Health Information Technology Implementation Research Articles

Proceedings of the 10th Conference on Health IT & Analytics

Proceedings of the 10th Conference on Health IT & Analytics (CHITA 2019). CHITA is an annual health IT and analytics research summit, including a doctoral consortium that each year gathers prominent scholars from more than 40 research institutes, and leading policy and practitioner attendees in a vibrant setting to discuss opportunities and challenges in the design, implementation and management of health information technology, artificial intelligence and advanced analytics. Its goal is to deepen our understanding of strategy, policy and systems fostering health IT and analytics effective use and to stimulate new research ideas with both policy and business implications. This forum provides a productive venue to facilitate interaction and collaboration among academia, government, and industry. Now in its tenth year, each year CHITA draws over 100 participants. Convened by the Center for Health Information & Decision Systems (CHIDS), support for CHITA is provided by the Robert H. Smith School of Business, the University of Michigan School of Public Health, and the U.S. Agency for Healthcare Research and Quality.

Patient Safety Culture, Health Information Technology Implementation, and Medical Office Problems That Could Lead to Diagnostic Error.

Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment or by leading to unnecessary or harmful treatment. The aim of the study was to investigate the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting, such as unavailable test results, unavailable medical records, or unpursued abnormal results. We used survey data from 925 medical offices nationwide that voluntarily submitted results to the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database. At the office level, we ran a multivariate regression model to estimate the effect of culture on problem frequency while controlling for office-reported implementation levels of health IT, office characteristics such as the number of locations, and survey characteristics such as the percent of respondents that were physicians. The most frequent problem was "results from a lab or imaging test were not available when needed"; across 925 offices, the average was 15% reporting that it happened daily or weekly. Higher overall culture scores were significantly associated with fewer occurrences of each problem assessed. Compared with offices with completed health IT implementation, offices in the process of health IT implementation had higher frequency of problems. This study offers insight into how patient safety culture and health IT implementation in medical offices can influence the frequency of breakdowns in processes of care, thereby identifying potential vulnerabilities that can increase diagnostic errors.

Functional IT Complementarity and Organizational Impacts: A Longitudinal Investigation

This paper examines functional IT complementarity between health information technology (HIT) applications and their performance effects on hospital-level measures of cost and quality. In conceptualizing functional IT complementarity, we emphasize whether HIT applications perform primary or support tasks in the clinical process, and whether they are applied in the same or different functional domains. Additionally, emphasizing the use context, we study if HIT impacts vary for chronic and acute health conditions. Finally, we examine both simultaneous and sequential complementarity, which is a departure from existing research that has largely studied simultaneous complementarity. Using four secondary data sources, we collected longitudinal data on HIT implementation levels, care quality and cost on 715 hospitals located in seven states in the U.S. We examined pairwise and three-way complementarity effects of HITs. Our central message is that in studies of complementarity and HIT, it is critical to pay attention to the sequence of technology implementation, the context of use and the functions for which technological applications are used. Our findings indicate that HIT applications demonstrate pairwise and three-way complementarity effects on care quality and cost; HIT applications impact quality and cost differently for acute and chronic conditions; and HIT applications provide both simultaneous and sequential complementarity, wherein combinations of HIT are synergistic both within a single time period and across time periods. We also find that three-way complementarity has significant economic effects on clinical quality and cost and experiential quality. In fact, our post hoc analyses indicate that three-way sequential complementarity effects are particularly significant, which research can miss if three-way and sequential complementarities are not examined. Based on our empirical results, we develop seven propositions to extend HIT complementarity theorizing. Future research can contextualize these propositions and test them in different empirical contexts to contribute to the IT complementarity perspective. In light of the extensive research in HIT and IT complementarity, this study contributes to the IS literature by examining phenomena not emphasized in the prior literature, reporting new, consequential results, and providing nuanced theorizing in HIT and complementarity domains.

Change management and adoption of health information technology (HIT)/eHealth in public hospitals in Ghana: A qualitative study

In Ghana, as with other developing countries, there are several health information technology (HIT) initiatives as interventions to improve healthcare delivery. HIT implementation undoubtedly results in change. However, most studies relating to HIT implementation readiness have constantly neglected the role of change in successfully implementing HIT. This study intends to identify factors affecting successful change management as part of preparation towards successfully implementing HIT in public hospital in Ghana. To carry out this study, we conducted in-depth interviews with a matrix of HIT senior managers and thematically analyzed the data. The data was transcribed and uploaded into a Nvivo 11 software for analysis using thematic analysis techniques. Five (5) themes were discovered. They are: 1) Stakeholder participation; 2) Proof of experience in similar project; 3) Availability of committed change agents/all-levels-change representatives; 4) Clearly articulated change implementation strategy; and 5) Training and improvement mechanism (post-implementation). A fresh call is made for more attention to be paid to change as part of preparatory measures towards the adoption of HIT in Ghana using the five cardinal approaches identified as a guide.

Development of a Multi-Layer Systems Engineering Visualization for Diabetes Team Coordination

Systems engineering tools have proven helpful for healthcare organizations to map sociotechnical systems, particularly prior to health IT implementation. However, these systems engineering tools are limited in that they cannot easily capture the complexities of chronic care activities. The purpose of this work is to introduce Diabetes care Roles, Information Flows and Team coordination (DRIFT), a tool and visualization framework that addresses system granularity, temporal dynamics, and sociotechnical factors within a chronic care context. Task analyses, process mapping, and information flow attributes from (N=30) semi-structured interviews of diabetes care team members were synthesized in the creation of DRIFT, including recommendations for incorporation into clinical care team coordination tasks.

Everything but the Kitchen Sink: A Mixed Methods Approach to Health IT Usability Testing

Usability testing has become a necessary step to successfully implement health information technology, but despite the expanded variety of usability methods, systems still are not guaranteed to meet user needs in a hectic and dynamic healthcare environment. The present work discusses some of the metrics employed with the intent of usability testing clinical decision support alerts for the early identification of sepsis patients. By utilizing methods such as eye tracking, think aloud protocols, human computer interaction, and more, health information technology can be adequately developed to ensure effective, efficacious, and optimal integration.

Beyond TAM and UTAUT: Future directions for HIT implementation research.

The Technology Acceptance Model (TAM) and Unified Theory of Acceptance and Use of Technology (UTAUT) have been used widely in studies of health information technology (HIT) implementation. However, TAM and UTAUT have also been criticized for being overly simplistic (TAM) and for taking a narrow perspective, which focuses only on individual adopters' beliefs, perceptions and usage intention. Furthermore, with thousands of studies using these theories, their contribution to knowledge has reached a plateau. In this commentary, we discuss some of the criticism of TAM and UTAUT, and argue that biomedical informatics research would benefit from shifting attention from these theories to multi-dimensional approaches that can better capture the complexity of issues surrounding implementation and use of HIT. We propose a number of future undertakings which, in our opinion, are more likely to move the field forward.

Using Patient and Family Engagement Strategies to Improve Outcomes of Health Information Technology Initiatives: Scoping Review.

BackgroundMany health care organizations around the world have implemented health information technologies (ITs) to enhance health service efficiency, effectiveness, and safety. Studies have demonstrated that promising outcomes of health IT initiatives can be obtained when patients and family members participate and engage in the adoption, use, and evaluation of these technologies. Despite knowing this, there is a lack of health care organizations using patient and family engagement strategies to enhance the use and adoption of health ITs, specifically.ObjectiveThis study aimed to answer the following three research questions (RQs): (1) what current frameworks or theories have been used to guide patient and family engagement in health IT adoption, use, implementation, selection, and evaluation?, (2) what studies have been done on patient and family engagement strategies in health IT adoption, use, implementation, selection, and evaluation?, and (3) what patient and family engagement frameworks, studies, or resources identified in the literature can be applied to health IT adoption, use, implementation, selection, and evaluation?MethodsThis scoping review used a five-step framework developed by Arksey and O’Malley and adapted by Levac et al. These steps include the following: (1) identifying the RQ, (2) identifying relevant studies, (3) selecting studies, (4) charting relevant data, and (5) summarizing and reporting the result. Retrieved academic and grey literature records were evaluated using a literature review software based on inclusion and exclusion criteria by two independent reviewers. If consensus was not achieved, two reviewers would resolve conflicts by discussion. Research findings and strategies were extracted from the studies and summarized in data tables.ResultsA total of 35 academic articles and 23 gray literature documents met the inclusion criteria. In total, 20 of the 35 included studies have been published since 2017. Frameworks found include the patient engagement framework developed by Healthcare Information and Management Systems Society and the patient and family engagement framework proposed by Carman et al. Effective strategies include providing patients with clear expectations and responsibilities and providing reimbursement for time and travel. The gray literature sources outlined key considerations for planning and supporting engagement initiatives such as providing patients with professional development opportunities, and embedding patients in existing governance structures.ConclusionsSeveral studies have reported their findings regarding successful strategies to engage patients and family members in health IT initiatives and the positive impact that can emerge when patients and family members are engaged in such initiatives in an effective manner. Currently, no framework has consolidated all of the key strategies and considerations that were found in this review to guide health care organizations when engaging patients and family members in a health IT–specific project or initiative. Further research to evaluate and validate the existing strategies would be of value.

Researching Collective Mindfulness and Health IT: A Framework and Translation to Context-Specific Questions.

To improve patient safety, hospital organisations are encouraged to run their operations in line with high reliability organisations' collective mindfulness principles and practices. For the same safety goals, they also implement health information technology (IT). However, little is known about whether, or how, health IT can impact organisational mindfulness, and thereby safety. We propose that research in this area can be approached through a simple framework of overarching, umbrella questions, then carefully translated into nuanced context-specific questions and study designs. The framework and approach we propose provides a structure for comparing results from studies of collective mindfulness and health IT, across different clinical contexts and IT applications.

Multi-Institutional, Large-Scale, International Applied Clinical Informatics Research Through the Clinical Informatics Research Collaborative (CIRCLE).

There is a critical need need for multi-institutional, large-scale, international applied clinical informatics research, given the global, widespread use of commercially-available electronic health records with different designs, capabilities, configurations, and implementation strategies. The Clinical Informatics Research Collaborative (CIRCLE) aims to identify and develop best practices for safe and effective health information technology design, development, implementation, use, and evaluation.

Workforce Development Strategy for Health Information System Implementation at the Public Health System of Buenos Aires.

One of the challenges of implementing health information and communication technology is the need for a skilled workforce that understands health care and ITC. There are also people and organizational challenges involved. This work describes the strategies to create such a workforce for the public network of healthcare facilities in the City of Buenos Aires, which include promoting the adoption of technologies and providing lines of contention for continuous training.

Implementing Mobile Health Interventions to Capture Post-Operative Patient-Generated Health Data.

Background: The implementation of health information technology interventions is at the forefront of most hospital institutional policy agendas. Despite the availability of numerous apps and mobile platforms focusing on specific areas in healthcare the widespread integration into clinical practice can be a complex process. Here we present guidelines and methodology that we have learned in the implementation process of new technology and an overview of some of the current barriers and enablers specific to implementation of post-surgical site surveillance technology. Methods: Analysis of the experience of successful information technology (IT) implementation in different healthcare systems reveals that, despite differences among patient groups, care providers, and hospitals, there are common barriers and enablers to implementation of health IT. Results: The process of implementation in organizations and among individuals can be most successful by identifying barriers and enablers within three key stakeholder groups: (1) patients; (2) care providers/clinicians; and (3) manager/administration within healthcare systems. This can be achieved by specific engagement and co-design processes establishing clear benefits, sufficient incentives, and adequate support for clinicians as well as payer-provider relationships, marketplace competition and privacy legislation. Conclusions: The successful implementation of such programs requires appropriate strategic planning to address the needs of three specific components: patients, care provider, and policymakers/healthcare management understanding and acceptance.

Collective Mindfulness and Processes of Sensemaking in Health IT Implementation.

High reliability organisations operate safely in situations of high risk by organising for collective mindfulness. They do so through five ongoing processes geared towards anticipating, containing, and making sense of the unexpected. The five processes are: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. The theory of collective mindfulness builds on Hutchins's theory of distributed cognition (the 'collective mind' of ship navigation teams) and on Langer's theory of mindfulness about individuals' interpreting information in context. However, in the theory of collective mindfulness, attention is paid not to individual cognition or decision making, but to collective processes of sensemaking emerging from individuals' interactions in dealing with an equivocal environment. In health informatics, the theory of collective mindfulness can be used to explain health information technology (IT) development and implementation, across its life cycle, and inform guidance towards mindful management of IT projects. For example, applied to a case of electronic health record implementation in a hospital context, the theory explains how mindful management of the sense-making challenges of post-roll out adaptation processes contributes to a 'successful' IT project. Further, the theory challenges a static and linear understanding of success (or failure) of health IT initiatives, supporting instead an argument for outcomes - be it reliability and safety, or IT project success - as collective, complex and dynamic achievements of mindful organising practices.

Using Actor-Network Theory to Study Health Information Technology Interventions.

This chapter introduces Actor-Network Theory, a sociotechnical approach to studying health information technology implementation. The chapter is intended as a pragmatic introduction to the field, acknowledging that there are many contested features of an Actor-Network Theory informed methodology. Nevertheless, the approach can be usefully drawn on to help to focus data collection and sampling. A case study describing the application of Actor-Network Theory to study the "failed" implementation of national electronic health records in England as part of a national "top-down" implementation program illustrates the main tenets of the approach and provides concrete examples of how Actor-Network Theory may be applied. In doing so, this chapter offers a reflexive account of how Actor-Network Theory has provided a nuanced analysis of how the implementation of national electronic health records affected different stakeholders, organizations and technology.

The role of self-efficacy, flexibility, and gender in pharmacy students' health information technology readiness

IntroductionPharmacy students' characteristics and attitudes towards health information technology (HIT) may influence their willingness to learn, adopt, and utilize technology in healthcare settings. Future pharmacists will play a key role in the successful implementation of HIT, yet their technology readiness is not well understood. The goal of this study was to understand pharmacy students' attitudes regarding HIT and identify personal characteristics and psychosocial factors that predict their readiness to use HIT in future clinical practice. MethodsUsing an anonymous online survey, data were collected from 148 pharmacy students. Linear regression modeling was used to determine if gender, flexible thinking, and openness to using technology, and technology self-efficacy were associated with students' readiness to utilize HIT tools in future clinical practice. ResultsRegression modeling successfully explained 15% of the variance in predicting students' readiness to utilize HIT tools: F(3, 144) = 8.31, p < 0.001 with an R2 of 0.148 (adj R2 = 0.13). Greater information technology self-efficacy, more openness to change (in academic/work settings), and being male were associated with readiness to utilize HIT. ConclusionsWith the increased adoption of HIT in pharmacy practice, innovative approaches to HIT education are needed. Curricula that help students overcome obstacles to embracing technology may now be warranted. With enhanced training and engagement involving more than just didactic lessons, pharmacy students may not only feel confident in their ability to embrace HIT in future practice but feel professional satisfaction, increasing the likelihood for improved patient care and health system sustainability.

Invisible work and changing roles: Health information technology implementation and reorganization of work practices for the inpatient nursing team

Hospitals have invested heavily in health information technology (HIT) which has been promoted as an integral component of quality, safe, and efficient health-care delivery. Research on the expanding use of such technology, however, has shown that user/technology interactions are shaped through practices of use that can yield far from normative, even unexpected outcomes. Drawing upon focus group and interview data from an inpatient, two-hospital health system in the United States, this paper considers the perceived impact of HIT implementation on work practices and roles for nurse managers and unit clerks. We find that HIT implementation generated significant reconfigurations of work practices at the expense of nurse/patient interaction. Following such changes, nursing leadership described re-prioritizing patient care and interaction - perceived to them as essential to the patient experience and unit functioning - through realignments in staffing that prioritized more versatile staff and task delegation of largely invisible, articulation work to unit clerks. Despite maintaining an integral role as “gatekeeper” and the “face on the floor,” unit clerks experienced significant reconfigurations of their work and some concomitant uncertainty about their role. We consider the implications of our findings for literature on the socio-materiality of HIT, with particular attention to literature on work practices, roles, and the visibility of work within organizational power hierarchies.

Adapting and validating informatics competencies for senior nurse leaders in the Canadian context: Results of a Delphi study

BackgroundNurse leaders in senior leadership positions in various parts of the world can play an important role in the acquisition, implementation and use of health information technologies. To date, international research related to nurse leader informatics competencies has been carried out in specific healthcare delivery contexts with very specific health information technology environments. In this body of literature, the definition of a ‘nurse leader’ has not been clearly defined. As a result, it is challenging for senior nurse leaders in leadership and management positions in other countries to apply this research to their unique contexts. PurposeThe objective of this study was to obtain consensus on the informatics competencies of priority to senior Canadian nurse leaders. The goal of completing this work was to adapt and validate a set of nurse leader informatics competencies to be endorsed and supported nationally. MethodsThis study used a modified Delphi technique with a panel of nurse leaders with significant informatics knowledge from across Canada. Three rounds of information gathering were completed electronically. In Round 1, participants were provided a series of 26 potential competency statements obtained from a review of the literature; they were asked to comment on the clarity and wording of each statement. Two statements were eliminated after Round 1 due to redundancy. In Rounds 2 and 3, participants rated the remaining competency statements on a 7-point Likert scale for relative priority to nurse leaders. ResultsA total of 25, 24 and 23 participants completed the survey in Rounds 1, 2 and 3 respectively. Consensus was achieved at the end of Round 3 with the inclusion of 24 competency statements. All of the statements had a mean of 5 or greater on a 7-point Likert scale (1=low priority and 7=high priority). ConclusionsThe study participants agreed upon 24 informatics competency statements of priority to Canadian nurse leaders. These competencies will be presented to senior national nursing leaders and nursing informatics organizations for endorsement. Inspired by work completed in the United States, the authors plan to develop a self-assessment instrument for use by Canadian nurse leaders using the identified competency statements. Future anticipated work includes identifying and creating resources for nurse leaders to develop these important informatics competencies.

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.

Linking Quality Improvement and Health Information Technology through the QI-HIT Figure 8.

The implementation of health information technology (HIT) is complex. A method for mitigating complexity is incrementalism. Incrementalism forms the foundation of both incremental software development models, like agile, and the Plan-Do-Study-Act cycles (PDSAs) of quality improvement (QI), yet we often fail to be incremental at the union of the disciplines. We propose a new model for HIT implementation that explicitly links incremental software development cycles with PDSAs, the QI-HIT Figure 8 (QIHIT-F8). We then detail a subsequent local HIT implementation where we demonstrated its use. The QIHIT-F8 requires a reprioritization of project management activities around tests of change, strong QI principles to detect these changes, and the presence of both baseline and prospective data about the chosen indicators. These conditions are most likely to be present when applied to indicators of high strategic importance to an organization.

Health Information Technology Acceptance Framework for diabetes management

This study examined the level of acceptance of Health Information Technology (HIT) as tools for diabetes care and management, in six selected tertiary hospitals in southwestern zone of Nigeria. Using both quantitative and qualitative methods, this study was conducted amongst selected healthcare stakeholders namely Nurses, Doctors, Laboratory Scientists, Pharmacists, ICT unit Professionals, Medical Record Officers, and Type-2 diabetes out-patients available in the designated hospitals. Adapting Technology Acceptance and Chronic Care Models, the level of HIT acceptance by the respondents in the study area was measured in terms of Perceived Ease-of-Use, Perceived Usefulness, and the Perceived Unintended Consequences relating to HIT, while also considering the roles of the government, community and healthcare organizations. One hundred and fifty (150) respondents were examined, each for both Staff and Patients, and the factor variables studied on a 5-point Likert rating scale of measurement from 1 (Strongly Disagree) to 5 (Strongly Agree). The results revealed strong perception of Staff and Patients about HIT implementation and acceptance and showed that in some cases, the perception of Staff and patients about HIT acceptance are the same, while different in some. The study concluded that for acceptability of HIT, hospitals have to embark on ‘continuous’ training for the HIT users, so that users would familiarize themselves with the system, and it will be fully incorporated into their workflow. Based on the findings, a conceptual Health Information Technology Acceptance Framework for Chronic diseases' management, especially for diabetes mellitus was developed.