Ebook: Driving Quality in Informatics: Fulfilling the Promise

“If you build it, they will come.”

In the past, this seemed to be the dominant paradigm for technology development and implementation in healthcare. This initial paradigm often led to poor user satisfaction and failed implementations of healthcare information technology. In the last few decades, informatics has embraced user-centered design principles to improve both the design and adoption of information and communication technologies. However, frequently the end-user is perceived to only be the clinician.

Although the data in healthcare are about and are received from patients, patients are not usually perceived of as end-users of health information or health information technology. In the popular press, we are seeing a grass-roots effort from patients to change their role in their own health management. A change to a more dynamic partnership with clinicians means we need tools that are able to support patients as well as clinicians in this partnership. New online tools and mobile applications are sprouting up to fill the demand, but rigorous evaluation of these tools can be lacking; leading to questionable quality and concerns for patient safety. The informatics field has the expertise to provide critical leadership in this area.

The call for this year's conference asked for authors to consider the role and voice of the patient. Patients themselves were invited to contribute papers describing their experiences in healthcare and their use of their own data. The papers here reflect not only the informatics innovations in the field, but also explore how to include the patients when considering design, implementation and long-term adoption of health information systems.

We hope that the knowledge shared between ITCH 2015 participants will generate further discussions and collaborations and lead to breakthroughs in delivering effective and inclusive healthcare worldwide.

Karen Courtney

School of Health Information Science

University of Victoria

Victoria, British Columbia

Canada

Training providers appropriately, particularly early in their caregiving careers, is an important aspect of electronic medical record (EMR) implementation. Considerable time and resources are needed to bring the newly hired providers ‘up to speed’ with the actual use practices of the organization. Similarly, universities lose valuable clinical training hours when students are required to spend those hours learning organization-specific EMR systems in order to participate in care during clinical rotations. Although there are multiple real-world barriers to university/health care organization training partnerships, the investment these entities share in training care providers, specifically nurses, to use and understand EMR technology encourages a question: What would be the cumulative effect of integrating a mutually agreed upon EMR system training program in to nursing classroom training on downstream hospital costs in terms of hours of direct caregiving lost, and benefits in terms of number of overall EMR trained nurses hired? In order to inform the development of a large scale study, we employed a dynamic systems modeling approach to simulate the theoretical relationships between key model variables and determine the possible effect of integrating EMR training into nursing classrooms on hospital outcomes. The analysis indicated that integrating EMR training into the nursing classroom curriculum results in more available time for nurse bedside care. Also, the simulation suggests that efficiency of clinical training can be potentially improved by centralizing EMR training within the nursing curriculum.

Innovation in healthcare services and clinical service redesign is a must because currently gaps exist between the care that people should receive for disease management and the actual care they receive. Directors and other decision makers should be aware of key challenges in the design, implementation and deployment of telehealth. In this paper, we discuss how telehealth enable chronic disease management, population health management and patient engagement, and what are the biggest challenges with getting value out of telehealth.

The objective of this paper is to investigate the experiences of using a digital marketing platform to promote the use of an internet based health encyclopedia in Saudi Arabia. Key informant interviews, meeting documentation, and Google Analytics were the data collection sources used in the study. Findings show that using a digital marketing platform led to a significant increase in the number of visitors to the health encyclopedia. The results demonstrate that digital marketing platforms are effective tools to be used for promoting internet based health education interventions. Future work will examine long-term educational impacts and costs in using digital marketing platforms to promote online healthcare sites in Saudi Arabia.

The objective of this paper is to report on the preliminary findings of the implementation process of a pharmacy inventory management system at a local Saudi hospital. Meeting documents, key informant interviews, and experience of the researcher were part of the data collection sources used in the study. A thematic analysis of the data was conducted. Preliminary findings show that the implementation process of the pharmacy inventory management system needs the involvement and support of senior management and experienced technical expertise. Future research will focus on investigating the impacts of the pharmacy inventory management system on workflow and medication errors.

The objective of this paper is to investigate the experiences of implementing a pharmacy automation drug dispensing system in Saudi Arabia. Key informant interviews, meeting documents, and experience of the researcher were the data collection sources used in the study. A thematic analysis of the data was conducted. Study results discuss the organizational challenges prior to implementation as well as details of the implementation process. Preliminary results show improvements in the services provided by the pharmaceutical department. Lessons learned are also discussed. The work presented in this paper is preliminary and more research is needed to evaluate the overall impact of the new pharmacy automation system on services provided by the pharmaceutical department.

This paper outlines a quality assurance (QA) process and a multiple case, explorative, electronic medical records (EMRs) project in Ontario. The project, dedicated to Advancing and Leveraging the Investment Value of EMRs (ALIVE) was an eight-month investigation of improvements to EMRs in terms of the technical elements of patient records that could be optimized through data standardization and the social elements needed to integrate value into the everyday functioning of primary care (PC) organizations. We argue that standardized and structured data offer substantial clinical value in PC insofar as it enables more proactive chronic disease prevention and management (CDPM). While PC clinicians may have had the opportunity to look the other way with respect to enabling technologies in the past, imminent health system reforms demand more meaningful use of EMRs moving forward.

Nurses have an immense impact on the growth and scope of Telehealth as they embrace diverse roles. TeleNursing introduces transformational change which positively impacts both clients and providers, increasing access to care and reducing the time and costs associated with traveling for health care. Integration of clinical support and remote diagnostic tools inspire new uses of Telehealth, thus enabling care previously only possible in person to be delivered virtually. Nurses currently leverage Telehealth to deliver care and education, monitor clients remotely and support medical consultations. Over 90% of Island Health nurses surveyed recommend Telehealth as a care modality to clients and 100% support Telehealth as a means to increase care to vulnerable communities. Programs wish to increase uptake of TeleNursing but face numerous challenges regarding funding, resourcing, scheduling and geographical ownership. TeleNursing goes beyond clinical support and has the potential to exponentially expand Telehealth services, normalizing Telehealth as a care modality. Nurses look to Telehealth to improve their ability to partner with clients over distance, providing surgical care, maternal/pediatric care and group education

One information source for the Personally Controlled Electronic Health Record is the consumer repository. This paper reports on the use of community based participatory research, as a project method, derived from an initiative where people with complex chronic conditions and their carers attended a rural health promotion and lifestyle modification program. Through co-operative inquiry embedded in the research approach, health promotion workers and their clients were actively supported to adopt and use the PCEHR as an intervention. Simultaneously they were encouraged to reflect on its design, mechanisms for its implementation and their perceptions of its overall impact on consumer's ability to self-manage complex conditions.

Healthcare costs are driven by a surprisingly small number of patients. Predicting who is likely to require care in the near future could help reduce costs by pre-empting use of expensive health care resources such as emergency departments and hospitals. We describe the design of an architecture for a joint hospital-primary care data warehouse (JDW) that can monitor the effectiveness of in-hospital interventions in reducing readmissions and predict which patients are most likely to be admitted to hospital in the near future. The design identifies the key governance elements, the architectural principles, the business case, the privacy architecture, future work flows, the IT infrastructure, the data analytics and the high level implementation plan for realization of the JDW. This architecture fills a gap in bridging data from two separate hospital and primary care organizations, not a single managed care entity with multiple locations. The JDW architecture design was well received by the stakeholders engaged and by senior leadership at the hospital and the primary care organization. Future plans include creating a demonstration system and conducting a pilot study.

There is a knowledge gap regarding the human factors that can lead to successful implementation and adoption of health technologies specific for supporting people with dementia (PD) and their spousal caregivers (SC). This paper extends and applies a community-based framework to review some recent examples of technologies and studies that have targeted this population. Examined characteristics include the: people, environment, task management, technology implementation and design, and the ethical and socio-technical considerations associated with technologies used to support PD in the community.

We are investigating the feasibility and effectiveness of establishing a library of patient narratives to inform patient-centered research in the U.S. Veterans Affairs organization. Using qualitative methods, we conducted a needs assessment of 15 researchers and then interviewed and videotaped 11 veterans with traumatic brain injury or diabetes. We developed a method for displaying the narratives to researchers modeled after a UK initiative called DIPEx and then performed preliminary usability testing. We found that it is not only feasible to provide researchers with patient narratives that could help guide their research, but that similar narratives might be useful to practitioners, health system decision makers, and other patients as well.

There is a need to determine if organizations working with health information technology are aware of technology-induced errors and how they are addressing and preventing them. The purpose of this study was to: a) determine the degree of technology-induced error awareness in various Canadian healthcare organizations, and b) identify those processes and procedures that are currently in place to help address, manage, and prevent technology-induced errors. We identified a lack of technology-induced error awareness among participants. Participants identified there was a lack of well-defined procedures in place for reporting technology-induced errors, addressing them when they arise, and preventing them.

There is a potential to reduce medication errors by supporting the use of medication reconciliation through electronic Personal Health Records. The lead user method was used to identify specific goals and activities that are required to have in an electronic medication reconciliation tool and to provide a synthesized visual design that would reflect these requirements. Lead users identified two major functionalities of a proposed medication reconciliation tool: ability to view and edit certain medication information when reconciling medication lists and share most current, reconciled medication lists with selected providers.

The paper presents results from a workshop with a group of patients in a Danish General Practice (GP). The workshop facilitated a dialogue on patients' roles and activities in daily health care by using a participatory design inspired method and pointed towards a pluralistic view on patients' participation represented by the terms ‘mixed’, ‘social’ and ‘fluent participation’. The results challenge future research on Information and Communication Technology to support patient participation in health promoting activities by questioning how to embrace pluralistic opportunities for patient participation, which is especially important to GPs treating a broad group of patients.

Danish citizens' attitudes and expectations to eHealth is being investigated in this paper with the aim is to explore how the Danish citizens perceive eHealth. Data has been collected through a national survey with 1.058 respondents (80% participated by e-mail, 20% by telephone). We found that the majority of the Danish citizens had experience with use of eHealth and a positive view on eHealths impact on future healthcare. However, the citizens neither using nor trusting eHealth, belong to the socio-economic weak population with no or very little education suggesting a need for the designers and planners to revisit their patient empowerment strategies.

Accessing appropriate clinical placement positions for all health profession students can be expensive and challenging. Increasingly simulation, in a range of modes, is being used to enhance student learning and prepare them for clinical placement. Commonly these simulations are focused on the use of simulated patient mannequins which typically presented as single-event scenarios, difficult to organise, and usually scenarios include only a single healthcare profession. Computer based simulation is relatively under-researched and under-utilised but is beginning to demonstrate potential benefits. This paper describes the development and trialling of an entirely virtual 3D simulated environment for inter-professional student education.

In this paper we describe our integration of teaching about the use of electronic health records into a fourth year undergraduate nursing course. We report on our method of integration and issues, challenges and limitations of the approach. We present our findings using a case study approach that includes a description of the context and EHR software used.

KnowMe is a patient created personal story of key life events both medical and non-medical that enables clinicians to understand what matters to the patient, not what's the matter with them. By shifting the Electronic Health Record (EHR) focus to knowing when a patient was at their best, what's important to them, their personal health goals, and care preferences, clinicians and patients can collaboratively work together in creating a treatment plan that aligns resources tailored to the their needs.

Clinical decision support (CDS) for atrial fibrillation is expected to ease the implementation of often-complex guidelines for atrial fibrillation and anticoagulation. Most clinical decision support systems (CDSS) for anticoagulation are stand-alone systems that do not integrate with electronic medical records (EMR). We have developed an architecture that consists of a computerized CDS that can integrate with multiple EMRs and multiple patient health records (PHRs). The design process revealed some significant issues that were resolved through systematic business/clinical analysis and creative clinical design in the diagnostic and treatment domains. Key issues identified and resolved include: 1) how to correctly allocate existing patients into various CDSS states (e.g., MAINTENANCE, HOLD, DISCONTINUE, etc), 2) identify when a patient becomes eligible for CDSS guidance over time, 3) how the CDSS maintains information about the patient's anticoagulation state and 4) how to transform vague human-readable concepts to explicit computable concepts. The management of anticoagulation for atrial fibrillation is no easy task and we believe our architecture will improve patient care at all levels and ultimately better balance the reduction of stroke risk while minimizing harms from major bleeding. In addition, the architecture presented is scalable to other treatment guidelines and is scalable to multiple EMRs and PHRs, making it suitable for use in a platform approach.

In both Europe and North America, patients are beginning to gain access to their health records in electronic form. Using the open source cityEHR as an example, we have focussed on the needs of clinical users to gather requirements for patient access and have implemented these requirements in a new application called cityEHR-PA. The development of a separate application for patient access was necessary to address requirements for security and ease of use. The use of open standards throughout the design of the EHR allows the possibility of third parties to develop applications for patient access, consuming the individual patient record extracted from the full EHR.

The overall purpose of this study was to learn how community-dwelling older adults would interact with our prototype multi-user telehealth kiosk and their views about its usability. Seven subjects participated in laboratory-based usability sessions to evaluate the physical design, appearance, functionality and perceived ease of use of a multi-user telehealth kiosk prototype. During usability testing participants recommended 18 new features (29% of comments), identified 15 software errors (23% of comments) and 29 user interface errors (47% of comments).

The complex process of developing policies and planning services requires the compilation and collation of evidence from multiple sources. With the increasing numbers of people living longer there will be a high demand for a wide range of aged care services to support people in ageing well. The premise of ageing well is based on providing an ageing population with quality care and resources that support their ongoing needs. These include affordable healthcare, end of life care improvement, mental health services improvement, care and support improvement for people with dementia, and support for healthy ageing. The National Health and Medical Research Council funded a research project to develop a policy tool to provide a framework to assist policy makers and service planners in the area of ageing well in rural and regional Australia. It was identified that development of an electronic version of the policy tool could be useful resulting in a small pilot development being undertaken and tested with policy makers and service planners. This paper describes the development and trialling of a tablet based application used to assess the acceptability of computerised forms for participants actively involved in policy development. It reports on the policy developer's experience of the electronic tool to support ageing well policy making based on evidence.

A pragmatic evaluation framework for evaluating the usability and usefulness of an e-learning intervention for a patient clinical information scheduling system is presented in this paper. The framework was conceptualized based on two different but related concepts (usability and usefulness) and selection of appropriate and valid methods of data collection and analysis that included: (1) Low-Cost Rapid Usability Engineering (LCRUE), (2) Cognitive Task Analysis (CTA), (3) Heuristic Evaluation (HE) criteria for web-based learning, and (4) Software Usability Measurement Inventory (SUMI). The results of the analysis showed some areas where usability that were related to General Interface Usability (GIU), instructional design and content was problematic; some of which might account for the poorly rated aspects of usability when subjectively measured. This paper shows that using a pragmatic framework can be a useful way, not only for measuring the usability and usefulness, but also for providing a practical objective evidences for learning and continuous quality improvement of e-learning systems. The findings should be of interest to educators, developers, designers, researchers, and usability practitioners involved in the development of e-learning systems in healthcare. This framework could be an appropriate method for assessing the usability, usefulness and safety of health information systems both in the laboratory and in the clinical context.

Adherence is the degree to which patients comply with their caregivers prescribed treatments. Lack of adherence due to various causes negatively affects health objectives. Prior work in the field of medication management has indicated the usefulness of IT as a possible aid for those who have difficulty adhering to prescribed medication regimes. In this paper we present a medication management system (SmartMed) that has been designed to monitor and increase adherence. The SmartMed system consists of a portable pill bottle device, a local base station, and a cloud data service. It reminds users when it is time to take their medications, and acquires adherence data which is accessible for applications that query the data service. The project was undertaken as an undergraduate engineering design project. This paper describes the design and prototype implementation of this system and provides direction for future work.