Ebook: Context Sensitive Health Informatics and the Pandemic Boost

This volume presents the papers from the International Conference on “Context Sensitive Health Informatics” held at The University of Sydney in July 2023. Context Sensitive Health Informatics (CSHI) concerns health information technologies and their environments. Environments may be people in various 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 and organized by the International Medical Informatics Association (IMIA) working groups “Human Factors Engineering for Healthcare Informatics”, “Organizational and Social Issues” and “Technology Assessment and Quality Development in Health Informatics”. The CSHI 2023 conference is sponsored by the: Digital Health and Informatics Network at The University of Sydney; Australian Institute of Health Innovation at Macquarie University; Research Institute for Innovative Solutions for Well-Being and Health at the University of Technology Sydney; Community and Primary Health Care Network at The University of Sydney; Human Factors and Ergonomics Society of Australia; and eHealth NSW. We would like to thank the sponsors for making it possible to organize the conference and publish the proceedings.

We thank the students and researchers who submitted their research papers to this conference. We also want to thank the members of the Scientific Program Committee for their efforts in establishing 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 the conference.

Adeola Bamgboje-Ayodele

Mirela Prgomet

Craig Kuziemsky

Peter Elkin

Christian Nøhr

July 2023

While there is a global desire to increase digital health capacity, digital health should transform health services delivery rather than simply automate – or worse – replicate existing practices. Failing to capitalize on this transformative potential misses an opportunity to engage patients and other users to provide a more person-centered experience. However, digital transformation done recklessly can disrupt workflow, alienate users, and jeopardize patient safety, as we have observed with implementation of many digital health tools. This paper uses a telemedicine example to provide insight into how digital health innovation can be a meaningful enabler of health system transformation. Examining different ways to leverage digital health technologies is crucial to best capitalize on their potential.

Involving clinician users in the design and development of Clinical Decision Support (CDS) systems is touted to improve the fit between system and user needs. However, the impact of clinician involvement on CDS acceptance and use in practice has not been systematically studied. This review aimed to identify the approaches taken to involve clinicians in CDS development and understand the impact of these approaches on barriers and facilitators to acceptance and use in hospital settings over time. Twenty-three studies met full inclusion criteria. Clinician involvement was rarely described in depth and no comparative studies were identified. Despite frequently reporting perceived ease of use, included studies still reported barriers to acceptance and use shortly after CDS implementation and years later. Future studies should report clinician involvement in adequate detail to enable understanding of its impact on CDS acceptance and use over time. Additional recommendations for future research, including conducting comparative studies and maintaining clinician involvement beyond implementation, are described.

Usability and user experience are central quality attributes of electronic health record (EHR) systems. Usability evaluation studies typically focus on short-term use and situational usability, although feedback collected during operational use provides input for future information systems development. An abundance of studies report on physicians’ dissatisfaction with the usability of their EHR systems and many show an association between poor usability and physician burnout. However, there is a scarcity of large long-term monitoring studies assessing end users’ experiences with EHRs. We report on the results from four large (n=3,929–4,628) national cross-sectional usability surveys conducted among Finnish physicians in 2010, 2014, 2017, and 2021. The main finding was that the perceptions of physicians working in public health centres had changed for the better but those working in public hospitals reported similar or even more negative experiences in 2021 than in 2010–17; they rated only system responsiveness to inputs as having improved. Based on this finding, systematic research-based monitoring of EHR development from the end users’ perspectives should be continued.

Perceptions of errors associated with healthcare information technology (HIT) often depend on the context and position of the viewer. HIT vendors posit very different causes of errors than clinicians, implementation teams, or IT staff. Even within the same hospital, members of departments and services often implicate other departments. Organizations may attribute errors to external care partners that refer patients, such as nursing homes or outside clinics. Also, the various clinical roles within an organization (e.g., physicians, nurses, pharmacists) can conceptualize errors and their root causes differently. Overarching all these perceptual factors, the definitions, mechanisms, and incidence of HIT-related errors are remarkably conflictual. There is neither a universal standard for defining or counting these errors. This paper attempts to enumerate and clarify the issues related to differential perceptions of medical errors associated with HIT. It then suggests solutions.

The use of an electronic medical record (EMR) during a student’s clinical placement is intricately linked with student learning and skill development necessary to become a competent healthcare professional. However, significant variation currently exists in student EMR access and use within healthcare. In this study, we bring to light evidence of this variability amongst medical, nursing, pharmacy, and allied health student placements, both in policy and in practice. We found some health districts lack student policies on EMR use, as well as prohibiting important tasks including record writing capabilities. There was also variation in exposure to EMR training. In order to provide healthcare students with optimal education that includes technological competency, we identify a need for changes to both policies and practices.

With digital systems permeating the healthcare sector, the healthcare workforce (clinical and administrative) need insight in biomedical health informatics (BMHI) to some degree. This study shows how novices in BMHI had to knock hard on several doors to find and become part of a community of practice to gain such expertise within BMHI. While it may be generally understood that gaining access to expertise is important, our findings suggest that more attention is needed to how such access is gained. The study exemplifies that the needed skills and competencies are difficult to identify in the individual projects and are highly situated – not least because it requires access to various experts in communities of practices. Therefore, there is a continued need to reframe the necessary education and training. Knowing when to knock on doors, which doors to knock on, and keeping doors open is central to becoming – and keep on being – a part of a community of practice centring on health information technology and BMHI.

Technology failures in telehealth are common, and clinicians need the skills to diagnose and manage them at the point of care. However, there are issues beyond technology failures mediating the effective use of telehealth. We must teach best-practice procedures for conducting telemedicine visits and include in instructional simulations commonly encountered failure modes so students can build their skills. To this end, we recruited medical students to conduct a Healthcare Failure Modes and Effects Analysis (HFMEA) to predict failures in telemedicine, their potential causes, and the consequences to develop and teach prevention strategies. Sixteen students observed telehealth appointments independently. Based on their observations, we identified four categories of failures in telemedicine: technical issues, patient safety, communication, and social and structural determinants. We proposed a normalized workflow that included management and prevention strategies. Our findings can inform the creation of new curricula.

The primary goal of large-scale electronic health record (EHR) suites is to meet the needs of a broad range of users in healthcare institutions. EHR suites are extensively configurable, which makes it possible to tailor them to diverse professional practices and users. However, while users such as physicians and nurses may have clearly defined responsibilities, clerical personnel (i.e. secretaries) conduct “in-between” or invisible work that is not as easily defined. Therefore, it may be more difficult to tailor EHR suites to their needs. Moreover, because secretaries are quite low in the hospital hierarchy, it is difficult for them to obtain satisfactory solutions. In this paper, we explore the challenges of configuring the EHR suite for secretary workflows in the Health Platform program in central Norway.

The DetecIP project aims to implement multifactorial dynamic rules within a computerized decision support system (CDSS) for pharmaceutical analysis of orders to reduce the rate and severity of iatrogenic hyperkalemia and acute kidney injury. However, understanding the impact of this intervention (if any) requires that the way in which it influences the work systems and processes also be studied. This study presents the preliminary results of the analysis of the work contexts in which these rules will be implemented. A series of semi-structured interviews exploring the dimensions of the systems engineering initiative for patient safety (SEIPS) were conducted with healthcare professionals involved in the prevention and management of iatrogenic risks in five hospital units. Data were analyzed to identify current barriers and facilitators to the prevention and management of iatrogenic risks. Preliminary results from a geriatric unit and a cardiology unit reveal that, despite overall similarities in work processes, differences in the availability and location of physicians and clinical pharmacists influence how iatrogenic risks are managed. These contextual differences could influence the impact of the new CDSS rules once implemented.

Electronic medication management systems (EMMS) have been implemented in most acute care settings in Australia to reduce medication error rates. One of the key challenges related to the introduction of EMMS in hospitals is the uptake of informal “workarounds” by clinicians, including nurses. In this study, we aimed to examine one workaround in depth, nurses not documenting medication administration in the EMMS at the time of administration. We conducted a review of incident reports to identify the factors that contribute to this workaround occurring and the consequences or potential consequences of this workaround on patients. We identified a range of contributing factors, with factors relating to the user (e.g. nurses being time poor) occurring most frequently in incident reports. The most frequently seen consequence of this workaround was the patient receiving an additional dose. This research revealed that strategies to reduce the uptake of this workaround should consider user and organisational factors rather than just EMMS design alone.

Antimicrobial stewardship (AMS) programs in hospitals comprise coordinated strategies to optimise antimicrobial use. The COVID-19 pandemic had a significant impact on the healthcare system, including AMS. This study aimed to understand the work processes of AMS teams during COVID-19 hospital restrictions and the role technology played in supporting AMS. Observations and interviews were conducted with AMS teams at two hospitals in Sydney, Australia. Participants reported an increase in antimicrobial use, a loss of resources for AMS activities, and reduced in-person interactions. Meetings were performed through videoconferencing, which resulted in greater access to information but led to poorer communication and impacted interdisciplinary relationships. As COVID-19 restrictions recede, AMS program changes should be evaluated to understand the most effective strategies to facilitate evidence-based AMS practices.

Hospitals faced extraordinary challenges during the pandemic. Some of these were directly related to patient care—expanding capacities, adjusting services, and using new knowledge to save lives in a dynamically changing situation. Other challenges were regulatory. The COVID-19 pandemic significantly disrupted routine hospital infection control practices. We report the results of an interview study with 13 individuals associated with infection control in a small independent hospital. We employed the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework and as a basis to analyze data. The findings revealed how routine practices and protocols were displaced in notable ways. Due to COVID-19, clinical activities were modified, and the increased demands of regulatory reporting became laborious, and punitive if reports were late. Strategies are needed to mitigate increases in healthcare-associated infections. Our examination of the information flows, transformation, and needs shows areas in which digital tool creation and the use of a trained informatics workforce could ameliorate and automate many processes.

Digital health can play a key role in diagnostic stewardship, which refers to the coordinated guidance and interventions to ensure the appropriate utilisation of diagnostic tests for therapeutic decision-making. Outcomes of test result management and the impacts of digital health are a result of the interaction between dimensions of a complex environment. This poster will present preliminary findings from a scoping review which identifies the stewardship mechanisms that facilitate safe and effective electronic management of test results.

Cross-disciplinary approaches to remediate complex healthcare service delivery issues may have merit. This study aims to establish the potential benefits of applying service design and evaluative research concepts in healthcare. Specifically, this study aims to demonstrate how a Customer Journey Map and a Logic Model could be used in unison to identify and remedy service delivery gaps to reduce barriers to care. This study provides systems thinking approach to solving operational issues in healthcare.

The COVID-19 pandemic has placed unprecedented strain on global health systems, and the ability to safely and effectively deliver care. Further, it has impacted the mental health of global populations, in particular healthcare providers (i.e., physicians, nurses). In a service delivery context, much can be learned about empathy both from a provider and patient lens. Thus, the literature was explored to see if the concept of journey mapping was used to illustrate the intersections and pain points of the clinical workflow along the physician journey.

Mobile health applications (mHealth apps) can provide effective self-management instruments for patients and offer advanced approaches to treatment. However, little is known about how the older population perceives the opportunity of using mHealth apps as a non-drug intervention. We aimed to identify the opinions and experiences of older people in Australia and gain new insights into their engagement with this modern approach to health treatment. We conducted a qualitative study with 21 Participants to explore users’ perspectives on adopting and using mHealth apps and their awareness of the social factors influencing their uptake. The results show that a trusting doctor-patient relationship positively affects older adults’ perceptions of mHealth apps. Consequently, the social influence of the General Practitioner (GP) plays a crucial role in the use of mHealth apps, while the social influence through family and friends seems to be less critical.

The widespread adoption of mobile phones and increasing mobile connectivity globally create opportunities to access remote and disadvantaged populations. Mobile health interventions in low- and middle-income countries have substantial reach and potential to promote the socio-emotional and cognitive development of children. This study presents co-design workshop findings relating to the user experience of a mobile application – Thrive by Five – which intends to promote healthy early childhood development globally, particularly in low- and middle-income countries. Here, findings from workshops conducted in 11 countries in Asia, Africa, and Oceania are presented. Key feedback on the mobile application user experience indicated several necessary changes, such as simplifying and localising the language, incorporating short videos or animations, adding more bright colours and illustrations, and making numerous improvements and additions to the app features and functionality. The findings contribute to advancing mobile health, context-sensitive technologies, user experience design, and low-resource setting technology co-design.

The COVID-19 pandemic has rapidly increased the possibilities for conducting Decentralized Clinical Trials (DCT). This paper addresses the potential for conducting DCT in Denmark and discusses how this potential can improve equity in digital healthcare. From stakeholder interviews, we learned that DCT has the potential to be implemented, as DCT guidelines are in place in Denmark. DCT can potentially improve equal access and inclusion of diverse populations, home administration of medication, retention and compliance, and monitoring of patients and side effects. While DCT has potential in a Danish context, the challenges regarding DCT need to be considered carefully, particularly concerning equity in digital health.

The Social Brain Toolkit is a novel suite of web-based interventions to support people with acquired brain injury and their close others with communication difficulties post-injury. The aim of this study was to investigate potential impacts of the Toolkit’s wider political, economic, regulatory, professional, and sociocultural context on its implementation, scalability, and sustainability. Nine people with academic, healthcare or industry experience implementing digital health interventions prior to and during COVID-19 were individually interviewed. Data were deductively analysed according to the Non-adoption, Abandonment, Scaleup, Spread and Sustainability framework, with a focus on the domain of the ‘Wider system’. Results indicated that COVID-19 facilitated a pivot to virtual care models which was timely for the implementation of the Social Brain Toolkit; political and economic changes were entwined; and risk management, data compliance and governance were key considerations for healthcare professionals and organisations.