International Journal of Medical Informatics - Articles in Press

Use of electronic information systems in nursing management - Corrected Proof

Johanna Lammintakanen, Kaija Saranto, Tuula Kivinen — 2010-03-08

Abstract: Purpose: The purpose of this study is to describe nurse managers’ perceptions of the use of electronic information systems in their daily work. Several kinds of software are used for administrative and information management purposes in health care organizations, but the issue has been studied less from nurse managers’ perspective.Methods: The material for this qualitative study was acquired according to the principles of focus group interview. Altogether eight focus groups were held with 48 nurse managers from both primary and specialized health care organizations. The nurse managers were asked in focus groups to describe the use of information systems in their daily work in addition to some other themes. The material was analyzed by inductive content analysis using ATLAS.ti computer program.Results: The main category “pros and cons of using information systems in nursing management” summarized the nurse managers’ perceptions of using electronic information systems. The main category consisted of three sub-categories: (1) nurse managers’ perceptions of the use of information technology; (2) usability of management information systems; (3) development of personnel competencies and work processes.Conclusions: The nurse managers made several comments on the implementation of immature electronic information systems which caused inefficiencies in working processes. However, they considered electronic information systems to be essential elements of their daily work. Furthermore, the nurse managers’ descriptions of the pros and cons of using information systems reflected partly the shortcomings of strategic management and lack of coordination in health care organizations.

The influence of text characteristics on perceived and actual difficulty of health information - Corrected Proof

Gondy Leroy, Stephen Helmreich, James R. Cowie — 2010-03-08

Abstract: Purpose: Willingness and ability to learn from health information in text are crucial for people to be informed and make better medical decisions. These two user characteristics are influenced by the perceived and actual difficulty of text. Our goal is to find text features that are indicative of perceived and actual difficulty so that barriers to reading can be lowered and understanding of information increased.Methods: We systematically manipulated three text characteristics, – overall sentence structure (active, passive, extraposed-subject, or sentential-subject), noun phrases complexity (simple or complex), and function word density (high or low), – which are more fine-grained metrics to evaluate text than the commonly used readability formulas. We measured perceived difficulty with individual sentences by asking consumers to choose the easiest and most difficult version of a sentence. We measured actual difficulty with entire paragraphs by posing multiple-choice questions to measure understanding and retention of information in easy and difficult versions of the paragraphs.Results: Based on a study with 86 participants, we found that low noun phrase complexity and high function words density lead to sentences being perceived as simpler. In the sentences with passive, sentential-subject, or extraposed-subject sentences, both main and interaction effects were significant (all p<.05). In active sentences, only noun phrase complexity mattered (p<.001). For the same group of participants, simplification of entire paragraphs based on these three linguistic features had only a small effect on understanding (p=.99) and no effect on retention of information.Conclusions: Using grammatical text features, we could measure and improve the perceived difficulty of text. In contrast to expectations based on readability formulas, these grammatical manipulations had limited effects on actual difficulty and so were insufficient to simplify the text and improve understanding. Future work will include semantic measures and overall text composition and their effects on perceived and actual difficulty.Limitations: These results are limited to grammatical features of text. The studies also used only one task, a question-answering task, to measure understanding of information.

Improving quality of care. A systematic review on how medical registries provide information feedback to health care providers - Corrected Proof

2010-03-02

Abstract: Objective: To determine (1) how medical registries provide information feedback to health care professionals, (2) whether this feedback has any effect on the quality of care and (3) what the barriers and success factors are to the effectiveness of feedback.Data sources: Original articles in English found in MEDLINE Pubmed covering the period January 1990 to August 2007.Review method: Titles and abstracts of 6223 original articles were independently screened by two reviewers to determine relevance for further review.Data extraction and analysis: We used a standardized data abstraction form to collect information on the feedback initiatives and their effectiveness. The effect of the feedback was only described for analytic papers, i.e. papers that attempted to objectively quantify the effect on the quality of care and to relate this effect to feedback as an intervention. For analysis of the effectiveness, we categorized the initiatives based on the number of elements added to the feedback.Results: We included 53 papers, describing 50 feedback initiatives, of which 39 were part of a multifaceted approach. Our results confirm previous research findings that adding elements to a feedback strategy positively influences its effectiveness. We found 22 analytic studies, four of which found a positive effect on all outcome measures, eight found a mix of positive- and no effects and ten did not find any effects (neither positive nor negative). Of the 43 process of care measures evaluated in the analytic studies, 26 were positively affected by the feedback initiative. Of the 36 evaluated outcome of care measures, five were positively affected. The most frequently mentioned factors influencing the effectiveness of the feedback were: (trust in) quality of the data, motivation of the recipients, organizational factors and outcome expectancy of the feedback recipients.Conclusions: The literature on methods and effects of information feedback by medical registries is heterogeneous, making it difficult to draw definite conclusions on its effectiveness. However, the positive effects cannot be discarded. Although our review confirms findings from previous studies that process of care measures are more positively influenced by feedback than outcome of care measures, further research should attempt to identify outcome of care measures that are sensitive to behaviour change as a result of feedback strategies. Furthermore, future studies evaluating the effectiveness of feedback should include a more extensive description of their intervention in order to increase the reproducibility of feedback initiatives and the generalizability of the results.

Revisiting the online health information reliability debate in the wake of “web 2.0”: An inter-disciplinary literature and website review - Corrected Proof

Samantha A. Adams — 2010-02-26

Abstract: Purpose: The purpose of this inter-disciplinary literature review was to explore renewed concerns about the reliability of online health information in light of the increasing popularity of web applications that enable more end-user-generated content (“web 2.0”).Methods: The findings are based on a literature and web review. Literature was collected at four different points between October 2006 and October 2008 and included 56 sources from 10 academic disciplines. The web review consisted of following 6 blogs (including both new and archived posts, with comments) and one wiki for a period of 1.5 months and assessing the content for relevancy on six points, totaling 63 sources altogether.Results: The reliability issues that are identified with respect to “web 2.0” reiterate more general concerns expressed about the web over the last 15 years. The difference, however, lies in the scope and scale of potential problems. Social scientists have also pointed to new issues that can be especially relevant for use of web 2.0 applications in health care. Specific points of renewed concern include: disclosure of authorship and information quality, anonymity and privacy, and the ability of individuals to apply information to their personal situation. Whether or not end-users understand what social scientists call “negative network externalities” is a new concern. Finally, not all reliability issues are negative—social networking and the shift from text-based information to symbolic information, images or interactive information, are considered to enhance patient education and to provide opportunities to reach diverse groups of patients.Conclusions: Interactive and collaborative web applications undeniably offer new opportunities for reaching patients and other health care consumers by facilitating lay information creation, sharing and retrieval. However, researchers must be careful and critical when incorporating applications or practices from other fields in health care. We must not easily dismiss concerns about reliability as outdated. Specific issues related to use of newly popular web applications for health purposes must be addressed. Nonetheless, the articles reviewed here also clearly show that potential problems can be addressed and the positive aspects of the technologies embraced.

Using ontologies for structuring organizational knowledge in Home Care assistance - Corrected Proof

Aida Valls, Karina Gibert, David Sánchez, Montserrat Batet — 2010-02-25

Abstract: Purpose: Information Technologies and Knowledge-based Systems can significantly improve the management of complex distributed health systems, where supporting multidisciplinarity is crucial and communication and synchronization between the different professionals and tasks becomes essential. This work proposes the use of the ontological paradigm to describe the organizational knowledge of such complex healthcare institutions as a basis to support their management. The ontology engineering process is detailed, as well as the way to maintain the ontology updated in front of changes. The paper also analyzes how such an ontology can be exploited in a real healthcare application and the role of the ontology in the customization of the system. The particular case of senior Home Care assistance is addressed, as this is a highly distributed field as well as a strategic goal in an ageing Europe.Materials and methods: The proposed ontology design is based on a Home Care medical model defined by an European consortium of Home Care professionals, framed in the scope of the K4Care European project (FP6). Due to the complexity of the model and the knowledge gap existing between the – textual – medical model and the strict formalization of an ontology, an ontology engineering methodology (On-To-Knowledge) has been followed.Results: After applying the On-To-Knowledge steps, the following results were obtained: the feasibility study concluded that the ontological paradigm and the expressiveness of modern ontology languages were enough to describe the required medical knowledge; after the kick-off and refinement stages, a complete and non-ambiguous definition of the Home Care model, including its main components and interrelations, was obtained; the formalization stage expressed HC medical entities in the form of ontological classes, which are interrelated by means of hierarchies, properties and semantically rich class restrictions; the evaluation, carried out by exploiting the ontology into a knowledge-driven e-health application running on a real scenario, showed that the ontology design and its exploitation brought several benefits with regards to flexibility, adaptability and work efficiency from the end-user point of view; for the maintenance stage, two software tools are presented, aimed to address the incorporation and modification of healthcare units and the personalization of ontological profiles.Conclusions: The paper shows that the ontological paradigm and the expressiveness of modern ontology languages can be exploited not only to represent terminology in a non-ambiguous way, but also to formalize the interrelations and organizational structures involved in a real and distributed healthcare environment. This kind of ontologies facilitates the adaptation in front of changes in the healthcare organization or Care Units, supports the creation of profile-based interaction models in a transparent and seamless way, and increases the reusability and generality of the developed software components. As a conclusion of the exploitation of the developed ontology in a real medical scenario, we can say that an ontology formalizing organizational interrelations is a key component for building effective distributed knowledge-driven e-health systems.

Socio-technical considerations in epilepsy electronic patient record implementation - Corrected Proof

2010-02-24

Abstract: Purpose: Examination of electronic patient record (EPR) implementation at the socio-technical interface. This study was based on the introduction of an anti-epileptic drug (AED) management module of an EPR in an epilepsy out-patient clinic. The objective was to introduce the module to a live clinical setting within strictly controlled conditions to evaluate its usability and usefulness.Methods: Qualitative and quantitative methods were employed in an observational field study. A purposeful sample of specialists in epilepsy care (2 doctors and 2 nurses) was recruited. Perception of usefulness and ease of use of the AED module, impact on work processes, and accuracy of use were evaluated using feedback meetings, evaluation forms, ethnographic analysis and data validation techniques. Emerging issues were grouped into three key themes: human, organisational and technological.Results: The electronic patient record use was studied for 49 patients over the course of 18 out-patient clinics. While participants varied in their approach to interacting with the AED module, they expressed satisfaction with its usability and performance. The necessary co-existence of the paper and electronic record, and changes to customary work practice were considered the biggest challenges. 82% accuracy in the use of the electronic record was determined.Conclusions: Achieving successful electronic patient record implementation is complex. While technical challenges exist, it is possibly more important to acknowledge the social considerations. Initially, an increase in medical record fragmentation and disruption to workflow can arise with the introduction of the technology. Realising the benefits of electronic patient records will require the management of a lengthy transition phase.

Understanding handling of drug safety alerts: a simulation study - Corrected Proof

Heleen van der Sijs, Teun van Gelder, Arnold Vulto, Marc Berg, Jos Aarts — 2010-02-22

Abstract: Purpose: To study correctness of drug safety alert handling and error type in a computerized physician order entry (CPOE) system in a simulated work environment.Methods: Disguised observation study of 18 physicians (12 from internal medicine and 6 from surgery) entering 35 orders of predefined patient cases with 13 different drug safety alerts in a CPOE. Structured interviews about how the generated drug safety alerts were handled in the simulation test and resemblance of the test to the normal work environment. Handling and reasons for this were scored for correctness and error type.Results: Thirty percent of alerts were handled incorrectly, because the action itself and/or the reason for the handling were incorrect. Sixty-three percent of the errors were categorized as rule based and residents in surgery used incorrect justifications twice as often as residents in internal medicine. They often referred to monitoring of incorrect substances or parameters. One alert presented as a second alert in one screen was unconsciously overridden several times. One quarter of residents showed signs of alert fatigue.Conclusion: Although alerts were mainly handled correctly, underlying rules and reasoning were often incorrect, thereby threatening patient safety. This study gave an insight into the factors playing a role in incorrect drug safety alert handling that should be studied in more detail. The results suggest that better training, improved concise alert texts, and increased specificity might help. Furthermore, the safety of the predefined override reason ‘will monitor’ and double alert presentation in one screen is questioned.

A human factors and survey methodology-based design of a web-based adverse event reporting system for families - Corrected Proof

2010-02-22

Abstract: Purpose: Adverse event reporting systems allow healthcare institutions to detect and prevent recurrence of avoidable patient harm. It is known that standard reporting systems, which are initiated by clinicians, detect only a minority of chart-documented adverse events. The objective of the study was to develop a web-based system, the Family Reporting System (FRS), to elicit adverse event reports from families of children admitted to hospital through survey methodology and human factors engineering techniques.Measurements: Face validity and usability were measured via standardized survey instruments. Utility was measured via the rate, typology, degree of harm, likelihood of recurrence, quality of information, and inter-rater agreement analysis of the reported events.Results: The FRS has good face validity, excellent usability, and good clinical utility.Conclusion: The application of survey and human factors methodologies to the design of an electronic system is an effective means of developing an electronic adverse event reporting system for the use of families of pediatric patients.

Analysis of communicative behaviour: Profiling roles and activities - Corrected Proof

Inger Dybdahl Sørby, Øystein Nytrø — 2009-09-22

Abstract: Objectives: In this paper we present a method for processing and presentation of data recorded through structured observation of clinicians’ information and communication activities. The activities are encoded as sequences of distinctive speech acts, and resulting profiles of communicative behaviour are visualized in radar graphs. Example profiles resulting from the analysis of three clinicians’ communicative behaviour during pre-rounds meetings and medication activities are given.Methods: The communicative acts profiles are based on empirical data from an observational study performed at a Norwegian university hospital. A fifth-year medical student spent 20 days in two different hospital wards, following one physician at a time in daily, patient-centred work. The observer recorded the clinicians’ information and communication activities during several ward situations such as pre-rounds meetings, ward rounds, and patient discharge. The data was recorded by means of an observation form consisting of a mixture of codes and free-text fields. The recorded data was post-processed by associating each event with one predefined communicative act, and resulting profiles for three individual physicians in different situations have been created as radar graphs.Results/conclusion: The approach is an efficient and useful means for studying clinicians’ information and communication patterns in hospital wards. The method can be used to illustrate variations among individual clinicians in similar situations and to compare profiles of different roles or hospital wards. Given proper validation, the approach may serve as an important tool to inform the design of new clinical information systems.

Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance - Corrected Proof

William L. Galanter, Daniel B. Hier, Chiang Jao, David Sarne — 2009-01-30

Abstract: Objective: The problem list is a key and required element of the electronic medical record (EMR). Problem lists may contribute substantially to patient safety and quality of care. Physician documentation of the problem list is often lower than desired. Methods are needed to improve accuracy and completeness of the problem list.Design: An automated clinical decision support (CDS) intervention was designed utilizing a commercially available EMR with computerized physician order entry (CPOE) and CDS. The system was based on alerts delivered during inpatient medication CPOE that prompted clinicians to add a diagnosis to the problem list. Each alert was studied for a 2-month period after implementation.Measurements: Measures included alert validity, alert yield, and accuracy of problem list additions.Results: At a 450 bed teaching hospital, the number of medication orders which triggered alerts during all 2-month study periods was 1011. For all the alerts, the likelihood of a valid alert (an alert that occurred in patients with one of the predefined diagnoses) was 96±1%. The alert yield, defined as occuring when an alert led to addition of a problem to the problem list, was 76±2%. Accurate problem list additions, defined as additions of problems when the problem was determined to be present by expert review, was 95±1%.Conclusion: The CDS problem list mechanism was integrated into the process of medication order placement and promoted relatively accurate addition of problems to the EMR problem list.

Blog-based applications and health information: Two case studies that illustrate important questions for Consumer Health Informatics (CHI) research - Corrected Proof

Samantha A. Adams — 2009-01-30

Abstract: Weblogs (blogs), together with podcasts and wikis are part of the larger body of next-generation communication applications dubbed “web 2.0.” Within the specific area of health care, little attention has been devoted to understanding what applications are available to the lay public and how these are being used. In this study, a literature review on blogs and blogging practices was conducted, followed by case study analyses of two separate sites that use blogging tools to help patients and other lay web end-users record health-related experiences. This paper explores the diverse purposes for which blogging applications can be (or are being) used in relation to health and introduces the idea of “health goal-oriented” blogging. The discussion focuses on relevant informatics questions that arise with respect to the use of blogs and makes suggestions for subsequent research.

A cross-case analysis of technology-in-use practices: EPR-adaptation in Canada and Norway - Corrected Proof

Nina Boulus, Pernille Bjorn — 2009-01-30

Abstract: Purpose: To identify and characterize enabling factors that support a continuous adaptation of technology and work practices in the health care sector.Methods: Cross-case analysis of two longitudinal ethnographic studies of managing the gradual adaptation of electronic patient records, one in Canada and one Norway.Results: The cross-case analysis revealed that technology-in-use practices developed more rapidly in one of the cases, and one of the major driving forces was the establishment of a special committee and the associated project meetings. Based on the literature and grounded in the empirical observations, we complement and expand the notion of project meetings as composed of continuous reflection-on-practice activities to construct technology-in-use practices.Conclusion: We characterize reflection-on-practice activities as frequent encounters of negotiations of work practices and technology use, providing internal actors a space for systematic evaluation of suggested changes. Further we argue that representatives of the affected professions should not only participate, but also have a mandate to make and evaluate decisions of the technology-in-use practices of the particular group.

Scenarios to capture work processes in shared homecare—From analysis to application - Corrected Proof

Maria Hägglund, Isabella Scandurra, Sabine Koch — 2009-01-30

Abstract: Background: Shared homecare is increasingly common, and in order to develop ICT that support such complex cooperative and interdisciplinary work it is crucial to obtain an understanding of work processes at the clinical level before the development is initiated. It is also crucial, but difficult, to correctly transfer this insight to the development team.Method: User-centered scenario building in interdisciplinary working groups is applied for capturing cooperative work routines, information demands, and other central preconditions in shared homecare.Results: Use of scenarios for analysis of cooperative work and as information carrier is described via a case from the multi-disciplinary OLD@HOME project. Both current and future work scenarios were elicited. To illustrate the process of transforming scenarios into more technical descriptions (use cases), and finally into an application, examples showing the transparency in resulting use cases and in the implemented system are provided.Conclusion: In this case study, scenarios proved to be useful not only in initial system development phases but throughout the entire development process, improving accessibility and assessment of end user needs. For the development team, scenarios assisted in solving usability issues, and served as a basis for describing use cases and for further system development. More importantly, the shared care scenarios ensured the provision of different perspectives on common work processes, which are often neglected in conventional requirements specifications. This also improved understanding between different clinical groups and between clinicians and developers.

A longitudinal study of usability in health care: Does time heal? - Corrected Proof

Jesper Kjeldskov, Mikael B. Skov, Jan Stage — 2009-01-30

Abstract: We report from a longitudinal laboratory-based usability evaluation of a health care information system. The purpose of the study was to inquire into the nature of usability problems experienced by novice and expert users, and to see to what extend usability problems of a health care information system may or may not disappear over time, as the nurses get more familiar with it—if time heals poor design? As our method for studying this, we conducted a longitudinal study with two key studies. A usability evaluation was conducted with novice users when an electronic patient record system was being deployed in a large hospital. After the nurses had used the system in their daily work for 15 months, we repeated the evaluation. Our results show that time does not heal. Although some problems were not experiences as severe, they still remained after 1 year of extensive use. On the basis of our findings, we discuss implications for evaluating usability in health care.

The roles of MDs and RNs as initiators and recipients of interruptions in workflow - Corrected Proof

Juliana J. Brixey, David J. Robinson, James P. Turley, Jiajie Zhang — 2009-01-30

Abstract: Background: Previous research studies have focused on the recipients of interruptions because of the negative impact interruptions have on task performance. It is equally important to understand the initiators of interruptions to help design strategies to lessen the number of interruptions and the possible negatives consequences. The purpose of this study was to examine MDs and RNs as initiators and recipients of interruptions.Methods: This was an instrumental case study using the shadowing method. A convenience sample of five attending trauma MDs and eight RNs were observed during the 07:00–15:00 and 15:00–21:00 shifts in the trauma section of a level one trauma center.Result: Seventy hours of observations were recorded. Initiator and recipient of an interruption emerged as major roles during categorization of the notes. Medical doctors and RNs were found to be the recipient of an interruption more frequently than the initiator. Findings from this study indicate that MDs and RNs initiate interruptions most often through face-to-face interactions and use of the telephone.Conclusions: A role-based taxonomy of interruptions was derived from the recorded notes. Strategies to successfully manage interruptions must consider both the role of initiator as well as the recipient when an interruption occurs. It is suggested that the role-based taxonomy presented in this paper be used to classify interruptions in future studies.

Social network analysis of medication advice-seeking interactions among staff in an Australian hospital - Corrected Proof

Nerida Creswick, Johanna I. Westbrook — 2009-01-30

Abstract: Purpose: To examine the medication advice-seeking network of staff in a hospital ward.Methods: Social network analysis was carried out in a renal ward of an Australian metropolitan teaching hospital. The medication advice-seeking interactions of doctors, nurses, allied health professionals (including a pharmacist) and a ward clerk were examined using data from questionnaires administered to staff. The questionnaire listed all staff who worked in the ward and sought information from respondents regarding their interactions with each staff member. Data were analysed using social network software, UCINET. Analyses performed included geodesic distance, network density, strength of ties, reciprocation of relations, and centrality of individuals. NetDraw was used to produce social network diagrams.Results: A very high response rate of 96% was achieved with 45 of 47 staff returning the questionnaire. On average, there is little interaction between each of the staff members in the medication advice-seeking network, with even less interaction between staff from different professional groups. Nurses are mainly located on one side of the network and doctors on the other. However, the pharmacist is quite central in the medication advice-seeking network as are some senior nurses and a junior doctor.Conclusions: When hospital clinical staff seek medication advice from other members of a ward it tends to be sought from those in their profession. However key individuals in the ward are relied upon for the provision of medication advice by staff from all professions. Social network analysis can be used to examine the complex medication advice-seeking interactions amongst staff in a hospital ward, providing useful quantitative baseline data against which to compare the effect of interventions, such as an electronic medication system, on interactions.