to live several of their golden years with a chronic illness. The introduction of community paramedicine in BC allows for a care delivery model that expands the role of qualified paramedics to include the delivery of prevention, health promotion and primary care services in the community. The implementation of the Community Paramedicine Initiative in rural and remote BC highlights a transformational approach to health care delivery empowered by a technology enabled perspective of community needs.

Background: The patient-centered medical home (PCMH) concept requires collaboration among clinicians both within the medical home clinic, and outside the clinic. As we redesign health information technology (HIT) to support transformation to the PCMH, we need to better understand these collaboration patterns. This study provides quantitative data describing these collaborations in order to facilitate the design of systems to allow for more efficient collaboration.

Approach: Eighty-four clinicians in eight clinics identified their two most recent significant collaborators – one each within the clinic and in the medical neighborhood. They also identified the communication channels used in these collaborations. We used k-means clustering to identify communication patterns.

Results: Within the clinic, half of the primary care providers (PCPs) identified a care manager as their most recent collaborator. Outside specialists were their most common external collaborators. Ninety-two percent of the non-PCP participants identified PCP's as their most recent internal collaborators.

The best model for communication channel usage (p < .0001) had six clusters. In general, inside communications were more informal but outside collaborations were more often formal written communications (faxes, letters) or the exchange of electronic health record progress notes. But there were exceptions to these patterns and in many cases multiple channels were used for the same collaboration.

Conclusion: Systems design (and redesign) needs to focus on reducing communications load and increasing communication effectiveness while maintaining flexibility.

The cityEHR is an example of an open source EHR system which stores clinical data as collections of XML documents. The records gathered in routine clinical care are a rich source of longitudinal data for use in clinical studies. We describe how the standard language XQuery can be used to identify cohorts of patients, matching specified criteria. We discuss methods for ensuring good data quality and the issues in implementing XML queries on longitudinal data sets.

Over 15 years, a broad spectrum of activities was undertaken to realize a health IT infrastructure in the Netherlands. In this paper we reflect on the history, challenges, accomplishments, changes, and the way forward. It shows that the infrastructure depends on technical, legal, and semantic aspects, which are frequently reciprocally related. It also highlights the fact that the role of health professionals and of patients is increasingly considered as a crucial element.

Engaging patients in the self-management decision-making provides opportunities for positive health outcomes. The process of shared decision-making (SDM) is touted as the pinnacle of patient-centred care, yet it has been difficult to implement in practice. Access to tools resulting from the integration of all health data and clinical evidence, and an ease of communications with care providers are needed to engage patients in self management decision-making. Personal health record (PHR) technology is a promising approach for overcoming such barriers. Yet there is a scarcity of studies on system design for SDM via PHR. This paper describes the design and implications of a system for SDM via PHR.

Medication non-adherence is a global problem that has been studied over the past 40 years. Despite the large number of studies there is not an agreed upon definition of “adherence” in the literature. The lack of a consistent definition has resulted in issues in adherence research, clinical implementation, and HIT system development. In this paper a critical review of adherence literature is conducted. Based on this review, a new Adherence Interaction Model (AIM) is proposed and described in detail. AIM considers provider recommendations, the patient's interpretation of the recommendations, and the patient's behavior and provides the foundation for building a more objective view of adherence. AIM provides a foundation for future formalization of medication adherence concepts.

Computerized Provider Order Entry (CPOE) systems have been shown to introduce new problems into clinical environments. Given the communication intensive nature of these systems considering the language(s) of communication can provide insight into their function and subsequent problems. The current (as November 2015) CPOE literature was reviewed using the language concepts of syntax, semantics, and pragmatics as a lens. In total, 202 articles were considered, of these only 46 received a full review. 145 results related to language concepts were extracted from these articles. These were categorized into five categories: syntax, semantics, system-pragmatics, syntax-pragmatics, and semantic-pragmatics. In total key themes were synthesized. The themes identified can be used to direct further research in the area of CPOE systems. It was found that current literature heavily favors pragmatics concerns of language at the expense of considering underlying factors (syntax and semantics). The results support the use of language as a means of analyzing interactions between actors in communication intensive systems.

The continued escalation of clinical trial costs is becoming a public health concern. During the past decade, medical research funding peaked and there is growing concern that there may be insufficient resources to test many promising medical products. Recent changes in the regulatory environment create opportunities for the use of medical informatics to improve clinical trial operations and reduce costs. We report on a Medical Informatics Europe 2016 workshop conducted during the Health – Exploring Complexity (HEC) 2016 conference. We review presentation given on Secondary Data Use, eSource, and Data Quality in Clinical Trials and report on the workshop's discussions.

Medicaid beneficiaries in 6 North Carolina counties were randomly assigned to 1 of 3 clinical decision support (CDS) care transition strategies: (1) usual care (Control), (2) CDS messaging to patients and their medical homes (Reports), or (3) CDS messaging to patients, their medical homes, and their care managers (Reports+). We included 7146 Medicaid patients and evaluated transitions from specialist visit, ER and hospital encounters back to the patient's medical home. Patients enrolled in Medicare and Medicaid were not eligible. The number of care manager contacts was greater for patients in the Reports+ Group than in the Control Group. However, there were no treatment-related differences in emergency department (ED) encounter rates, or in the secondary outcomes of outpatient and hospital encounter rates and medical costs. Study monitors found study intervention documentation in approximately 60% of patient charts. These results highlight the importance of effectively integrating information interventions into healthcare delivery workflow systems.

Mental health is a pervasive challenge in the population and especially for university/college students on campuses across North America. Anxiety, stress and depression are on the rise and a scalable, economically sound innovation is essential to address these mental health challenges. The research team has conducted 8 focus groups in April to May 2016 in order to elicit perspectives of students at York University about their online activities and the development of an online mindfulness based Mental Health Virtual Community. This paper explains the main results of the qualitative analysis pertaining to the challenges and benefits of an online mindfulness based Mental Health Virtual Community.

Evaluating mobile health applications requires specific criteria. Research suggests evaluation grids and online web sites are available to provide a quick sense of ease for the health care professional wanting to use a mobile application without worrying about the quality, efficacy, and safety of the mobile application. This article will present a scoping review and explore the available resources for health care professionals.

In Canada, every individual has a right to their personal health information (PHI). As the use of consumer digital health solutions expands across Canada it is evident that a better understanding of the application of this right to individuals under the age of majority is needed. Research was undertaken between December 2015 and March 2016 which focused on various aspects of adolescent electronic access to PHI. The study included a privacy legal framework review; an environmental scan and literature review; a pan-Canadian survey and focus groups.

Virtual platforms using webinars, e-posters, e-newsletters, wikis and blogs connect people who have common interests in new ways. When those individuals are healthcare providers, a professional network that operates on a virtual platform can support their needs for learning, professional development and information currency. The practice of e-learning for continuing professional development is emerging , particularly in nursing where shift work shift inhibits their ability to attend conferences and classes. This article reports the experience of the InspireNet network that provided e-learning models to: 1) provide opportunities for healthcare providers to organize themselves into learning communities through development of electronic communities of practice; 2) support learning on demand; and 3) dramatically increase the reach of educational offerings.

With the emergence of personal health record (PHR) platforms becoming more widely available, this research focused on the development of privacy heuristics to assess PHRs regarding privacy. Existing sets of heuristics are typically not application specific and do not address patient-centric privacy as a main concern prior to undergoing PHR procurement. A set of privacy specific heuristics were developed based on a scoping review of the literature. An internet-based commercially available, vendor specific PHR application was evaluated using the derived set of privacy specific heuristics. The proposed set of privacy specific derived heuristics is explored in detail in relation to ISO 29100. The assessment of the internet-based commercially available, vendor specific PHR application indicated numerous violations. These violations were noted within the study. It is argued that the new derived privacy heuristics should be used in addition to Nielsen's well-established set of heuristics. Privacy specific heuristics could be used to assess PHR portal system-level privacy mechanisms in the procurement process of a PHR application and may prove to be a beneficial form of assessment to prevent the selection of a PHR platform with a poor privacy specific interface design.

The adoption and use of Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) is continuing to rise in North America. These systems contain data of varying degrees of quality, including poor quality or “dirty” data. Data entered into EMRs need to be clean or of high quality for them to be useful for a variety of reasons, including quality improvement, clinical decision support, population management, research and system management. There are two potential solutions to obtaining clean data from EMRs: data discipline and data cleansing. Data discipline focuses on ensuring that entry of data into EMRs is of high quality, while data cleansing focuses on cleaning data in the database. Clean data are necessary for healthcare providers to effectively manage chronic diseases and should lead to a reduction in the costs associated with those diseases. The objective of this paper is to compare the costs involved in implementing the two different data cleaning approaches by performing a Budget Impact Analysis (BIA) using diabetes as the exemplar in Canada. The BIA revealed that the cost to implement data discipline is $65 million whereas the cost to implement the data cleansing approach would be $21 million. Even though the cost may seem high, the cost of dirty data is even higher. Data discipline, data cleansing, or a combination of both approaches should be considered going forward.