Ebook: Context Sensitive Health Informatics: Redesigning Healthcare Work

This volume presents the papers of the International Conference on “Context Sensitive Health Informatics, Human and Socio-Technical approaches” held at Citi University in Hong Kong in August 2017.

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 organized/supported by the IMIA Working Groups Human Factors Engineering for Healthcare Informatics, Organizational and Social Issues, Technology Assessment & Quality Development in Health Informatics, and Primary Health Care Informatics,

The CSHI2017 Pre-MEDINFO Conference is sponsored by City University of Hong Kong, Department of Management Sciences and organized by faculty members receiving support from Theme-based Research Scheme – Delivering 21st Century Healthcare in Hong Kong – Building a Quality-and-Efficiency Driven System (Grant No. T32-102/14N). The editors want to thank the sponsors and the local organizing committee for making it possible to have the conference in Hong Kong

We would also like to thank Mathias Kragh Nielsen for setting up and maintaining the conference web site, and Line Dausel Vinther for editing all the papers. We also would like to acknowledge Linda W. Peute from Department of Medical Informatics, Academic Medical Center, Amsterdam for designing the logo for 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.

Christian Nøhr

Craig Kuziemsky

Zoie Shui-Yee Wong

July 2017

Health informatics applications will be a cornerstone in the next generation quality-and-efficiency health care system. Health care is delivered from many different specialties, to many different patients with complex diseases and comorbidity. A one size fits all approach is not adequate to reach the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. Health informatics applications must be built to be adaptable and sensitive to the complex contexts they will be used in. To enhance patient-centeredness in the 21st Century healthcare, research attention should be focused on investigating and designing models contributing to effective health information retrieval process.

The challenge of providing services that meet the growing needs of an ageing population is one confronted by communities across Australia and internationally. The aim of this study was to: a) undertake semi-structured interviews and focus groups across a sample of service and technical staff to identify the interconnection between communication, information, work practices and performance; and b) carry out a comprehensive review of existing data sources to identify the data linkages required to identify and monitor performance across different dimensions of the quality of aged care spectrum. The results from this study provided empirical evidence of the interconnection between communication, information, work practices and performance; and highlighted numerous potential data linkages which can be used to monitor performance across different dimensions of aged care. These included: the uptake and utilisation of community care services, community aged care client interactions and transitions (with hospitals and other health care providers), and quality of life measures (e.g., health and safety status, symptoms of depression and anxiety, social integration and mortality rates).

The development of hospital-acquired pressure ulcers signals low quality of care. Despite the established guidelines and best practices on pressure ulcer prevention, the incidence of pressure ulcers in hospital remains high. To meet the challenges of consistently translating best practices into effective clinical practices and promote effective teamwork communication and interprofessional collaboration, we consider the failure of consistent care delivery as loss of information and reveal the opportunities of informatics methods to reinforce information delivery, evidenced by typical cases. We, then, explain and summarize information-related issues existing at the initial assessment upon hospital admission, routine treatments, and team communication. Clinical decision support methods are promising in addressing these issues by optimizing care plans, improving adherence to best practices, reinforcing effective team communication, and customizing event report feedback.

A significant number of U.S. health sciences libraries have closed since the mid-1990's. A pilot study was conducted with academic physicians to understand the impact of closing the health sciences library in the teaching hospital with which they were affiliated. A brief survey was designed and distributed to fourteen faculty members with thirteen useable responses received. The study elicited a context-sensitive perspective on the closing of the library with the most noteworthy outcome being the additional time required by attending physicians and trainees to perform the work that previously was performed by library staff. The loss of the expert literature search, instructional services, journal request, and interlibrary loan services had the most significant impact on study participants. Further research is needed to understand the long term consequences of closing hospital-based health sciences library on the education of physicians.

This paper discusses how health information technologies like tele-care, tele-health and tele-medicine can improve the condition for high-need patients, specifically in relation to access. The paper addresses specifically the values of timeliness and equity and how tele technological solutions can support and enhance these values. The paper introduces to the concept of scaffolding, which constitutes the framework for dynamic, appropriate, caring and embracing approaches for engaging and involving high-need patients that are vulnerable and exposed. A number of specific considerations for designing tele-technologies for high-need patients are derived, and the paper concludes that ethical and epistemological criterions for design are needed in order to meet the needs and requirements of the weak and exposed.

Considerable effort and resources have been dedicated to improving the quality and safety of patient care through health information systems, but there is still significant scope for improvement. One contributing factor to the lack of progress in patient safety improvement especially where technology has been deployed relates to an over-reliance on purely objective, quantitative, positivist research paradigms as the basis for generating and validating evidence of improvement. This paper argues the need for greater recognition and accommodation of evidence of improvement generated through more subjective, qualitative and pragmatic research paradigms to aid patient safety especially where technology is deployed. This paper discusses how acknowledging the role and value of more subjective ontologies and pragmatist epistemologies can support improvement science research. This paper illustrates some challenges and benefits from adopting qualitative research methods in patient safety improvement projects, particularly focusing challenges in the technological era. While adopting methods that can more readily capture, analyse and interpret direct user experiences, attitudes, insights and behaviours in their contextual settings, patient safety can be enhanced ‘on the ground’ and errors reduced and/or mitigated, challenges of using these methods with the younger “technologically-centred” healthcare professionals and patients needs to recognised.

Current efforts to improve nursing handover frequently use prescriptive approaches based on research evidence of handover issues within a single nursing ward or nursing specialty. Despite reported handover improvement, few studies adequately consider the transferability of results to other nursing handover environments or acknowledge the unique attributes that supported sustained improvement. With the increasing diffusion of electronic tools it has become even more critical to ensure that socio-technical issues that may impact on the quality and safety of nursing handovers are identified. This paper describes a qualitative research project that examined nursing handover in three different wards – General Medicine, General Surgery and Department of Emergency Medicine in a tertiary teaching hospital. Through conduct of a detailed analysis of nursing handover processes, this paper highlights the similarities and differences in the handover among the three different wards and presents five key socio-technical insights to support safe nursing handover.

The increasing recognition of the value of effective interprofessional collaboration has promoted interprofessional education (IPE) among healthcare professionals. The IPE pilot program initiative at UTHealth matriculated students from the disciplines of biomedical informatics, biomedical sciences, dentistry, medicine, nursing and public health. There has been a pressing need for developing an assessment tool in reflecting how IPE participants recognize and understand the other disciplines including clinical informatics in nowadays' practice. This paper reports our development process of the assessment tool, which is still under an iterative, in-depth refinement and aiming at greater collaborations.

Access to expert practitioners or geographic distance can compound the capacity for appropriate supervision of health professionals in the workplace. Guidance and support of clinicians and students to undertake new or infrequent procedures can be resource intensive. The Helping Hands remote augmented reality system is an innovation to support the development of, and oversee the acquisition of procedural skills through remote learning and teaching supervision while in clinical practice. Helping Hands is a wearable, portable, hands-free, low cost system comprised of two networked laptops, a head-mounted display worn by the recipient and a display screen used remotely by the instructor. Hand hygiene was used as the test procedure as it is a foundation skill learned by all health profession students. The technology supports unmediated remote gesture guidance by augmenting the object with the Helping Hands of a health professional. A laboratory-based study and field trial tested usability and feasibility of the remote guidance system. The study found the Helping Hands system did not compromise learning outcomes. This innovation has the potential to transform remote learning and teaching supervision by enabling health professionals and students opportunities to develop and improve their procedural performance at the workplace.

Successful implementation of mobile technology for informal learning and continuing professional development within healthcare settings cannot be achieved or sustained, until end-users recognise that the benefits of using this innovation, outweigh the issues of non-use. At a systems level there is a need for standards, guidelines and codes of conduct to support deployment of mobile technology at an individual level. The aim of this research was to explore findings of a previous focus group study to elucidate priorities for action, provide evidence and focus impetus for advocating progression of the installation of standards and guidelines at an organisation level. The study confirms nurse supervisors' preparedness and readiness to employ mobile learning at point of care. However, successful implementation requires organisations engaging with, and embracing the evolving digital landscape, and supporting this new andragogy. Organisational level commitment will promote contemporary nursing practice, support the best clinical outcomes for patients, and provide educational support for nurses. Nurse leaders and professional bodies must drive and guide development of robust standards, guidelines, and codes of conduct to prioritise mobile learning as a component of digital professionalism within healthcare organisations.

Background. Little research has been conducted about the quality, benefits, costs, and financial considerations associated with health information technology (HIT), particularly informatics technologies, such as e-prescribing, from the perspective of all its stakeholders.

Objectives. This research effort sought to identify the stakeholders involved in e-prescribing and to identify and rank-order the positives and the negatives from the perspective of the stakeholders to create a framework to assist in the development of incentives and payment mechanisms which result in better managed care.

Methods. The Delphi method was employed by enlisting a panel of experts. They were presented with the results of initial research in an online survey of questions which sought to prioritize the quality, benefit, cost, and financial effects of e-prescribing from the perspective of each stakeholder. From the results of this study, a framework was presented to framework experts.

Results. The experts added stakeholders and positives and negatives to the initial lists and rank-ordered the positives and negatives of e-prescribing from the perspective of each stakeholder. The aggregate results were summarized by category of stakeholder. The framework experts evaluated the framework.

Conclusions. Positives and negatives can be rank-ordered from the perspective of each stakeholder. A useful framework was created.

This is a project proposal derived from an urge to re-define the governance of ICT in healthcare towards regional and national standardization of the patient pathways. The focus is on a two-levelled approach for governing EPR systems where the clinicians' model structured variables and patient pathways. The overall goal is a patient centric EPR portfolio. This paper define and enlighten the need for establishing the socio- technical architect role necessary to obtain the capabilities of a modern structured EPR system. Clinicians are not capable to moderate between the technical and the clinical.

Information and communication technologies (ICT) have the potential to greatly enhance our ability to develop community reliance and sustainability to support disaster management. However, developing community resilience requires the sharing of numerous resources and the development of collaborative capacity, both of which make ICT design a challenge. This paper presents a framework that integrates community based participatory research (CBPR) and participatory design (PD). We discuss how the framework provides bounding to support community driven ICT design and evaluation.

Clinical communication and clinical supervision of junior healthcare professionals are identified as the two most common preventable factors to reduce medical errors. While multiple strategies have been implemented to improve clinical communication, clinical supervision has not attracted as much attention. This is in part due to the lack of understanding of clinical supervision. Furthermore, there is a lack of exploration of information communication technology (ICT) in assisting the delivery of clinical supervision from the perspective of users (i.e. junior clinicians). This paper presents a study to understand clinical supervision from the perspective of medical and pharmacy interns. The important elements of good clinical supervisors and good clinical supervision have been presented in this paper based on our study. More importantly, our results suggest a distinction between good supervisors and good supervisions. Both these factors impact on patient safety. Through discussion of user requirements of good supervision by users (interns), this paper then explores and presents a conceptual framework to assist in the discussion and design of ICT by healthcare organisations to improve clinical supervision of interns and therefore improve patient safety.

Heart failure is a prevalent, progressive chronic disease costing in excess of $1billion per year in Australia alone. Disease self-management has positive implications for the patient and decreases healthcare usage. However, adherence to recommended guidelines is challenging and existing literature reports sub-optimal adherence. mHealth applications in chronic disease education have the potential to facilitate patient enablement for disease self-management. To the best of our knowledge no heart failure self-management application is available for safe use by our patients. In this paper, we present the process established to co-design a mHealth application in support of heart-failure self-management. For this development, an interdisciplinary team systematically proceeds through the phases of Stanford University's Design Thinking process; empathise, define, ideate, prototype and test with a user-centred philosophy. Using this clinician-led heart failure app research as a case study, we describe a sequence of procedures to engage with local patients, carers, software developers, eHealth experts and clinical colleagues to foster rigorously developed and locally relevant patient-facing mHealth solutions. Importantly, patients are engaged in each stage with ethnographic interviews, a series of workshops and multiple re-design iterations.

This paper uses a qualitative approach, specifically; narrative analysis, to contextualize user's formulation of an understanding of a personalized meal planning service within the ambient assisted living domain. By focusing on how user's, in this case elderly over 65, formed an understanding of a service, and, what they thought valuable in using the service, based on their understanding. The results indicate how user's compare their initial understanding to their experienced understanding, formed during usage, and how this affects their value formulation of specific service aspects. The paper gives not only provides valuable insight into contextualizing aspects of health and wellness services, but to aspects of importance for implementation, by showing how value aspects of services from a user perspective are important to consider during these processes.

Information communication technologies (ICTs) may improve health delivery by enhancing informational continuity of care and enabling secondary use of health data including public health surveillance and research. ICTs also introduce concerns related to privacy. In this paper, we examine and address this tension in the context of the development and implementation of a novel platform that will enable the documentation and communication of patient-specific ADE information, titled ActionADE. We explored privacy concerns qualitatively from the perspective of patients. Our findings will inform a series of recommendations for system design that seek to balance the need to both share and protect personal health information.

There is a widespread consensus that it is important to involve patient in their own care, both for the reasons of quality and safety in healthcare and for the sake of the patients' individual rights. The appreciation of patient participation and related notions such as patient empowerment, patient centered care, patient involvement, patient as co-producers of health et cetera, indicate that the role of the patient have changed over the last decades. It has changed from being a passive recipient of treatment to becoming an active and responsible agent. In this paper, we examine these new roles of the patients and discuss the challenges in realizing them. We include the notion of Patient Reported Outcome (PRO) and suggest that realizing this concept indicate a shift in the understanding of participation/empowerment. Participation of patients in a PRO paradigm means to provide patient with a highly-structured task both in terms of the kind of information the health care system requests, and in terms of how and when. It means to focus on what patients do. Further we suggest that a more precise term to denote the new role allocated to the patient would be patient work, not participation or empowerment. To recognize that being a patient is work, would imply a direct emphasis on competences required and the the time needed, on the division of labor and on the necessary condition for doing the work.

eHealth applications can allow patients to view, manage and track their health conditions while also allowing healthcare providers to monitor and update their patients' healthcare information in a timelier manner. There is a need for studies to describe what common ground is needed for eHealth applications to facilitate communication between patients and healthcare providers. This paper proposes the Patient-Healthcare Provider Factors for Communication (PHPFC) model that describes patient and provider eHealth communication factors as well as a set of integrated factors to support development of common ground between the two groups.

Stimulating widespread interests of the population to participate in behavioural changes through information and technology has been an aim of much health informatics research. The recent widespread participation of the augmented reality game Pokémon Go which encourages exercises, provides significant insights into the potential of information technology to improve healthcare intervention on obesity-related disease. Does Pokémon Go point to another way of achieving health benefits using mobile devices? This paper analyses the features of Pokémon Go in relation to potential health benefits. This paper suggests from the perspective of a user on changes to the game that potentially could help with obesity, mental health cardiovascular health and vitamin D deficiencies. While the impact of augmented reality games on improving exercises might be substantial, the question of sustainability and likely long-term health outcomes remain debatable. The rapid uptake of Pokémon Go by the population around the world, however, should serve as a useful lesson for information and technological design to improve outcomes obesity-related diseases in the future.

The aging population creates tremendous pressure to healthcare. To resolve, scholars recognized the solution to this challenge is integrated care. To facilitate integrated care, health information technologies (HIT) is a critical enabler. This paper will first review how technology enhanced integrated care, and review on the existing literatures in system effective use and the three key external factors that enable HIT implementation. Applying Burton-Jones and Volkoff's contextualized theories of effective use of HIT to understand the role of health informatics and technology in the unique context of Hong Kong, we have conducted a case study research to identify the levers for improving HK integration of care through HIT.