Health Information Technology Systems Research Articles

Physician champions' perspectives and practices on electronic health records implementation: challenges and strategies.

ObjectivePhysician champions are “boots on the ground” physician leaders who facilitate the implementation of, and transition to, new health information technology (HIT) systems within an organization. They are commonly cited as key personnel in HIT implementations, yet little research has focused on their practices and perspectives.Materials and MethodsWe addressed this research gap through a qualitative study of physician champions that aimed to capture their challenges and strategies during a large-scale HIT implementation. Email interviews were conducted with 45 physician champions from diverse clinical areas 5 months after a new electronic health record (EHR) system went live in a large academic medical center. We adopted a grounded theory approach to analyze the data.ResultsOur physician champion participants reported multiple challenges, including insufficient training, limited at-the-elbow support, unreliable communication with leadership and the EHR vendor, as well as flawed system design. To overcome these challenges, physician champions developed their own personalized training programs in a simulated context or in the live environment, sought and obtained more at-the-elbow support both internally and externally, and adapted their departmental sociotechnical context to make the system work better.Discussion and ConclusionsThis study identified the challenges physician champions faced and the strategies they developed to overcome these challenges. Our findings suggest factors that are crucial to the successful involvement of physician champions in HIT implementations, including the availability of instrumental (eg, reward for efforts), emotional (eg, mechanisms for expressing frustrations), and peer support; ongoing engagement with the champions; and appropriate training and customization planning.

Using an Evidence-Based Approach for Electronic Health Record Downtime Education in Nurse Onboarding.

Electronic health record systems have been widely implemented throughout healthcare settings over the last few years, and nurses rely on these systems to obtain information about patients, make clinical decisions, and deliver safe and appropriate care. Health information technology systems have electronic health record downtime episodes both due to scheduled maintenance and unforeseen circumstances. The ability to deliver safe and effective care during electronic health record downtime episodes is important, yet training on electronic health record downtime is rarely included for nursing staff. This quality improvement project implemented an electronic health record downtime training course and administered it to 50 onboarding nurses within the hospital facility. The participants indicated a positive perception of electronic health record downtime preparedness after the course offering related to ability to find and follow downtime procedures. However, no precourse metrics were obtained, and therefore it is uncertain if this positive perception is a direct result of the electronic health record downtime training course. While initial results are promising, further investigation will need to be conducted to determine training course effectiveness.

Minimizing Medication Errors from Electronic Prescription Transmission-Digitizing Compounded Drug Preparations.

Lack of standardization related to compounded drug preparations, especially in the transition of care situations, threatens patient safety by facilitating medication error. This paper outlines progress to-date from the United States Pharmacopeia (USP) Expert Panel on the Exchange of Compounded Drug Preparation Information in Health IT Systems. The work plan developed for the group is focused on proposing a set of encoding rules that would govern how compounded nonsterile drug preparations (CNSPs) are digitized and exchanged, including patient electronic health records (EHR), pharmacy systems, e-prescribing (eRx), and other Health IT (HIT) systems to ensure a seamless compounding process tailored to the needs of an individual patient. Included in this work are identifying authorized compounding monographs, surveying provider and end-user groups for information about data specificity during e-prescribing, and generating guidelines for the development of a compatible data model for clinical formulation identifiers (CF-IDs). This paper will also discuss how evolving nomenclature standards for CNSPs within HIT systems are part of a quality assurance system for comprehensive medication management (CMM) in children, thereby minimizing medication errors across the continuum of care. Finally, a network approach for the design of medication management systems for children and their families/caregivers is proposed.

Key Factors Affecting Ambulatory Care Providers' Electronic Exchange of Health Information With Affiliated and Unaffiliated Partners: Web-Based Survey Study.

BackgroundDespite the potential benefits of electronic health information exchange (HIE) to improve the quality and efficiency of care, HIE use by ambulatory providers remains low. Ambulatory providers can greatly improve the quality of care by electronically exchanging health information with affiliated providers within their health care network as well as with unaffiliated, external providers.ObjectiveThis study aimed to examine the extent of electronic HIE use by ambulatory clinics with affiliated providers within their health system and with external providers, as well as the key technological, organizational, and environmental factors affecting the extent of HIE use within and outside the health system.MethodsA Web-based survey of 320 ambulatory care providers was conducted in the state of Illinois. The study examined the extent of HIE usage by ambulatory providers with hospitals, clinics, and other facilities within and outside their health care system–encompassing seven kinds of health care data. Ten factors pertaining to technology (IT [information technology] Compatibility, External IT Support, Security & Privacy Safeguards), organization (Workflow Adaptability, Senior Leadership Support, Clinicians Health-IT Knowledge, Staff Health-IT Knowledge), and environment (Government Efforts & Incentives, Partner Readiness, Competitors and Peers) were assessed. A series of multivariate regressions were used to examine predictor effects.ResultsThe 6 regressions produced adjusted R-squared values ranging from 0.44 to 0.63. We found that ambulatory clinics exchanged more health information electronically with affiliated entities within their health system as compared with those outside their health system. Partner readiness emerged as the most significant predictor of HIE usage with all entities. Governmental initiatives for HIE, clinicians’ prior familiarity and knowledge of health IT systems, implementation of appropriate security, and privacy safeguards were also significant predictors. External information technology support and workflow adaptability emerged as key predictors for HIE use outside a clinic’s health system. Differences based on clinic size, ownership, and specialty were also observed.ConclusionsThis study provides exploratory insights into HIE use by ambulatory providers within and outside their health care system and differential predictors that impact HIE use. HIE use can be further improved by encouraging large-scale interoperability efforts, improving external IT support, and redesigning adaptable workflows.

Visualizing Purpose and Functionality Overlaps of Health IT Systems using an Abstraction Hierarchy

The development of health IT fuels a digitalization process that affects the work of hospital staff negatively in the case of poor integration of IT systems. A challenge lies in keeping track of the existing IT systems and possible overlapping functions. The Abstraction Hierarchy model from the Cognitive Work Analysis framework describes how parts of a complex system relate to the over-arching goals of the system, which could work as an overview of the IT systems. In this study, we explore how an Abstraction Hierarchy can be used to visualize how IT systems’ functions overlap, interfere with, or depend on each other. The Abstraction Hierarchy was developed based on documentation, interviews, and a study visit at a hospital ward. The overlaps in functionality visualized in the Abstraction Hierarchy could serve as indicators for the need for further investigation of effects on the hospital staff’s work.

A service-based RBAC & MAC approach incorporated into the FHIR standard

Health Information Exchange (HIE) provides a more complete health record with the aim to improve patient care with relevant data gathered from multiple Health Information Technology (HIT) systems. In support of HIE, the Health Level Seven (HL7) XML standard was developed to manage, exchange, integrate, and retrieve electronic health information. In 2011, the Fast Healthcare Interoperable Resources (FHIR) standard, based on HL7, was proposed to facilitate the development of mobile Health (mHealth) apps with HIT data sharing via a common modeling format. FHIR utilizes RESTful APIs enabled with a FHIR server for information usage and exchange in the cloud. FHIR has a security specification, but does not define actual security mechanisms for secure data exchange via service invocations. If services are the primary means of access, there must be a way to control who can invoke which service at which time. This paper proposes the use of Role-Based Access Control (RBAC) and Mandatory Access Control (MAC) to define permissions based on role and/or the sensitivity level of services. This is accomplished by evolving RBAC and MAC to support permissions on services (as opposed to the usual object view) at a model level applied to a setting where a mobile application is using RESTful APIs. The resulting service-based model is incorporated into the FHIR standard to control the access of who can invoke which services of FHIR RESTful APIs that manage the sensitive healthcare data; work is demonstrated via an mHealth application that interacts with the OpenEMR HIT system via the HAPI FHIR server.

Health Information Technology System ("Roadmap 2.0") in the Context of Hematopoietic Cell Transplantation

Health Information Technology System ("Roadmap 2.0") in the Context of Hematopoietic Cell Transplantation

Patient-centered Design Grounded in User and Clinical Realities: Towards Valid Digital Health

Valid design of patient-centered digital health or health information technology (IT) systems is based on a thorough and accurate understanding of both “user reality” and “clinical reality.” Type 1 Design Error (User-Reality Error) occurs when designers do not accommodate user characteristics, tasks, context of use, needs, or preferences. Type 2 Design Error (Clinical-Reality Error) occurs when designers do not accommodate the clinical reality, including biomedical knowledge, clinical workflows, and organizational requirements. Both types of errors can invalidate the design, leading to products being rejected by patient end-users or their healthcare delivery systems, product non-use or inappropriate use, and risk of harm. This paper describes our attempts to achieve valid health IT design and avoid the two design errors. We performed iterative, patient-centered design to prototype a mobile application, Power to the Patient (P2P), supporting heart failure self-care management. Our multidisciplinary team of human factors, cardiology, and design experts developed and iteratively refined requirements based on data collection, review, and testing with patient research participants, a patient advisory board, a clinical advisory board, and experts on the team. We describe our process and reflect on working with multiple stakeholders toward the goal of valid health IT design.

Assessment of non-negative matrix factorization for the preprocessing of long-term ECG

Background. With the advent of health information technology and wearable acquisition systems, long-term ECG are more and more used in long-term cardiac tolerability studies of new compounds. Nevertheless, the accurate analysis of such long signals requires reliable and fast signal processing algorithms. Objectives. The objective of this study is to assess the practical relevance of innovative matrix factorization methods for the preprocessing of long-term ECG. Those signals are generally noisy with complex baseline wander and require preprocessing, such as filtering, to perform a correct analysis. Our goal is to present two innovative algorithms of matrix factorization to detect R-peaks in long-term ECG. Methods. The two tested methods are called Independent Component Analysis (ICA) and Non-Negative Matrix Factorization (NMF). They are both source separation methods whose goal is to isolate each component of an ECG: R-peak, P and T waves, noise, baseline wander etc. On the one hand, ICA assumes that all subcomponents of the signal are statistically independent from each other and on the other hand, Non-Negative Matrix Factorization is a method that uses the non-negativity of the spectrogram of the ECG to separate the different time-frequency patterns. The two signal processing methods were implemented in the Matlab computing environment. Results. The proposed approaches are tested on the MIT-BIH Arrythmia and Noise Stress Test databases: ICA shows a strong drawback by returning the different sources in a random order making compulsory a reconnaissance step or the action of a specialist. Whereas NMF achieves high results in terms of sensitivity and specificity in general even in case of complex baseline wander and highly noisy signals. Conclusion. This study emphasizes promising results of a new long-term ECG preprocessing technique based on a matrix factorization method. This approach simultaneously undertakes three tasks: denoising, baseline wander removal and peak R detection.

Developing a Safety Case for Electronic Prescribing.

It is now recognised that Health IT systems can bring benefits to healthcare, but they can also introduce new causes of risks that contribute to patient harm. This paper focuses on approaches to modelling and analysing potential causes of medication errors, particularly those arising from the use of Electronic Prescribing. It sets out a systematic way of analysing hazards, their causes and consequences, drawing on the expertise of a multidisciplinary team. The analysis results are used to support the development of a safety case for a large-scale Health IT system in use in three teaching hospitals. The paper shows how elements of the safety case can be updated dynamically. We show that it is valuable to use the dynamically updated elements to inform clinicians about changes in risk, and thus prompt changes in practice to mitigate the risks.

How Do Healthcare Professionals Personalize Their Software? A Pilot Exploration Based on an Electronic Health Records Search Engine.

To improve user experience, many health IT systems provide personalization options allowing end users to tailor the software to their needs and preferences. However, few studies have investigated if healthcare professionals actually make full use of this feature. As an initial step towards understanding end users' software personalization behavior in healthcare, we conducted a pilot study to examine how clinicians, staff, and researchers customized a search engine designed to facilitate information retrieval from electronic health records. The results show that a majority of the end users (82.4%) did not make an effort to modify the system's default settings. Among those who did, they more often changed its 'look-and-feel' than its functionality offerings. We conclude that future research is warranted to study the rationale underlying healthcare professionals' software personalization decisions both to optimize user experience and to avoid building complex and costly personalization options that are unused or underutilized.

Open or Closed: A Project Proposal for Investigating Two Different EHR Platform Approaches.

Technical platforms form the fundament on which IT systems and Electronic Health Records (EHRs) are implemented. The use of either open or proprietary standards and technologies for information modelling and interoperability have implications for how clinical and health data is handled and made available for the system users. In Norway, two different EHRs are procured in different health regions of the Specialist healthcare service. The two platforms are characterized as one being open platform-based and the other being closed platform-based. The study aims to identify and describe consequences and implications related to two different platform approaches for EHRs from an end-user perspective. The study will employ three methods of data capturing; scoping study, interviews, and questionnaires. Data will be systematically analyzed through proven methods. Interviews and questionnaire data will be gathered from European hospitals having implemented EHRs in recent years. Results will be compared to the Norwegian context. The technical platform used for health IT systems in general, and the EHR specifically, can have substantial consequences for clinicians and organization of work. Closed platform-based EHRs still constitutes the majority of the market, but open platform approaches are rapidly gaining popularity. An assessment of the consequences related to different platform designs can shed light on the implications the chosen technical approach will have on clinical and organizational practice.

Sustainable Information Infrastructures: Insights from a Realist Synthesis.

Policy makers and health system managers in many countries are advocating the deployment of inter-operable health information technology systems, spanning organisations in a health economy, believing that they will be clinically effective. The case for investments has not, however, been made to date. This paper presents early results from a systematic review of the effects of inter-operable systems on patient safety. The review uses the realist synthesis method, which focuses on evidence about the decisions and actions that link interventions and outcomes, as well as the evidence about those outcomes. The evidence base is sufficient to identify plausible arguments for investments in inter-operable systems. This said, there is limited empirical evidence about each of the steps in the sequences of events. We comment on implications for the design of sustainable socio-technical solutions. We suggest that current gaps in the evidence base are in areas where informatics field methods can make a valuable contribution to our understanding of the role of inter-operable systems in patient safety.

Emotional Intelligence and Online Healthcare

As the North American healthcare system moves to online value-based care, the importance of engaging patients and families continues to intensify. However, simply engaging patients and families to improve their subjective satisfaction will not be enough for providers who want to maximize value. True optimization entails developing deep and long-term relationships with patients through understanding their needs. This article discusses the result of a research conducted in Canada. Out of 1100 questionnaires which were distributed, 850 valid returns were obtained. The collected data were analyzed using a SPSS 20.0 statistical. The findings indicate that IT healthcare is rapidly growing. However, despite a significant number of initiatives in Canada related to online health information, lack of interoperability remains one of the major challenges in implementing successful health IT systems at this time.

Organizational implications of implementing a new adverse drug event reporting system for care providers and integrating it with provincial health information systems.

Cross-sector collaborations between academia, government, and private industry, known as Triple Helix configurations, are increasingly common. In the health Information Technology (IT) sector, such configurations often also include health delivery organizations where technology is implemented and used. The complexity of collaborating within and between multiple organizations can present hurdles for innovators that are seldom discussed in the literature. We outline challenges we encountered in cross-sector collaboration and offer some guiding principles for decision-makers, academics, industry partners, and health delivery organizations to successfully negotiate divergent approaches to innovation and implementation. We discuss an innovative project that aims to implement a researcher-designed adverse drug event reporting system into clinical care and integrate it with provincial and health authority IT systems. Based on our experience, implementing an interoperable health IT system must extend beyond technical integration to encompass meaningful stakeholder engagement to ensure utility for end-users and beneficial impact for participating organizations.

Patientensicherheitsgefährdungen durch die Nutzung von IT in onkologischen Ambulatorien: eine prospektive Analyse des Informationsmanagements

ObjectivesThorough management of patient information is crucial in cancer care in order to avoid errors. Clinicians need complete, up-to-date information to be able to develop an adequate mental model of the patient's situation. The aim of the present study was to identify patient safety hazards coming with the use of health information technology (HIT): patient safety hazards in three outpatient oncology infusion centers were assessed and priority topics identified. Additionally, the number of information sources clinicians have to use in order to get an idea of the patient's situation was systematically assessed. Interviews and observations were conducted with one nurse and one doctor of each ambulatory infusion center. Principal resultsInformation management-related patient safety hazards were omnipresent in daily care: eleven topics were identified from 125 assessed patient safety hazards. Three of them were particularly relevant to the clinicians’ development of an adequate mental model about the patient: patient-related information was not stored in one place but often fragmented in different HIT systems; despite the introduction of HIT, paper documentation remained in place for certain information, making access difficult and increasing the number of relevant sources; the lack of usability of the HIT systems made it difficult to retrieve patient information in a timely manner. Clinicians needed to use between 5 and 11 sources of information to get a more complete picture of a patient's situation. Major conclusionsOverall, it has been shown that the design of the HIT systems is not sufficiently adapted to the work processes and does not support clinicians in being fully informed about a patient. The topics identified point to future system design and areas for improvement. In this process, it is very important to align the real work requirements with the design of the HIT and to evaluate and monitor the actual implementation and use of HIT.

Real-Time Automated Hazard Detection Framework for Health Information Technology Systems

ABSTRACTAn increase in the reliability of Health Information Technology (HIT) will facilitate institutional trust and credibility of the systems. In this paper, we present an end-to-end framework for improving the reliability and performance of HIT systems. Specifically, we describe the system model, present some of the methods that drive the model, and discuss an initial implementation of two of the proposed methods using data from the Veterans Affairs HIT and Corporate Data Warehouse systems. The contributions of this paper, thus, include (1) the design of a system model for monitoring and detecting hazards in HIT systems, (2) a data-driven approach for analysing the health care data warehouse, (3) analytical methods for characterising and analysing failures in HIT systems, and (4) a tool architecture for generating and reporting hazards in HIT systems. Our goal is to work towards an automated system that will help identify opportunities for improvements in HIT systems.

Parental Perceptions of Displayed Patient Data in a PICU: An Example of Unintentional Empowerment.

To explore the perceptions of parents of pediatric patients in a PICU regarding real-time open electronic health record data displayed in patient rooms. Cross-sectional qualitative interview study. PICU in a large Midwestern tertiary-care children's hospital. Parents of patients in a PICU (n = 33). Qualitative data were collected through in-person semi-structured, individual, and small-group interviews. Data were collected from March 2016 to July 2016, with approval from the study hospital's institutional review board. Data were analyzed using inductive thematic analysis. Results included positive effects of accessing real-time open electronic health record data on family empowerment, situation awareness, potential error detection, understanding of medical data, and facilitating discussions during rounds. Concerns were reported regarding privacy of information as well as potential misinterpretation of displayed data. We identified several ways to improve this collaborative technology to make it more family-centered. This study suggests that a new health information technology system providing continuous access to open electronic health record data may be an effective way to empower and engage parents in the PICU, but potential drawbacks were also noted. The results also provide insights into the collaborative use of health information technology in the PICU setting.

Building Usability Knowledge for Health Information Technology: A Usability-Oriented Analysis of Incident Reports.

The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety. This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues? A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents. A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information. Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

Exploration and Initial Development of Text Classification Models to Identify Health Information Technology Usability-Related Patient Safety Event Reports.

With the pervasive use of health information technology (HIT) there has been increased concern over the usability and safety of this technology. Identifying HIT usability and safety hazards, mitigating those hazards to prevent patient harm, and using this knowledge to improve future HIT systems are critical to advancing health care. The purpose of this work is to demonstrate the feasibility of a modeling approach to identify HIT usability-related patient safety events (PSEs) from the free-text of safety reports and the utility of such models for supporting patient safety analysts in their analysis of event data. We evaluated three feature representations (bag-of-words [BOWs], topic modeling, and document embeddings) to classify HIT usability-related PSE reports using 5,911 manually annotated reports. Model results were reviewed with patient safety analysts to gather feedback on their usefulness and integration into workflow. The combination of term frequency-inverse document frequency BOWs and document embedding features modeled with support vector machine (SVM) with radial basis function (RBF) had the highest overall precision-recall area under the curve (AUC) and f1-score, 72 and 66%, respectively. Using only document embedding features achieved a similar precision-recall AUC and f1-score performance with the SVM RBF model, 70 and 66%, respectively. Models generally favored specificity and sensitivity over precision. Patient safety analysts found the model results to be useful and offered three suggestions on how it can be integrated into their workflow at the point of report entry, in a visual dashboard layer, and to support data retrievals. Text mining and document embeddings can support identification of HIT usability-related PSE reports. The positive feedback received on the HIT usability model shows its potential utility in real-world applications.