International Journal of Medical Informatics - Articles in Press

Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages - Corrected Proof

2012-02-02

Highlights: ► The percentage of participants with adherence >95% was higher on SMS group. ► Different adherence measures should be taken to get consistent/comparable results. ► 81.81% of HIV participants who received SMS thinks it helped to take medications. ► Some Brazilian-HIV participants who received SMS felt that someone care about them.Abstract: Objective: To assess whether a warning system based on mobile SMS messages increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based treatment regimens and their impressions and satisfaction with respect to incoming messages.Design: A randomized controlled trial was conducted from May 2009 to April 2010 with HIV-infected Brazilian women. All participants (n=21) had a monthly multidisciplinary attendance; each participant was followed over a 4-month period, when adherence measures were obtained. Participants in the intervention group (n=8) received SMS messages 30min before their last scheduled time for a dose of medicine during the day. The messages were sent every Saturday and Sunday and on alternate days during the working week. Participants in the control group (n=13) did not receive messages.Measurements: Self-reported adherence, pill counting, microelectronic monitors (MEMS) and an interview about the impressions and satisfaction with respect to incoming messages.Results: The HIV Alert System (HIVAS) was developed over 7 months during 2008 and 2009. After the study period, self-reported adherence indicated that 11 participants (84.62%) remained compliant in the control group (adherence exceeding 95%), whereas all 8 participants in the intervention group (100.00%) remained compliant. In contrast, the counting pills method indicated that the number of compliant participants was 5 (38.46%) for the control group and 4 (50.00%) for the intervention group. Microelectronic monitoring indicated that 6 participants in the control group (46.15%) were adherent during the entire 4-month period compared to 6 participants in the intervention group (75.00%). According to the feedback of the 8 participants who completed the research in the intervention group, along with the feedback of 3 patients who received SMS for less than 4 months, that is, did not complete the study, 9 (81.81%) believed that the SMS messages aided them in treatment adherence, and 10 (90.90%) responded that they would like to continue receiving SMS messages.Conclusion: SMS messaging can help Brazilian women living with HIV/AIDS to adhere to antiretroviral therapy for a period of at least 4 months. In general, the results are encouraging because the SMS messages stimulated more participants in the intervention group to be adherent to their treatment, and the patients were satisfied with the messages received, which were seen as reminders, incentives and signs of affection by the health clinic for a marginalized population.

Effects of a short text message reminder system on emergency department length of stay - Corrected Proof

2012-02-02

Highlights: ► We designed SMS automatic transmission system linked to consultation order. ► The CPOE-based SMS project reduced LOS of consulted patients in the ED. ► This intervention facilitated the decision-making process of consulting physicians.Abstract: Purpose: Specialty consultations and waiting for admission to a hospital bed are major contributors to increased length of stay and overcrowding in the emergency department. We implemented a computerized short messaging service to inform care providers of patient delay in order to reduce length of stay. The purpose of this study was to evaluate the effects of this strategy on length of stay in the emergency department.Methods: This was a before-and-after observational study. Prior to this study, we registered the mobile phone numbers of all board certified specialists into a computerized physician order entry database and developed an auto-sending short messaging program linked to consultation orders. The short message was transmitted at 2 and 4h after consultation, when a disposition was not yet established, and at 8h after the admission order if the patient was still waiting. The length of stay of consulted patients and intervals such as consultation time (registration–consultation), disposition time (consultation–admission decision), and boarding time (admission decision–hospitalization) of admitted patients were compared between the pre-implementation (September 2009) and post-implementation period (November 2009). Subgroup analyses of disposition time were performed according to time of consultation and the number of consultations.Results: A total of 7518 patients visited the emergency department during the pre-periods and post-periods. Among them, 3335 patients required specialty consultations. The median length of stay of consulted patients decreased significantly after implementation of the messaging system (pre-207min vs. post-193min, p<0.001). Among admitted patients, the median length of stay decreased by 36min from 294min to 258min (p<0.001). In the subgroup analysis, times for establishing patient dispositions decreased significantly when the consultation was performed at night and when there was only one department consulted. The numbers of patients with disposition times within 2 and 4h and boarding times within 8h were all increased after implementation of the short message service program.Conclusions: This study suggested that the computerized physician order entry-based short messaging service program, used to inform decision-makers of patient delay, could reduce the length of stay for consulted patients in the emergency department.

Prescribers’ interactions with medication alerts at the point of prescribing: A multi-method, in situ investigation of the human–computer interaction - Corrected Proof

2012-02-01

Highlights: ► A richer understanding of prescribers’ interactions with alerts during patient care. ► Actionable recommendations to improve alert design. ► A framework that describes prescribers’ interactions with alerts. ► Evidence that alert designs more closely match clinical pharmacist mental-models. ► Alert interface components that should be enhanced to support non-pharmacists.Abstract: Purpose: Few studies have examined prescribers’ interactions with medication alerts at the point of prescribing. We conducted an in situ, human factors investigation of outpatient prescribing to uncover factors that influence the prescriber–alert interaction and identify strategies to improve alert design.Methods: Field observations and interviews were conducted with outpatient prescribers at a major Veterans Affairs Medical Center. Physicians, clinical pharmacists, and nurse practitioners were recruited across five primary care clinics and eight specialty clinics. Prescribers were observed in situ as they ordered medications for patients and resolved alerts. Researchers collected 351 pages of typed notes across 102 hours of observations and interviews. An interdisciplinary team identified emergent themes via inductive qualitative analysis.Results: Altogether, 320 alerts were observed among 30 prescribers and their interactions with 146 patients. Qualitative analysis uncovered 44 emergent themes and 9 overarching factors, which were organized into a framework that describes the prescriber–alert interaction. Prescribers’ ability to act on alerts was impeded by the alert interface, which did not adequately support all prescriber types.Conclusions: This empiric study produced a novel framework for understanding the prescriber–alert interaction. Results revealed key components of the alert interface that influence prescribers and indicate a need for more universal design. Actionable design recommendations are presented and may be used to enhance alert design and patient safety.

Bedside information technology to support patient-centered care - Corrected Proof

2012-01-30

Highlights: ► Requirements for a bedside communication tool were identified. ► Patients’ and nurses’ information requirements are prioritized differently. ► Nurses’ information requirements are focused on patient safety. ► Patients’ information requirements are focused on understanding their care plan.Abstract: Purpose: Patients and health care providers often lack real time access to information at the bedside required to provide safe patient-centered care. Both groups identified pertinent information needed at the patient's bedside. The purpose of our research was to identify the essential data elements that will be used to define requirements for a useful bedside communication tool in the acute care hospital setting.Methods: Descriptive research methods were used to identify bedside information requirements through group and individual interviews. Data from patients and health care providers were analyzed to identify common themes, compiled into a survey, and validated by both groups.Results: Thirty-seven information requirements were identified and classified under five themes: (1) plan of care, (2) patient education, (3) communication of safety alerts, (4) diet, and (5) medications. A survey completed by 30 patients and 30 health care providers confirmed 36 specific bedside information requirements (mean≥5 on an 11-point scale). Patients and health providers each identified 24 specific information requirements that were similar in importance. When compared with nurses, significant differences were noted in the degree to which patients identified knowing the “daily routine schedule,” e.g. when their doctor typically sees patients as a key requirement for the electronic bedside communication tool, t=3.52, p=.001.Conclusion: Patients and health care providers identified information requirements at the bedside to promote self-care management of healthcare needs and an understanding of the hospital environment. Accurate, easily accessed information at the bedside is needed for providing safe patient-centered care.

Caring for individual patients and beyond: Enhancing care through secondary use of data in a general practice setting - Corrected Proof

Marianne Tolar, Ellen Balka — 2012-01-30

Highlights: ► The case reports on the successful implementation of secondary usage of EMR data. ► A continuous process of cultivating EMR data has to be in place. ► To ensure accessibility for secondary purposes a shared coding system is needed. ► Initiatives have to be integrated into daily work practices to enhance sustainability.Abstract: It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends.Purpose: In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes.Methods: This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC.Results: The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place.Preconditions: Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation.Consequences: Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders.Conclusions: The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals.

Evaluation of mobile phone and Internet intervention on waist circumference and blood pressure in post-menopausal women with abdominal obesity - Corrected Proof

Min-Jeong Park, Hee-Seung Kim — 2012-01-24

Highlights: ► The mobile phone and internet intervention improved waist circumference and body weight at 12 weeks in post-menopausal women. ► A significant mean decrease in blood pressure was observed for the intervention group. ► The web-based intervention using mobile phone and Internet decreased total cholesterol and low-density lipoprotein-cholesterol.Abstract: Purpose: The present study evaluated whether an intervention using a short message service (SMS) by personal cellular phone and Internet would reduce cardiovascular risk factors in post-menopausal women with abdominal obesity over 12 weeks.Methods: This is a quasi-experimental design with pre and post tests. Participants were recruited from the gynecology outpatient and family medicine departments of a tertiary care hospital located in an urban city of South Korea. Only 67 subjects completed the entire study, 34 in the intervention group and 33 controls. The goal of intervention was to reduce waist circumference (WC), body weight (BW) and blood pressure (BP) levels. Before the intervention, demographic variables, WC, BW, BP, fasting plasma glucose (FPG) and serum lipids were measured as pre-test data. The WC, BW, BP, FPG and serum lipids were measured again 12 weeks later. Patients in the intervention group were requested to record their WC, BW, BP, type and amount of diet and exercise in a weekly web-based diary through the Internet or by cellular phone. The researchers sent weekly recommendations on diet and exercise as an intervention to each patient, by both cellular phone and Internet. The intervention was applied for 12 weeks.Results: WC and BW significantly decreased by 3.0cm and 2.0kg, respectively, at 12 weeks compared with the baseline in the intervention group. However, the mean changes in the control group significantly increased by 0.9cm and 0.7kg. Systolic BP (SBP) and diastolic BP (DBP) significantly decreased by 6.5 and 4.6mmHg in the intervention group, respectively. The mean changes in the control group were not significant in either SBP or DBP. A significant mean decrease in total cholesterol (TC) was observed for the intervention group by 12.9mg/dl, while the control group showed a significant mean increase by 1.5mg/dl. Low-density lipoprotein-cholesterol (LDL-C) for the intervention group showed a significant mean decrease 11.3mg/dl. The mean change in the control group was, however, not significant.Conclusion: Web-based individual intervention using both SMS and Internet improved WC, BW, BP, TC, and LDL-C during 12 weeks in post-menopausal women with abdominal obesity.

Online usability and patients with long-term conditions: A mixed-methods approach - Corrected Proof

Hans C. Ossebaard, Erwin R. Seydel, Lisette van Gemert-Pijnen — 2012-01-20

Highlights: ► Online informational needs of patients i.c. navigation and content should be met in a personalized way to avoid attrition and to encourage adherence. ► eHealth literacy scale (eHEALS) does not seem to cover all aspects of digital skills. ► Patient perspective is indispensable for usability research in consumer health informatics. ► Mixed social scientific techniques deliver useful results regarding usability improvement and information seeking behavior.Abstract: Background: To improve the information position of health care consumers and to facilitate decision-making behavior in health the Dutch ministry of Health commissioned the National Institute for Public Health and the Environment to develop, host and manage a public national health and care portal (www.kiesbeter.nl) on the Internet. The portal is used by over 4 million visitors in 2010. Among them, an increasing amount of patients that use the portal for information and decision making on medical issues, healthy living, health care providers and other topics.Objective: First objective is to examine what usability aspects of the portal kiesBeter.nl matter for chronic patients and their informal carers with regard to information seeking, self-management, decision making, on line health information and other variables. Second objective is to make evidence-based practical recommendations for usability improvement.Methods: An innovative combination of techniques (semi-structured interviews; eHealth Literacy scale; scenario-based study using think-aloud protocol and screen capture software; focus group) is used to study usability and on line information seeking behavior in a non random judgment sample of three groups of patients (N=21) with long-term medical conditions (arthritis, asthma and diabetes).Results: The search strategy mostly used (65%) by the relatively well-educated subjects is ‘orienteering’. Users with long-term conditions and their carers expect tailored support from a national health portal, to help them navigate, search and find the detailed information they need. They encounter serious problems with these usability issues some of which are disease-specific. Patients indicate a need for personalized information. They report low impact on self-management and decision making. Overall judgment of usability is rated 7 on a Likert type 0–10 scale. Based on the outcomes recommendations could be formulated. These have led to major adaptations to improve usability.Limitations: A non-representative composition of a small non random judgment sample does not permit generalization to other populations and cognitive bias cannot be quantified. However if mixed methods are applied valid conclusions can be drawn with regard to usability issues.

Oncology team members’ perceptions of a virtual navigation tool for cancer patients - Corrected Proof

Kristen R. Haase, Carmen G. Loiselle — 2012-01-16

Highlights: ► A web-based cancer navigation tool was presented to clinic team members. ► A qualitative approach served to explore team members’ perceptions of the tool. ► Overall, participants’ views were positive about the OIN™. ► Findings highlighted potential barriers pertaining to OIN™ uptake. ► Exploring multiple stakeholders views of e-health can enhance implementation.Abstract: Objectives: The Internet has become an important source of health information for patients and health care providers (HCPs) alike. Whereas studies have begun to document the effects of the internet on health behaviors and outcomes, surprisingly few studies have explored HCPs’ perceptions of the internet as a key resource accessed by patients. However, as HCPs are seen as pivotal in guiding patients toward these resources, it is timely to study their perceptions. Therefore, the present inquiry explores HCPs’ views of a recently developed high quality virtual navigation tool called the Oncology Interactive Navigator™ (OIN).Design: Using a qualitative approach, in-depth interviews were conducted with 16 members of a multidisciplinary colorectal oncology team and volunteers at a large Cancer Centre in Montreal, Quebec, Canada.Results: Content analysis revealed emerging themes centering on key benefits including: perceptions of a highly accessible, comprehensive high quality repository of cancer information; a means to further enhance HCP-patient communication and trust; and a significant catalyst to patient–family communication and support. Perceived drawbacks included patient (e.g., socio-demographic profile) and system's (e.g., professional roles and time constraints) characteristics that may limit OIN™ full implementation and uptake.Conclusions: The findings underscore the relevance of virtual navigation tools to ensure optimal person-centred care in cancer. Findings also suggest how virtual tools such as the OIN™ can best be used in practice as well as they guide strategies to adopt to optimize implementation of similar innovations in health care.

Record completeness and data concordance in an anesthesia information management system using context-sensitive mandatory data-entry fields - Corrected Proof

Alexander Avidan, Charles Weissman — 2012-01-16

Highlights: ► A commercial AIMS was enhanced with context-sensitive mandatory data-entry fields. ► One year after introduction, 99.6% of 12,290 anesthesia records had complete data. ► Concordances of entered data items with patients’ ages were 98.7–99.9%. ► The AIMS implementation was deemed successful by 98% of the anesthesiologists. ► Users rated the AIMS usability as very good, the data-entry forms as comfortable.Abstract: Background: Use of an anesthesia information management system (AIMS) does not insure record completeness and data accuracy. Mandatory data-entry fields can be used to assure data completeness. However, they are not suited for data that is mandatory depending on the clinical situation (context sensitive). For example, information on equal breath sounds should be mandatory with tracheal intubation, but not with mask ventilation. It was hypothesized that employing context-sensitive mandatory data-entry fields can insure high data-completeness and accuracy while maintaining usability.Methods: A commercial off-the-shelf AIMS was enhanced using its built-in VBScript programming tool to build event-driven forms with context-sensitive mandatory data-entry fields. One year after introduction of the system, all anesthesia records were reviewed for data completeness. Data concordance, used as a proxy for accuracy, was evaluated using verifiable age-related data. Additionally, an anonymous satisfaction survey on general acceptance and usability of the AIMS was performed.Results: During the initial 12 months of AIMS use, 12,241 (99.6%) of 12,290 anesthesia records had complete data. Concordances of entered data (weight, size of tracheal tubes, laryngoscopy blades and intravenous catheters) with patients’ ages were 98.7–99.9%. The AIMS implementation was deemed successful by 98% of the anesthesiologists. Users rated the AIMS usability in general as very good and the data-entry forms in particular as comfortable.Limitations: Due to the complexity and the high costs of implementation of an anesthesia information management system it was not possible to compare various system designs (for example with or without context-sensitive mandatory data entry-fields). Therefore, it is possible that a different or simpler design would have yielded the same or even better results. This refers also to the evaluation of usability, since users did not have the opportunity to work with different design approaches or even different computer programs.Conclusions: Using context-sensitive mandatory fields in an anesthesia information management system was associated with high record completeness rate and data concordance. In addition, the system's usability was rated as very good by its users.

Detection of infectious symptoms from VA emergency department and primary care clinical documentation - Corrected Proof

2012-01-13

Highlights: ► Infectious symptoms can be successfully detected within outpatient and emergency department Veteran's Administration notes. ► Assertion detection was critically important, as a majority of clinical symptom assertions were negative. ► Rule algorithms that incorporate negation with SNOMED-CT ontology encoding and keyword matching can improve NLP detection.Abstract: Objective: The majority of clinical symptoms are stored as free text in the clinical record, and this information can inform clinical decision support and automated surveillance efforts if it can be accurately processed into computer interpretable data.Methods: We developed rule-based algorithms and evaluated a natural language processing (NLP) system for infectious symptom detection using clinical narratives. Training (60) and testing (444) documents were randomly selected from VA emergency department, urgent care, and primary care records. Each document was processed with NLP and independently manually reviewed by two clinicians with adjudication by referee. Infectious symptom detection rules were developed in the training set using keywords and SNOMED-CT concepts, and subsequently evaluated using the testing set.Results: Overall symptom detection performance was measured with a precision of 0.91, a recall of 0.84, and an F measure of 0.87. Overall symptom detection with assertion performance was measured with a precision of 0.67, a recall of 0.62, and an F measure of 0.64. Among those instances in which the automated system matched the reference set determination for symptom, the system correctly detected 84.7% of positive assertions, 75.1% of negative assertions, and 0.7% of uncertain assertions.Conclusion: This work demonstrates how processed text could enable detection of non-specific symptom clusters for use in automated surveillance activities.

Qualitative and quantitative evaluation of EHR-integrated mobile patient questionnaires regarding usability and cost-efficiency - Corrected Proof

Fleur Fritz, Sebastian Balhorn, Markus Riek, Bernhard Breil, Martin Dugas — 2012-01-11

Highlights: ► High usability of mobile documentation. ► Cost-efficiency of mobile patient questionnaires. ► Pass documentation task on to patients. ► EHR-integrated patient reported outcomes data available for treatment and research.Abstract: Objectives: The objective of this evaluation study is to assess a web-based application, currently available on iPad, to document questionnaires regarding patient reported outcomes such as quality of life. Based on the single source approach, the results of these questionnaires are available in the electronic health record to be used for treatment and research purposes. The assessment focuses on the usability and efficiency of the system.Methods: The system usability scale questionnaire with seven additional items was used to rate the usability by the patients. It was formally validated by a Cronbach Alpha test. In addition, semi-structured interviews were conducted with patients and medical staff. Time and cost measures, based on official tables of costs, were taken through workflow observations. This study was conducted in the department of dermatology at the University Hospital of Münster, Germany from April to June 2011.Results: Using the web-based application questionnaire, results about patient reported outcomes like quality of life are immediately available in the electronic health record and can be used for treatment or research purposes. 118 patients and four staff members participated in the study. The usability score reached 80 from 100 points and patients as well as medical staff stated in the interviews that the usability of the web-based system was high, and they preferred it to the previously used paper-based questionnaires.In the setting of our pilot department the mobile devices amortized their costs after 6.7 months. In general, depending on the professional group who are going to post process the paper-based forms, the earliest break-even point to use mobile questionnaires is at 1737 paper sheets per year.Conclusion: The mobile patient questionnaires, integrated into the electronic health record, were well accepted in our pilot setting with high usability scores from patients and medical staff alike. The system has also proved to be cost-efficient compared to the paper-based workflow, given that a certain number of questionnaires is used per year.

Characterizing “information transfer” by using a Joint Cognitive Systems model to improve continuity of care in the aged - Corrected Proof

Iona Thraen, Byron Bair, Shantel Mullin, Charlene R. Weir — 2012-01-09

Abstract: Purpose: This study explores multidisciplinary and cross-sector health professional experiences with the information needs for safe patient transfers across the care continuum using a Joint Cognitive Systems (JCS) model. Qualitative experiences of three JCS components and their attributes and are presented.Methods: A qualitative content analysis using Joint Cognitive Systems constructs were extracted from sixteen multidisciplinary and cross-sector health professional interviews. Participants were asked to describe their information needs and experiences with the patient transfer process.Results: Information transfer associated with three JCS constructs (alignment of goals, enhanced control, and co-agency dynamics) was examined. The breakdown in the information transfer process might be due to the relative strengths of each sector's core expertise. Alignment must cross settings and disciplines and consist of the: (1) transfer of goal relevant and integrated information; (2) accommodation to the control attributes of increased clinical complexity, lack of systematic work processes and feedback or feed forward information; and (3) improvement in the co-agency dynamics of interdependency, trust, inter-related actions and expertise.Conclusions: Economic pressures and care complexities of the aged require improved effectiveness and efficiencies in the information transfer process. This study aims to understand the information transfer needs from hospitals to skilled nursing care laying a foundation towards a medical informatics solution. An informatics solution must accommodate the differing contextual environments and subsequent information needs and paradigms of the Joint Cognitive System of care across the continuum.

Key factors influencing the implementation success of a home telecare application - Corrected Proof

T.R.F. Postema, J.M. Peeters, R.D. Friele — 2012-01-09

Highlights: ► The introduction of home telecare seems to lead to mixed results in practice. ► We investigate key factors influencing implementation success. ► The stability of the technical and financial environment is key. ► The alignment of goals and implementation strategy is also found to be crucial. ► A champion-wise roll-out seems imperative for initial implementation.Abstract: Rationale: The introduction of home telecare in healthcare organizations has shown mixed results in practice. The aim of this study is to arrive at a set of key factors that can be used in further implementation of video communication. We argue that key factors are mainly found in the organizational climate for home telecare implementation, the characteristics of the implementation strategy and the available technology.Methods: Interviews were conducted in three care organizations with 27 respondents of different levels within and outside the organization. Implementation determinants, based on earlier research, were used as a categorization framework for the interviews.Results: We found that most prominent factors influencing implementation outcomes relate to the stability of the technical and the external environment and the alignment of organization, goals and implementation strategy.Conclusion: Because of the experimental nature of implementing video communication, attention to telecare influencers has been inconsistent and disorganized but it is becoming increasingly important. According to the respondents, a champion-led roll-out is imperative for implementation in order to advance to the next stage in home telecare and to organize services for substitution of care.

Implementation of computerized provider order entry in a neonatal intensive care unit: Impact on admission workflow - Corrected Proof

Alison K. Chapman, Christoph U. Lehmann, Pamela K. Donohue, Susan W. Aucott — 2012-01-09

Highlights: ► Introduction of CPOE improved pharmacy turnaround times. ► Despite improved pharmacy turnaround, there was no change in the time to the first dose of antibiotics. ► Admission workflow is a complex process, and will require a multifaceted approach in order to further improve antibiotic administration time in the neonatal intensive care unit.Abstract: Objective: The study objective was to determine if computerized provider order entry (CPOE) systems impaired or enhanced workflow in the neonatal intensive care unit (NICU) by comparing the timing of administration of the first dose of antibiotics before and after CPOE system implementation.Methods: We conducted a pre-post intervention comparative study of the length of time between admission and administration of initial antibiotics in neonates before and after a CPOE system was implemented. Clinical information and timing of antibiotic administration were collected on all inborn infants, who were admitted to the NICU in the first 4h of life and treated with antibiotics, for one year prior to the implementation of computerized order entry and for one year after the implementation.Results: Infants admitted to the NICU were similar in both periods (mean birth weight 2183g vs. 2091g, gestational age 33.3 weeks vs. 33.0 weeks). There was no significant difference in mean length of time from admission to antibiotic administration in the pre-CPOE group (131min [CI 124–139]) compared to the post-CPOE group (125min [CI 116–133]) (p=0.07). The mean time to pharmacy verification for a subset of patients was significantly shorter for patients in the post-CPOE group (61±58min) compared to the pre-CPOE group (88±76min) (p=<0.001).Conclusions: While the introduction of a CPOE system in the NICU did not significantly improve antibiotic administration times, the timeliness of an important aspect of the medication process, time to pharmacy verification, was improved. These findings imply other factors are impeding workflow. Further studies are needed to evaluate how CPOE systems combined with patient care activities affect workflow and overall patient care.

Prospective pilot study of a tablet computer in an Emergency Department - Corrected Proof

Steven Horng, Foster R. Goss, Richard S. Chen, Larry A. Nathanson — 2012-01-09

Highlights: ► Using a tablet computer can decrease time spent at a computer. ► Clinician's felt the tablet was easy to disinfect. ► Clinician expectations cannot be met by a change in form factor alone.Abstract: Background: The recent availability of low-cost tablet computers can facilitate bedside information retrieval by clinicians.Objective: To evaluate the effect of physician tablet use in the Emergency Department.Design: Prospective cohort study comparing physician workstation usage with and without a tablet.Setting: 55,000 visits/year Level 1 Emergency Department at a tertiary academic teaching hospital.Participants: 13 emergency physicians (7 Attendings, 4 EM3s, and 2 EM1s) worked a total of 168 scheduled shifts (130 without and 38 with tablets) during the study period.Intervention: Physician use of a tablet computer while delivering direct patient care in the Emergency Department.Main Outcome Measures: The primary outcome measure was the time spent using the Emergency Department Information System (EDIS) at a computer workstation per shift. The secondary outcome measure was the number of EDIS logins at a computer workstation per shift.Results: Clinician use of a tablet was associated with a 38min (17–59) decrease in time spent per shift using the EDIS at a computer workstation (p<0.001) after adjusting for clinical role, location, and shift length. The number of logins was also associated with a 5-login (2.2–7.9) decrease per shift (p<0.001) after adjusting for other covariates.Conclusion: Clinical use of a tablet computer was associated with a reduction in the number of times physicians logged into a computer workstation and a reduction in the amount of time they spent there using the EDIS. The presumed benefit is that decreasing time at a computer workstation increases physician availability at the bedside. However, this association will require further investigation.

The effects of EMR deployment on doctors’ work practices: A qualitative study in the emergency department of a teaching hospital - Corrected Proof

Sun Young Park, So Young Lee, Yunan Chen — 2012-01-05

Highlights: ► We examine direct and indirect effects of the deployment of the EMR system. ► Direct effect altered ED doctors’ workflows including increased workload and responsibility for residents and documentation location change. ► Indirect effect was a consequence of the altered workflow and indirectly affected clinical collaboration and patient care. ► Three design guidelines are suggested to be accounted for in future EMR system designs.Abstract: Objective: The goal of this study was to examine the effects of medical notes (MD) in an electronic medical records (EMR) system on doctors’ work practices at an Emergency Department (ED).Methods: We conducted a six-month qualitative study, including in situ field observations and semi-structured interviews, in an ED affiliated with a large teaching hospital during the time periods of before, after, and during the paper-to-electronic transition of the rollout of an EMR system. Data were analyzed using open coding method and various visual representations of workflow diagrams.Results: The use of the EMR in the ED resulted in both direct and indirect effects on ED doctors’ work practices. It directly influenced the ED doctors’ documentation process: (i) increasing documentation time four to five fold, which in turn significantly increased the number of incomplete charts, (ii) obscuring the distinction between residents’ charting inputs and those of attendings, shifting more documentation responsibilities to the residents, and (iii) leading to the use of paper notes as documentation aids to transfer information from the patient bedside to the charting room. EMR use also had indirect consequences: it increased the cognitive burden of doctors, since they had to remember multiple patients’ data; it aggravated doctors’ multi-tasking due to flexibility in the system use allowing more interruptions; and it caused ED doctors’ work to become largely stationary in the charting room, which further contributed to reducing doctors’ time with patients and their interaction with nurses.Discussion: We suggest three guidelines for designing future EMR systems to be used in teaching hospitals. First, the design of documentation tools in EMR needs to take into account what we called “note-intensive tasks” to support the collaborative nature of medical work. Second, it should clearly define roles and responsibilities. Lastly, the system should provide a balance between flexibility and interruption to better manage the complex nature of medical work and to facilitate necessary interactions among ED staff and patients in the work environment.

Internet use by the public to search for health-related information - Corrected Proof

Khalid M. AlGhamdi, Noura A. Moussa — 2012-01-05

Highlights: ► This subject has never been studied in Saudi Arabia. ► The use of Internet to search for health related information has been growing rapidly in Saudi Arabia. ► Our research draws the attention of health authorities about this practice.Abstract: Background: The use of the Internet to search for health-related information (HRI) has become a common practice worldwide. Our literature review failed to find any evidence of previous studies on this topic from Saudi Arabia.Objective: To determine the public use of the Internet in Saudi Arabia to search for HRI and to evaluate patients’ perceptions of the quality of the information available on the Internet compared to that provided by their health care providers.Methods: A self-administered questionnaire about Internet use to search for HRI was distributed randomly to male and female outpatients and visitors attending a public University Hospital in Riyadh, Saudi Arabia from January to May 2010. A Chi-squared test was used to assess the association between different categorical variables. Multiple logistic regression was used to relate the use of the Internet to search for HRI with various socio-demographic variables.Results: The questionnaire response was 80.1%, with completion of 801 of the 1000 distributed questionnaires; 50% (400/801) of respondents were males. The mean age of respondents was 32±11 years. The majority of respondents used the Internet in general (87.8%), and 58.4% of them (363/622) used the Internet to search for HRI. The majority stated a doctor was their primary source of HRI (89.3%, 654/732). This practice was considered useful by 84.2%, and the main reason behind it was sheer curiosity (92.7%, 418/451). Other reasons included not getting enough information from their doctor (58.5%, 227/413) and not trusting the information given by their doctor (28.2%, 101/443). Forty-four percent (205/466) searched for HRI before coming to the clinic; 72.5% of those discussed the information with their doctors and 71.7% (119/166) of those who did so believed that this positively affected their relationship with their doctor. Searching the Internet for health information was observed more frequently among the 30–39 year age group (OR=2.0, 95% CI 1.1–3.7), females (OR=3.8, 95% CI 2.3–6.4), individuals with university or higher education (OR=1.7, 95% CI 1.1–2.8), employed individuals (OR=2.7, 95% CI 1.4–4.9) and high income groups (OR=2.8, 95% CI 1.5–5.1).Conclusions: A proportion of the public searches the Internet to obtain HRI for various reasons, which could have consequences on their health and relationship with their doctors. Therefore, doctors should be aware of the health information available online to help guide patients to reliable websites. Health authorities should also be aware of the issue to offer regulations and solutions.

Structured electronic operative reporting: Comparison with dictation in kidney cancer surgery - Corrected Proof

2012-01-04

Highlights: ► First study operative report quality in kidney cancer surgery. ► First system evaluated that: (i) uses real time POC documentation embedded in the EPR; (ii) uses data fields that are searchable for research and quality assessment. ► Documentation with structured electronic templates improves quality of OR note.Abstract: Purpose: The purpose of this study was to evaluate the functionality of eKidney as a structured reporting tool in operative note generation. To do this, we compared completeness and timeliness of eKidney template-generated nephrectomy OR notes with standard narrative dictation.Methods: A group of academic uro-oncologists and medical informaticians at the University Health Network designed and adopted an electronic online, point-of-care clinical documentation tool, eCancerCareKidney (eKidney) for kidney cancer patient care. The optimal components of clinic and operative note templates, including those for nephrectomy, were agreed upon by expert consensus of the uro-oncologists. Clinician nephrectomy OR reports were analyzed for completeness, comparing those generated in eKidney with conventionally dictated notes. Patterns of missing information from both dictated and eKidney-generated reports were analyzed. The procedure, note completion and transcription dates were recorded which generated time intervals between these events. The records of 189 procedures were included in the analysis.Results: Comparison of clinicians who used both note generation modalities, revealed a mean completion rate of 92% for eKidney/structured notes and 68% for dictated notes (p<0.0001). There was no significant difference in completion rates between attending staff and trainees (residents and fellows) (p=0.131). Most notes were dictated/entered on the day of surgery. Dictated notes were transcribed to EPR a median of 2 days after dictation, however roughly 30% of dictated notes took 5 days or more to get transcribed. All notes generated using eKidney were uploaded to the EPR immediately.Limitations: Our study has three significant limitations. Firstly, our study was not randomized: physicians could elect to dictate or use eKidney. Secondly, we did not identify data from dictated notes that were not captured by eKidney. Third, we did not compare the time it took physicians to complete the fields in eKidney with the time it takes to dictate a note.Conclusions: We have demonstrated that the use of structured reporting improves the completeness and timeliness of documentation in kidney cancer surgery. eKidney is an example of the power of templates in ensuring that important details of a procedure are recorded. Future studies looking at user satisfaction, and research and educational potential of eKidney would be valuable.

Evaluating the use of a computerized clinical decision support system for asthma by pediatric pulmonologists - Corrected Proof

2011-12-29

Highlights: ► We evaluate a computerized decision support system for asthma care in a subspecialty clinic. ► Subspecialist-specific factors play a role in adoption of decision support systems. ► Examples include unique workflow patterns and high levels of subject matter expertise. ► Unique aspects of subspecialty environments should be considered when designing systems for these settings.Abstract: Purpose: To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center.Methods: We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic.Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use.Results: The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians.Conclusions: Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors.Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.

Adoption of electronic health records in Korean tertiary teaching and general hospitals - Corrected Proof

Dukyong Yoon, Byung-Chul Chang, Seong Weon Kang, Hasuk Bae, Rae Woong Park — 2011-12-29

Highlights: ► The prevalence of EHRs was higher in Korean hospitals than in US hospitals. ► Korea seems to have a high prevalence of CPOE systems. ► Korean hospitals require financial support before adopting EHR.Abstract: Purpose: This study examined the current prevalence of electronic health records (EHRs) in Korea and identified the factors that impede or facilitate the adoption of EHRs.Methods: We surveyed all tertiary teaching and general hospitals in Korea. The degree to which EHR systems were adopted was evaluated using the previously defined definitions of ‘comprehensive’ and ‘basic’ EHRs based on their electronic functionality. The effects of teaching status, size, and location of hospitals on EHR adoption were examined. We also investigated factors that impeded or facilitated the adoption of EHR systems.Results: The response rate was 39.0% (122/313), and 37.2% (95% confidence interval [CI] 31.9–42.6%) of Korean tertiary teaching and general hospitals had either basic or comprehensive EHR systems (50.2% of tertiary teaching hospitals, 35.0% of general hospitals). However, only 5.0% (CI 2.6–7.4%) had comprehensive EHR systems. Most Korean tertiary teaching and general hospitals, i.e., 87.0% (95% CI, 83.3–90.7%), have implemented computerized provider order-entry (CPOE) systems for medications, with larger hospitals more likely than smaller ones to have adopted some sort of EHRs (p-value<0.001). However, the prevalence of these systems did not differ according to the location of the hospital (metropolitan vs. non-metropolitan). According to the survey data, the capital requirements and high maintenance costs of EHR systems were the major barriers to their adoption, and government reimbursement or incentives were the most requested facilitators of their adoption.Conclusion: The rate at which EHR and CPOE for medications systems have been adopted by Korean tertiary teaching and general hospitals was higher than the rate of adoption by US hospitals. Financial aspects are reported to be the most important facilitators of and barriers to EHR adoption. Government financial support, especially to small hospitals, seems to be essential to promoting the adoption of EHRs by Korean hospitals.

Electronic decision protocols for ART patient triaging to expand access to HIV treatment in South Africa: A cross sectional study for development and validation - Corrected Proof

2011-12-19

Highlights: ► The protocol developed has good discriminating abilities for ART triaging. ► The sensitivity of this protocol is 87% and specificity is 47%. ► We identified areas for improvement for future ART triaging protocol studies. ► The PDA supports complete and thorough assessment by lower cadres of health staff. ► The PDAs were readily adopted by the clinic staff for this study.Abstract: Background: The shortage of doctors and nurses, along with future expansion into rural clinics, will require that the majority of clinic visits by HIV infected patients on antiretroviral therapy (ART) are managed by non-doctors. The goal of this study was to develop and evaluate a screening protocol to determine which patients needed a full clinical assessment and which patients were stable enough to receive their medications without a doctor's consultation. For this study, we developed an electronic, handheld tool to guide non-physician counselors through screening questions.Methods: Patients visiting two ART clinics in South Africa for routine follow-up visits between March 2007 and April 2008 were included in our study. Each patient was screened by non-physician counselors using the handheld device and then received a full clinical assessment. Clinicians’ report on whether full clinical assessment had been necessary was used as the gold standard for determining “required referral”. Observations were randomly divided into two datasets – 989 for developing a referral protocol and 200 for validating protocol performance.Results: A third of patients had at least one physical complaint, and 16% had five or more physical complaints. 38% of patients required referral for full clinical assessment. We identify a subset of questions which are 87% sensitive and 47% specific for recommended patient referral.Conclusions: The final screening protocol is highly sensitive and could reduce burden on ART clinicians by 30%. The uptake and acceptance of the handheld tool to support implementation of the protocol was high. Further examination of the data reveals several important questions to include in future referral algorithms to improve sensitivity and specificity. Based on these results, we identify a refined algorithm to explore in future evaluations.

Faxed Arabic prescriptions: A medication error waiting to happen? - Corrected Proof

H.J. Feldman, H. Al-Jalahma, R. Al-Ali, S. Reti — 2011-12-19

Highlights: ► Some non-Roman languages that use diacritical marks, can be problematic when faxed. ► We show potential errors with a high-potential for harm, when faxing Arabic text. ► We suggest strategies to protect against these errors if Arabic text is to be faxed.Abstract: Purpose: The Arabic language uses notations called diacritical marks around characters to change which letter a symbol represents, changing the word in which that letter is contained. We explore the potential for error of these marks when faxed in a critical case such as prescriptions. A large number of patients are hurt by medical errors each year . Extensive literature already documents the risks from handwritten prescriptions, while little work has been done with risks from reproduced printed prescriptions. No literature exists to examine risks of prescriptions in non-Roman character alphabets being reproduced. Reproduction via fax transmission is a common practice and often produces damaged copies which can lead to medication errors . Languages with diacritical marks, particularly small ones, used for critical contextual meaning would more likely be at risk for misreading due to fax damage.Methods: We generated text in English and Arabic reproducing common prescribing instructions, such as “every day” at various font sizes. This was placed on commonly used prescription paper, and reproduced via fax between 2 medical facility fax machines.Results: We demonstrate meaningful change of prescribing instructions in the Arabic text by both the fax compression algorithm changing the appearance of diacritical marks along with a large amount of stochastic noise and dropouts being present. This change produced a potentially dangerous change in the instructions in the example we present.Conclusions: Prescriptions that are faxed in languages that use diacritical marks to denote contextual meaning, are at high risk for misreading when reproduced via fax. We suggest mitigating strategies, including minimal font size and use of alliteration text in other languages.

Development and evaluation of data entry templates based on the entity-attribute-value model for clinical decision support of pressure ulcer wound management - Corrected Proof

Hyun-Young Kim, Hyeoun-Ae Park — 2011-11-14

Highlights: ► We identified 13 data entities for pressure ulcer wound management. ► Thirteen entity-attribute-value models were created to represent these entities. ► Six structured data entry templates and the relational database based on these models were developed and integrated with the CDSS to provide patient-specific recommendations. ► Five nurses successfully entered all data and retrieved expected recommendations in six scenarios except one. ► We conclude that the data models and structured data entry templates were useful in supporting decision making.Abstract: Purposes: The purpose of this study was to develop and evaluate the functionality of structured data entry templates using the entity-attribute-value (EAV) model for clinical decision support of pressure ulcer wound management.Methods: A data set for wound assessment of pressure ulcers that has commonly been recommended by clinical practice guidelines was identified, and then the EAV models on each data were developed. Structured data entry templates and a database were developed based on these EAV models. These were integrated with a knowledge engine into the clinical decision support system (CDSS) to provide patient-specific recommendations on pressure ulcer wound management. The functionality of the EAV model and structured data entry templates for the CDSS was evaluated heuristically by five nurse experts using clinical scenarios.Results: The data set containing 13 entities was identified and EAV models of these entities were created. Cardinalities and data types of attributes were defined to represent the models in more detail. Terms used in the EAV models were mapped to SNOMED CT concepts. Six data entry templates and the relational database with ten tables were developed. Five nurses successfully entered all data in the scenarios except one data element and retrieved expected recommendations successfully from the clinical decision support system when all data were entered correctly.Conclusions: The clinical data models and structured data entry templates developed in this study were useful in supporting clinical decision making on pressure ulcer wound management.

Smart pump alerts: All that glitters is not gold - Corrected Proof

2011-11-11

Highlights: ► Smart pump technology has shown to be effective in avoiding administration errors. ► The development of a practical drug library is key to the success of this technology. ► Information gathered in the first months of implementation can help to improve the quality of the drug library and to detect early usersî training needs. ► An exhaustive analysis of the alarms triggered allows to refine the technology and to distinguish alarms associated with real errors from the irrelevant ones.Abstract: Introduction: The implementation of smart pump technology can reduce the incidence of errors in the administration of intravenous drugs. This approach involves developing drug libraries for specific units and setting hard and soft limits for each drug. If a programming error occurs and these limits are exceeded, an alarm sounds and the infusion can be blocked. A detailed analysis of these alarms is essential in order not to bias the results in favor of a positive impact of this technology.Purpose: To evaluate the results of the first analysis of the use of smart infusion pumps and to assess the significance and practical implications of the alarms sounded.Methods: The study was performed by a multidisciplinary team that consisted of a clinical pharmacist, a pediatrician from the pediatric intensive care unit (PICU), and the chief nurse of the unit. A library of 108 drugs was developed over a 7-month period and introduced into 40 syringe pumps and 12 volumetric pumps (Alaris® with Plus software) before being applied in 6 of the 11 beds in the PICU. After four month's use, data were analyzed using the Guardrails® CQI v4.1 Event Reporter program.Results: Following the first four months of implementation, compliance with the drug library was 87%. By analyzing the alerts triggered, we were able to detect problems such as the need to increase user training, readjust limits that did not correspond to clinical practice, correct errors in the editing of the drug library and including a training profile.Conclusion: It is difficult to obtain accurate data on the true impact of this technology in the early stages of its implementation. This preliminary analysis allowed us to identify improvement measures to distinguish, in future evaluations, the alarms triggered by a real programming error from those caused by incorrect use.

A usability evaluation of a SNOMED CT based compositional interface terminology for intensive care - Corrected Proof

2011-10-26

Highlights: ► User-based usability evaluations of an interface terminology. ► Usability is evaluated on five aspects: effectiveness, efficiency, learnability, overall user satisfaction, and experienced usability problems. ► Detailed insight into how clinicians interact with a controlled compositional terminology through a terminology application. ► The extensiveness, complexity of the hierarchy, and the language usage of an interface terminology is defining for its usability.Abstract: Objective: To evaluate the usability of a large compositional interface terminology based on SNOMED CT and the terminology application for registration of the reasons for intensive care admission in a Patient Data Management System.Design: Observational study with user-based usability evaluations before and 3 months after the system was implemented and routinely used.Measurements: Usability was defined by five aspects: effectiveness, efficiency, learnability, overall user satisfaction, and experienced usability problems. Qualitative (the Think–Aloud user testing method) and quantitative (the System Usability Scale questionnaire and Time-on-Task analyses) methods were used to examine these usability aspects.Results: The results of the evaluation study revealed that the usability of the interface terminology fell short (SUS scores before and after implementation of 47.2 out of 100 and 37.5 respectively out of 100). The qualitative measurements revealed a high number (n=35) of distinct usability problems, leading to ineffective and inefficient registration of reasons for admission. The effectiveness and efficiency of the system did not change over time. About 14% (n=5) of the revealed usability problems were related to the terminology content based on SNOMED CT, while the remaining 86% (n=30) was related to the terminology application. The problems related to the terminology content were more severe than the problems related to the terminology application.Conclusions: This study provides a detailed insight into how clinicians interact with a controlled compositional terminology through a terminology application. The extensiveness, complexity of the hierarchy, and the language usage of an interface terminology are defining for its usability. Carefully crafted domain-specific subsets and a well-designed terminology application are needed to facilitate the use of a complex compositional interface terminology based on SNOMED CT.

Supporting medical communication for older patients with a shared touch-screen computer - Corrected Proof

Anne Marie Piper, James D. Hollan — 2011-04-15

Highlights: ► We examine the usability and appeal of a multiuser touch-screen for presenting electronic medical information to older patients. ► We found that older adults quickly adapted to the system and found it easy to use. ► Older adults suggested that having a shared view of their medical information on a shared touch-screen computer system would enhance communication.Abstract: Objective: Increasingly health care facilities are adopting electronic medical record systems and installing computer workstations in patient exam rooms. The introduction of computer workstations into the medical interview process makes it important to consider the impact of such technology on older patients as well as new types of interfaces that may better suit the needs of older adults. While many older adults are comfortable with a traditional computer workstation with a keyboard and mouse, this article explores how a large horizontal touch-screen (i.e., a surface computer) may suit the needs of older patients and facilitates the doctor–patient interview process.Method: Twenty older adults (age 60 to 88) used a prototype multiuser, multitouch system in our research laboratory to examine seven health care scenarios. Behavioral observations as well as results from questionnaires and a structured interview were analyzed.Results: The older adults quickly adapted to the prototype system and reported that it was easy to use. Participants also suggested that having a shared view of one's medical records, especially charts and images, would enhance communication with their doctor and aid understanding.Conclusion: While this study is exploratory and some areas of interaction with a surface computer need to be refined, the technology is promising for sharing electronic patient information during medical interviews involving older adults. Future work must examine doctors’ and nurses’ interaction with the technology as well as logistical issues of installing such a system in a real world medical setting.

Older adults: Are they ready to adopt health-related ICT? - Corrected Proof

Tsipi Heart, Efrat Kalderon — 2011-04-13

Abstract: Background: : The proportion of older adults in the population is steadily increasing, causing healthcare costs to rise dramatically. This situation calls for the implementation of health-related information and communication technologies (ICT) to assist in providing more cost-effective healthcare to the elderly. In order for such a measure to succeed, older adults must be prepared to adopt these technologies. Prior research shows, however, that this population lags behind in ICT adoption, although some believe that this is a temporary phenomenon that will soon change.Objectives: : To assess use by older adults of technology in general and ICT in particular, in order to evaluate their readiness to adopt health-related ICT.Method: : We employed the questionnaire used by Selwyn et al. in 2000 in the UK, as well as a survey instrument used by Morris and Venkatesh, to examine the validity of the theory of planned behavior (TPB) in the context of computer use by older employees. 123 respondents answered the questions via face-to-face interviews, 63 from the US and 60 from Israel. SPSS 17.0 was used for the data analysis.Results: : The results show that although there has been some increase in adoption of modern technologies, including ICT, most of the barriers found by Selwyn et al. are still valid. ICT use was determined by accessibility of computers and support and by age, marital status, education, and health. Health, however, was found to moderate the effect of age, healthier older people being far more likely to use computers than their unhealthy coevals. The TPB was only partially supported, since only perceived behavioral control (PBC) emerged as significantly affecting intention to use a computer, while age, contrary to the findings of Morris and Venkatesh, interacted differently for Americans and Israelis. The main reason for non-use was ‘no interest’ or ‘no need’, similar to findings from data collected in 2000.Conclusions: : Adoption of technology by older adults is still limited, though it has increased as compared with results of the previous study. Modern technologies have been adopted (albeit selectively) by older users, who were presumably strongly motivated by perceived usefulness. Particularly worrying are the effects of health, PBC, and the fact that many older adults do not share the perception that ICT can significantly improve their quality of life. We therefore maintain that older adults are not yet ready to adopt health-related ICT. Health-related ICT for the elderly should be kept simple and demonstrate substantial benefits, and special attention should be paid to training and support and to specific personal and cultural characteristics. These are mandatory conditions for adoption by potential unhealthy and older consumers.

Innovations in health care services: The CAALYX system - Corrected Proof

2011-04-11

Abstract: Purpose: This paper describes proposed health care services innovations, provided by a system called CAALYX (Complete Ambient Assisted Living eXperiment). CAALYX aimed to provide healthcare innovation by extending the state-of-the-art in tele-healthcare, by focusing on increasing the confidence of elderly people living autonomously, by building on the knowledge base of the most common disorders and respective characteristic vital sign changes for this age group.Methods: A review of the state-of-the-art on health care services was carried out. Then, extensive research was conducted on the particular needs of the elderly in relation to home health services that, if offered to them, could improve their day life by giving them greater confidence and autonomy. To achieve this, we addressed issues associated with the gathering of clinical data and interpretation of these data, as well as possibilities of automatically triggering appropriate clinical measures. Considering this initial work we started the identification of initiatives, ongoing works and technologies that could be used for the development of the system. After that, the implementation of CAALYX was done.Findings: The innovation in CAALYX system considers three main areas of contribution: (i) The Roaming Monitoring System that is used to collect information on the well-being of the elderly users; (ii) The Home Monitoring System that is aimed at helping the elders independently living at home being implemented by a device (a personal computer or a set top box) that supports the connection of sensors and video cameras that may be used for monitoring and for interaction with the elder; (iii) The Central Care Service and Monitoring System that is implemented by a Caretaker System where attention and care services are provided to elders, where actors as Caretakers, Doctors and Relatives are logically linked to elders. Innovations in each of these areas are presented here.Conclusions: The ageing European society is placing an added burden on future generations, as the ‘elderly-to-working-age-people’ ratio is set to steadily increase in the future. Nowadays, quality of life and fitness allows for most older persons to have an active life well into their eighties. Furthermore, many older persons prefer to live in their own house and choose their own lifestyle. The CAALYX system can have a clear impact in increasing older persons’ autonomy, by ensuring that they do not need to leave their preferred environment in order to be properly monitored and taken care of.

Using informatics to capture older adults’ wellness - Corrected Proof

2011-04-11

Abstract: Purpose: The aim of this paper is to demonstrate how informatics applications can support the assessment and visualization of older adults’ wellness. A theoretical framework is presented that informs the design of a technology enhanced screening platform for wellness. We highlight an ongoing pilot demonstration in an assisted living facility where a community room has been converted into a living laboratory for the use of diverse technologies (including a telehealth component to capture vital signs and customized questionnaires, a gait analysis component and cognitive assessment software) to assess the multiple aspects of wellness of older adults.Methods: A demonstration project was introduced in an independent retirement community to validate our theoretical framework of informatics and wellness assessment for older adults. Subjects are being recruited to attend a community room and engage in the use of diverse technologies to assess cognitive performance, physiological and gait variables as well as psychometrics pertaining to social and spiritual components of wellness for a period of eight weeks. Data are integrated from various sources into one study database and different visualization approaches are pursued to efficiently display potential correlations between different parameters and capture overall trends of wellness.Results: Preliminary findings indicate that older adults are willing to participate in technology-enhanced interventions and embrace different information technology applications given appropriate and customized training and hardware and software features that address potential functional limitations and inexperience with computers.Conclusion: Informatics can advance health care for older adults and support a holistic assessment of older adults’ wellness. The described framework can support decision making, link formal and informal caregiving networks and identify early trends and patterns that if addressed could reduce adverse health events.

User profiles and personas in the design and development of consumer health technologies - Corrected Proof

Cynthia LeRouge, Jiao Ma, Sweta Sneha, Kristin Tolle — 2011-04-11

Abstract: Background: “The graying of the globe” has resulted in exponential rise in health care expenses, over-worked health care professionals and a growing patient base suffering from multiple chronic diseases, one of which is diabetes. Consumer health technologies (CHT) are considered important catalysts for empowering health care consumers to take a proactive role in managing their health and related costs. Adoption rate and usability of such devices among the aging is far from being satisfactory. Past studies noted the motivation for adoption by the aging is dependent on the suitability/relevance, perceived usability and anticipated benefits associated with usage of technological innovation. Traditional information technology (IT) development adopts a systematic approach without necessarily using a specific user model that personalizes the system to the aging user groups. The aging patient population has unique needs arising from progressive deterioration in both physiological and psychological abilities. These needs are often ignored in the design, development, trial and adoption of consumer health products resulting in low adoption and usage.Objectives: The main objective of this research is to investigate the user-centered design (UCD), specifically user profiles and personas, as methodological tools to inform the design and development of CHT devices for an aging population. The adoption of user profile and persona has not received much attention in health care informatics research and, in particular, research involving CHT. Our work begins to fill this void in three ways. We (1) illuminate the process of developing CHT user profiles and personas for a Chinese elder population with a demanding health care needs, i.e., self-management of chronic diabetes, with the hope that the resulting profiles and personas may be used as foundational material for informing the design, development and evaluation of CHT in other similar contexts; (2) call attention to how to further enhance and complement traditional user profile and persona techniques for CHT design by integrating cognitive structures and present behavior that drive health care thinking, future behavior and demand; (3) show how the profiles and personas can be used to inform requirements, design and implementation decisions for a technology aimed at facilitating CHT adoption and diffusion for the elderly.Methodology: To exemplify process and application, we use an action-research methodology, where user profiles and personas of an aging patient population were developed. The resultant profiles and personas were leveraged to improve the design, development and implementation plans of a smart phone application to assist chronically ill aging Chinese diabetic population capable of disease self-management.Results: The results from the study show that user profile and persona can be a valuable methodological approach in capturing the conceptual model of the aging and informing the design and development decisions of CHT. The demonstration of techniques used in this study can serve as a guideline to CHT developers in bringing conceptual user modeling into the design of software interfaces targeted for users with specific health care needs. Specifically, the study provides guidance on the creation and use of profiles and personas to tap into the conceptual models of the targeted elderly population reflecting their preferences, capabilities and attitudes towards using technology in self-management care in general and the smart phone diabetes management application in particular. Insight into the mental model of the aging group has been shown to inform later stages of UCD development (e.g., the creation of prototypes and usability testing) as well as implementation and adoption strategies. The World Health Organization (WHO) predicts that by 2025, 80% of all new cases of diabetes are expected to appear in the developing countries. In fact, the number of diabetic patients in China is estimated to rise to 42.3 million in 2030 from 20.8 million in 2000. Thus, we investigate the Chinese aging population in order to demonstrate the process of developing and using user profile and persona. We hope that the resultant conceptual model of the Chinese aging diabetic population can be used in future research to guide CHT designers interested in designing health care devices for this vulnerable user group.

Development and evaluation of SOA-based AAL services in real-life environments: A case study and lessons learned - Corrected Proof

Erlend Stav, Ståle Walderhaug, Marius Mikalsen, Sten Hanke, Ivan Benc — 2011-04-11

Abstract: Intro: The proper use of ICT services can support seniors in living independently longer. While such services are starting to emerge, current proprietary solutions are often expensive, covering only isolated parts of seniors’ needs, and lack support for sharing information between services and between users. For developers, the challenge is that it is complex and time consuming to develop high quality, interoperable services, and new techniques are needed to simplify the development and reduce the development costs.This paper provides the complete view of the experiences gained in the MPOWER project with respect to using model-driven development (MDD) techniques for Service Oriented Architecture (SOA) system development in the Ambient Assisted Living (AAL) domain.Method: To address this challenge, the approach of the European research project MPOWER (2006–2009) was to investigate and record the user needs, define a set of reusable software services based on these needs, and then implement pilot systems using these services. Further, a model-driven toolchain covering key development phases was developed to support software developers through this process. Evaluations were conducted both on the technical artefacts (methodology and tools), and on end user experience from using the pilot systems in trial sites.Results: The outcome of the work on the user needs is a knowledge base recorded as a Unified Modeling Language (UML) model. This comprehensive model describes actors, use cases, and features derived from these. The model further includes the design of a set of software services, including full trace information back to the features and use cases motivating their design. Based on the model, the services were implemented for use in Service Oriented Architecture (SOA) systems, and are publicly available as open source software. The services were successfully used in the realization of two pilot applications. There is therefore a direct and traceable link from the user needs of the elderly, through the service design knowledge base, to the service and pilot implementations.The evaluation of the SOA approach on the developers in the project revealed that SOA is useful with respect to job performance and quality. Furthermore, they think SOA is easy to use and support development of AAL applications. An important finding is that the developers clearly report that they intend to use SOA in the future, but not for all type of projects. With respect to using model-driven development in web services design and implementation, the developers reported that it was useful. However, it is important that the code generated from the models is correct if the full potential of MDD should be achieved.The pilots and their evaluation in the trial sites showed that the services of the platform are sufficient to create suitable systems for end users in the domain.Conclusions: A SOA platform with a set of reusable domain services is a suitable foundation for more rapid development and tailoring of assisted living systems covering reoccurring needs among elderly users. It is feasible to realize a tool-chain for model-driven development of SOA applications in the AAL domain, and such a tool-chain can be accepted and found useful by software developers.

Designing and evaluating an electronic patient falls reporting system: Perspectives for the implementation of health information technology in long-term residential care facilities - Corrected Proof

Yi You Mei, Jenna Marquard, Cynthia Jacelon, Audrey L. DeFeo — 2011-04-11

Abstract: Background and purpose: Patient falls are the leading cause of unintentional injury and death among older adults. In 2000, falls resulted in over 10,300 elderly deaths, costing the United States approximately $179 million in incidence and medical costs. Furthermore, non-fatal injuries caused by falls cost the United States $19 billion annually. Health information technology (IT) applications, specifically electronic falls reporting systems, can aid quality improvement efforts to prevent patient falls. Yet, long-term residential care facilities (LTRCFs) often do not have the financial resources to implement health IT, and workers in these settings are often not ready to adopt such systems. Additionally, most health IT evaluations are conducted in large acute-care settings, so LTRCF administrators currently lack evidence to support the value of health IT.Methods: In this paper, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a LTRCF using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: (1) System-level benefits and costs, (2) system usability, via scenario-based use cases, (3) a holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and (4) user technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder.Results and conclusions: The electronic falls reporting system was successfully implemented, with 100% reporting at 3-months post-implementation. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to health IT implementations in other LTRCFs.