A mixed method observational study of strategies to promote adoption and usage of an application to support asthma self-management

BACKGROUND: Apps can potentially support asthma self-management, however attracting downloads and encouraging on-going adherence is challenging.OBJECTIVES: We observed the impact of different recruitment strategies and app features on adoption and continued use.METHODS: Practice nurses in five practices in Lothian/Oxford approached adults with active asthma to try out a prototype app. We also advertised the app via social media (Asthma UK; AUK Centre for Applied Research). We observed patients’ download and retention rates and sent pre- and post-trial questionnaires. We sampled 15 patients for interviews before and after using our app for one month to explore motivations, triggers and barriers to adoption and usage. Interviews were transcribed and analysed thematically with reference to the Fogg behaviour model.RESULTS: Social media attracted 87 users, but only 15 (17%) used the app for 30 days.  Practices recruited 24 patients, 13 (54%) continued for 30 days. Successful adoption was dependent on ease of downloading and sufficient motivation. Some patients needed technological assistance with downloading the app and starting to use the features.   Adherence was dependent on motivation derived from a sense that the healthcare professional and/or researcher was interested in the results, and that using an app to support their self-management could improve their asthma control.CONCLUSION: Social media attracted more downloads in a short time. However, most patients stopped using the app within a month.  Practices recruited fewer patients, but patents adhered longer to the app.  Dual promotion strategies (social media with practice support) may be the optimal approach to encourage adoption and adherence to telehealth

Five key strategic priorities of integrating patient generated health data into United Kingdom electronic health records

The integration of patient/person generated health data into clinical applications is a key strategic priority internationally. However, despite agreement on the overall direction of travel, there are still a range of challenges that inhibit progress in this area. These include technology-related factors (such as interoperability), use-related factors (such as data overload) and characteristics of the strategic environment (such as existing standards). Building on important policy deliberations from the United States that aim to navigate these challenges, we here apply emerging policy frameworks to the United Kingdom and outline five key priority areas that are intended to help policy makers make important strategic decisions in attempting to integrate patient/person generated data into electronic health records

Designing health information technology tools for behavioral health clinicians integrated within a primary care team

Background: Electronic health records (EHRs) are a key tool for primary care practice. However, EHR functionality is not keeping pace with the evolving informational and decision-support needs of behavioral health clinicians (BHCs) working on integrated teams. Objective: Describe workflows and tasks of BHCs working with integrated teams, identify their health information technology needs, and develop EHR tools to address them. Method: A mixed-methods, comparative-case study of six community health centers (CHCs) in Oregon, each with at least one BHC integrated in their primary care team. We observed clinical work and conducted interviews to understand workflows and clinical tasks, aiming to identify how effectively current EHRs supported integrated care delivery, including transitions, documentation, information sharing, and decision making. We analyzed these data and employed a user-centered design process to develop EHR tools addressing the identified needs. Results: BHCs used the primary care EHR for documentation and communication with other team members, but the EHR lacked the functionality to fully support integrated care. Needs include the ability to: (1) automate and track paper-based screening; (2) document behavioral health history; (3) access patient social and medical history relevant to behavioral health issues, and (4) rapidly document and track progress on goals. To meet these needs, we engaged users and developed a set of EHR tools called the BH e-Suite. Conclusion: Integrated primary care teams, and particularly BHCs, have unique information needs, workflows and tasks. These needs can be met and supported by the EHR with a moderate level of modification

Chief Information Officer team evolution in university hospitals: interaction of the three ‘C’s (CIO, CCIO, CRIO)

Background: The Chief Information Officer (CIO) and Chief Clinical Information Officer (CCIO) are now established senior roles in hospital practice. With increasing emphasis on optimising use of routine health data for secondary purposes and research, additional skills are required as part of the senior information officer team, particularly in academic health care institutions.Objective: Here we present the role of the Chief Research Information Officer (CRIO), as an emerging, and important, component of the senior information team.   Method: We review recent publications describing the composition of the senior information team, including CIO and CCIO roles, and present evidence for development of the CRIO as a distinct component of the team.Results: The CRIO is emerging as an additional senior role in academic healthcare institutions, whose roles include leadership of the informatics strategy and optimisation of routine data collection systems for research data use. Such individuals should be senior clinicians with experience in informatics, in addition to having established research expertise and knowledge of research processes, governance and academic networks.Conclusion: The CRIO is emerging as a distinct senior information leadership role in conjunction with the already established positions of CCIO and CIO, who together, can provide optimal oversight of digital activities across the organisation

Newborn screening data management: proposing a framework for Iran

INTRODUCTION: Different countries use a variety of methods to manage the newborn screening data. In this study, we aimed to compare the experiences of the selected countries to propose a framework for managing the newborn screening data in Iran.METHODS: In this comparative study, data were collected using electronic databases and the official website of the Department of Health in America, England and Australia. Data related to the process of newborn screening in Iran were collected using an open-ended questionnaire and reviewing the published documents.RESULTS: In this study, a framework for newborn screening data management was proposed which consisted of six main areas, namely; objectives, involved organisations, data elements, data collection processes, data classification systems and the methods of controlling data quality.CONCLUSION: The framework suggested in this study can help to re-organise the process of newborn screening with more focus on data management. These data can be used in conducting research and setting strategies for improving the quality of child health in the country

Patient-centric implementation of an electronic medication management system at a tertiary hospital in Western Sydney

Background: Traditional implementations of electronic medication management (EMM) systems have involved two common formats – a ‘big bang’ approach on the day of go-live, or a phased ward-by-ward approach over months.Objective: To describe the patient-centric roll-out, a novel implementation model in converting from paper to EMM.Method: This model iteratively converted a large tertiary teaching hospital to electronic from paper medication charts, commencing the roll-out in the emergency department (ED). The tenet of ‘one patient, one chart’ was maintained with new patients commenced on EMM, while existing inpatients were maintained on paper charts until their discharge. In the second week, all other intake points commenced patients on EMM, and in the third week, all remaining patients were manually converted to EMM. The implementation was assessed with training completion rates, staff satisfaction surveys, focus group interviews and incident logs.Results: At go-live, 79% of doctors, 68% of nurses and 90% of pharmacists were trained in the EMM system. The ED converted to electronic prescribing within 24 hours; by day 20, all patients were on EMM. Two hundred and thirty issues were logged, none critical, of which 22 were escalated. Of the 51,063 medications administered, there were 13 EMM-related clinical incidents including three double dosing errors, none of which led to an adverse event or death. Overall, 77% of staff surveyed were satisfied with the EMM implementation.Conclusions: The patient-centric roll-out model represents an innovative and safe approach with a single medication chart reducing transcription and improved medication safety for the patient and the organisation.

Learning health systems need to bridge the ‘two cultures’ of clinical informatics and data science

Background UK health research policy and plans for population health management are predicated upon transformative knowledge discovery from operational “Big Data”. Learning health systems require not only data, but feedback loops of knowledge into changed practice. This depends on knowledge management and application, which in turn depend upon effective system design and implementation. Biomedical informatics is the interdisciplinary field at the intersection of health science, social science and information science and technology that spans this entire scope. Issues In the UK, the separate worlds of health data science (bioinformatics, “Big Data”) and effective healthcare system design and implementation (clinical informatics, “Digital Health”) have operated as ‘two cultures’. Much NHS and social care data is of unusably poor quality. Substantial research funding is wasted on ‘data cleansing’ or by producing very weak evidence. There is not yet a sufficiently powerful professional community or evidence base of best practice to influence the practitioner community or the digital health industry. Recommendation The UK needs increased clinical informatics research and education capacity and capability at much greater scale and ambition to be able to meet policy expectations, address the fundamental gaps in the discipline’s evidence base and mitigate the absence of regulation.Independent evaluation of digital health interventions should be the norm, not the exception. Conclusions  Policy makers and research funders need to acknowledge the existing gap between the ‘two cultures’ and recognise that the full social and economic benefits of digital health and data science can only be realised by accepting the interdisciplinary nature of biomedical informatics and supporting a significant expansion of clinical informatics capacity and capability

SMASH! The Salford medication safety dashboard

Background: Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.Method: Based on initial system requirements we designed the dashboard’s user interface over 3 iterations with 6 general practitioners (GPs), 7 pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices.Results: A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (n=43) general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week.Conclusion: We have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care

Can we trust Electronic health records? The Smoking Test for Commission Errors.

Background: Considerable interest exists on using general practice electronic health records (EHR) for research and other uses. There is also concern on their quality.Aim: We suggest a simple test to assess errors of commission and in consequence overall EHR data quality that can be done on a periodical basis.Method: Patient records with simultaneous entries of three different stages on smoking were studied. The codes “Never smoked tobacco”, “smoker” and “ex-smoker” should follow this chronological order. It should then be possible to extrapolate the overall level of errors of commission for the organisation.Results: The Smoking Test in our sample found errors in 169 patients, with 60 cases where dual errors were discovered. We express it as an estimated error of commission level of 2.6% related to the total population of the practice.Conclusions: Considering the constant and regular entries on smoking status (83.59% of the entries were done over last month), we can conclude smoking entries analysis can serve as a simple test to periodically assess the overall EHR data quality, and any trends

What to expect from electronic patient record system implementation; lessons learned from published evidence

Background: Numerous studies have examined specific factors related to success, failure and implications of Electronic patient record (EPR) system implementations, but usually limited to specific aspects.  Objective: To review the published peer-reviewed literature and present findings regarding factors important in relation to successful EPR implementations and likely impact on subsequent clinical activity.Method: Literature reviewResults: 312 potential articles were identified on initial search of which 117 were relevant and included in the review. Several factors were related to implementation success, such as good leadership and management, infrastructure support, staff training and focus on workflows and usability. In general, EPR implementation is associated with improvements in documentation, and screening performance, and reduced prescribing errors, whereas there are minimal available data in other areas such as effects on clinical patient outcomes. The peer-reviewed literature appears to under-represent a range of technical factors important for EPR implementations, such as data migration from existing systems and impact of organisational readiness.Conclusion: The findings presented here represent synthesis of data from peer-reviewed literature in the field and should be of value to provide the evidence-base for organisations considering how best to implement an EPR system