Moving from paper based to electronic hospital discharge summaries : a mixed methods investigation

The move to electronic discharge summary systems was anticipated to solve the longstanding problems associated with poor data quality and reduce delay in the production and transmission of discharge summaries between secondary and primary care health care providers in the UK National Health Service. A consequence of investment in a national IT infrastructure for electronic health records has focused attention on template design and the IT system requirements. The routine practices of doctors involved in discharge summary construction, and other factors that contribute to the problems of delay and data quality, have been less well explored. This study aimed to gain an understanding of paper-based discharge summary construction in a secondary care context in order to identify and analyse the implications for improving electronic discharge summary systems, and potentially avoid inadvertent transfer of inherent problems. A mixed method case study design was used to examine the patient discharge process and the construction of discharge summaries in one NHS Hospital Trust. Data was collected through semi-structured interviews with hospital doctors (n=10) and simulated discharge summary production (n=10). A syntactic analysis was also performed on discharge summaries (n=11) and proformas (n=3). The data was analysed thematically and inductively in order to identify the factors that contribute to the twin problems of data quality and delay associated with discharge summaries. The pragmatic, semantic, syntactic conceptual framework (Morris, 1938), and Speech Act (Austin, 1962) and Mental Frame (Minsky,1981) theories, were used to analyse how information contained in discharge summaries was represented, interpreted and used. This study found that moving from a paper based to an electronic discharge summary system will not necessarily resolve the problems of poor data quality and delayed production of discharge summaries. More comprehensive solutions are required in order to facilitate more effective discharge summary communication between secondary and primary care health professionals, and to address entrenched custom and practice in current hospital practice. These include uni-professional (medical) orientation of discharge summaries, attitude of senior doctors, inadequate preparation of junior doctors, inconsistent data entry including absence of common usage of short forms and abbreviations, and little accountability for quality control. Recommendations include training for junior doctors, regulating the use of shortened forms, improving the features of data entry systems, structuring the clinical coding data and introducing systems to ensure greater organizational accountability for effective discharge communication. More comprehensive change related to the introduction of multidisciplinary contribution discharge summary construction and integration of discharge summary standards in care pathways may improve overall discharge summary quality.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Exploration of care continuity during the hospital discharge process

Background Communication regarding medicines at hospital discharge via discharge summaries is notoriously poor and negatively impacts on patient care. With the process being dependant on the quality of patient records during admission, junior doctors who write them and General Practitioners (GPs) who receive them, the objectives of this thesis were, with respect to discharge summaries, to:- assess their timeliness, accuracy and quality describe GP preferences explore experiences of junior doctors regarding their preparation. Methods Discharge summaries produced from one district general hospital were audited, as was the impact of changing the format of inpatient drug charts. A combination of observation, think-aloud and ethnographic interviews were conducted to investigate experiences of junior hospital doctors preparing summaries. A survey of GPs and junior doctors was undertaken to compare attitudes towards the discharge process. A pilot Discrete Choice Experiment (DCE) was developed and undertaken with GPs to determine their preferences with respect to the format, quality and timing of discharge summaries. Results A large proportion of discharge summaries were found to be inaccurate, however this was reduced when checked by a pharmacist. Key barriers to summary preparation identified were lack of time, training and knowledge of the patient. GPs perceived medicine changes on discharge summaries to be more important than did junior doctors. The DCE found that GPs were willing to trade timeliness of discharge summaries with accuracy. Discussion and conclusions The error rate within discharge summaries highlights the importance of a pharmacy accuracy check. The national requirement to deliver discharge summaries within 24 hours of discharge results in the pharmacist being bypassed and places additional pressure on junior doctors to prepare them in a timely manner, which might provide explanation for poor quality. Interestingly, GPs were willing to forego receipt of discharge summaries within 24 hours in preference for a reduced error rate. Keywords: patient discharge, discharge summary, patient transfer, interdisciplinary communication, medication errors

Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

Knowledge representation and text mining in biomedical, healthcare, and political domains

Knowledge representation and text mining can be employed to discover new knowledge and develop services by using the massive amounts of text gathered by modern information systems. The applied methods should take into account the domain-specific nature of knowledge. This thesis explores knowledge representation and text mining in three application domains. Biomolecular events can be described very precisely and concisely with appropriate representation schemes. Protein–protein interactions are commonly modelled in biological databases as binary relationships, whereas the complex relationships used in text mining are rich in information. The experimental results of this thesis show that complex relationships can be reduced to binary relationships and that it is possible to reconstruct complex relationships from mixtures of linguistically similar relationships. This encourages the extraction of complex relationships from the scientific literature even if binary relationships are required by the application at hand. The experimental results on cross-validation schemes for pair-input data help to understand how existing knowledge regarding dependent instances (such those concerning protein–protein pairs) can be leveraged to improve the generalisation performance estimates of learned models. Healthcare documents and news articles contain knowledge that is more difficult to model than biomolecular events and tend to have larger vocabularies than biomedical scientific articles. This thesis describes an ontology that models patient education documents and their content in order to improve the availability and quality of such documents. The experimental results of this thesis also show that the Recall-Oriented Understudy for Gisting Evaluation measures are a viable option for the automatic evaluation of textual patient record summarisation methods and that the area under the receiver operating characteristic curve can be used in a large-scale sentiment analysis. The sentiment analysis of Reuters news corpora suggests that the Western mainstream media portrays China negatively in politics-related articles but not in general, which provides new evidence to consider in the debate over the image of China in the Western media

Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

Mapping the Genres of Healthcare Information Work: An Interdisciplinary Study of the Interactions Between Oral, Paper, and Electronic Forms of Communication

Electronic Patient Records (EPRs) are becoming standard tools in healthcare, lauded for improving patient access and outcomes. However, the healthcare professionals who work with, around, and despite these technologies in their daily practices often regard EPRs as troublesome. In order to investigate how EPRs can prompt such opposing opinions, this project examines the EPR as a collection of communication genres set in complex contexts. In this project, I investigate an EPR as it was used on the Nephrology ward at a large, Canadian, urban, paediatric teaching hospital. In this setting, this study investigates EPR-use in relation to the following aspects of context: (a) the visual rhetoric of the EPR's user-interface design; (b) the varied social contexts in which the EPR was used, including a diversity of professional collaborators who had varying levels of professional experience; (c) the span of social actions involved in EPR use; and (d) the other genres used in coordination with the EPR. This qualitative study was conducted in two simultaneous stages, over the course of 8 months. Stage one consisted of a visual rhetorical analysis of a set of genres (including the EPR) employed by participants during a specific work activity. Stage two involved an elaborated, qualitative case study consisting of non-participant observations and semi-structured interviews. Stage two used a constructivist grounded theory methodology. A combination of theoretical perspectives -- Visual Rhetoric, Rhetorical Genre Studies, Activity Theory, and Actor-Network Theory -- supported the analysis of study data. This research reveals that participants routinely transformed EPR-based information into paper documents when the EPR's visual designs did not support the professional goals and activities of the participants. Results indicate that healthcare professionals work around EPR-based patient information when that genre's visual organization is incompatible with professional activities. This study suggests that visual rhetorical analysis, complemented with observation and interview data, can provide useful insights into a genre's social actions. This research also examines the effects of such EPR-to-paper genre transformations. Although at one level of analysis, the EPR-to-paper-genre transformation may be considered inefficient for participants and so should be automated, at another level of analysis, the same transformation activity can be seen as beneficially supporting the detailed reviewing of patient information by healthcare professionals. To account for this function in the transformation dysfunction, my research suggests that many contextual factors need to be considered during data analysis in order to construct a sufficiently nuanced understanding of a genre's social actions. To accomplish such an analysis, I develop a five-step approach to data analysis called 'context mapping. ' Context mapping examines genres in relation to the varied social contexts in which they are used, the span of social actions in which they are involved, and a range of genres with which they are coordinated. To conduct this analysis, context mapping relies heavily on theories of "genre ecologies" (Spinuzzi, 2003a, 2003b; Spinuzzi, Hart-Davidson & Zachry, 2004; Spinuzzi & Zachry, 2000) and "Knotworking" (Engestrom, Engestrom & Vahaaho, 1999). Context mapping's first three steps compile study data into results that accommodate a wide range of contextual analysis considerations. These three steps involve the use of a composite scenario of observation data, genre ecologies and the description of a starting point for analysis. The final two steps of this approach analyse results using the theory of Knotworking and investigate some of the implications of the patterns of genre use on the ward. Through context mapping analysis, this study demonstrates that EPR-based innovations created by a study participant could result in the generation of other improvisations, in a range of genres, by the original participant and/or by other collaborators. These genre modifications had ramifications across multiple social contexts and involved a wide range of genres and associated social actions. Context mapping analysis demonstrates how the effects of participant-made EPR-based variations can be considered as having both beneficial and detrimental effects in the research site depending on the social perspective adopted. Contributions from this work are directed towards the fields of Rhetorical Genre Studies, Activity Theory research, and Health Informatics research, as well as to the research site itself. This study demonstrates that context mapping can support text-in-context style research in complex settings as a means for evaluating the effects of genre uses

Investigating Clinical Pathway Effects in Hospitals: Current Evidence and Proposal for a Realist Approach

Clinical pathways (CPWs) are tools used by healthcare professionals to guide evidence-based practice by improving multidisciplinary communication, teamwork, and care planning to optimize patient outcomes. CPWs are continually developed and implemented in several healthcare settings; however, the evidence of their effectiveness in hospitals is debatable to date. There is no coherent theory that explains how CPWs work in different healthcare settings. The overall objective of this thesis is to investigate the effects of CPWs implemented in hospitals. The first part (study 1) of this thesis described a statistical method to refine an operational definition for CPWs that is useful for conducting CPWs research in healthcare. The refined operational definition was used to synthesize evidence from CPW literature. The second part (study 2) of the thesis investigated the effects of CPWs in hospitals following the Cochrane systematic review methodology. The key finding in this review was that stand-alone CPWs may reduce in-hospital complications and hospital costs compared to usual care (low-certainty evidence) and it is uncertain whether stand-alone CPWs reduces the length of hospital stay or improve adherence to recommended practice by healthcare providers (very low-certainty evidence). The final section of the thesis (study 3) is a realist review protocol following the realist methodology to describe an evidence-based approach for developing a realist program theory with the aim of filling the theoretical void on how clinical pathways work in hospitals to generate intended outcomes. Taken together, these studies make a valuable addition to the growing body of research on clinical pathways implemented in hospitals. There is an urgent need to develop an internationally agreed definition for clinical pathways that can inform the development of plausible theories on how they work in hospital environments

A modular, open-source information extraction framework for identifying clinical concepts and processes of care in clinical narratives

In this thesis, a synthesis is presented of the knowledge models required by clinical informa- tion systems that provide decision support for longitudinal processes of care. Qualitative research techniques and thematic analysis are novelly applied to a systematic review of the literature on the challenges in implementing such systems, leading to the development of an original conceptual framework. The thesis demonstrates how these process-oriented systems make use of a knowledge base derived from workflow models and clinical guidelines, and argues that one of the major barriers to implementation is the need to extract explicit and implicit information from diverse resources in order to construct the knowledge base. Moreover, concepts in both the knowledge base and in the electronic health record (EHR) must be mapped to a common ontological model. However, the majority of clinical guideline information remains in text form, and much of the useful clinical information residing in the EHR resides in the free text fields of progress notes and laboratory reports. In this thesis, it is shown how natural language processing and information extraction techniques provide a means to identify and formalise the knowledge components required by the knowledge base. Original contributions are made in the development of lexico-syntactic patterns and the use of external domain knowledge resources to tackle a variety of information extraction tasks in the clinical domain, such as recognition of clinical concepts, events, temporal relations, term disambiguation and abbreviation expansion. Methods are developed for adapting existing tools and resources in the biomedical domain to the processing of clinical texts, and approaches to improving the scalability of these tools are proposed and evalu- ated. These tools and techniques are then combined in the creation of a novel approach to identifying processes of care in the clinical narrative. It is demonstrated that resolution of coreferential and anaphoric relations as narratively and temporally ordered chains provides a means to extract linked narrative events and processes of care from clinical notes. Coreference performance in discharge summaries and progress notes is largely dependent on correct identification of protagonist chains (patient, clinician, family relation), pronominal resolution, and string matching that takes account of experiencer, temporal, spatial, and anatomical context; whereas for laboratory reports additional, external domain knowledge is required. The types of external knowledge and their effects on system performance are identified and evaluated. Results are compared against existing systems for solving these tasks and are found to improve on them, or to approach the performance of recently reported, state-of-the- art systems. Software artefacts developed in this research have been made available as open-source components within the General Architecture for Text Engineering framework

Best practices for environmental cleaning in healthcare facilities : in resource-limited settings, Version 2

This document provides guidance on best practices for environmental cleaning procedures and programs in healthcare facilities in resource-limited settings. It was developed as a collaboration between the Centers for Disease Control and Prevention (CDC) and the Infection Control Africa Network (ICAN).Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings is a publication of the Division of Healthcare Quality Promotion in the National Center for Emerging and Zoonotic Infectious Diseases within CDC and the Education Working Group of the Infection Control Africa Network.Suggested citation: CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019. Available at: https://www.cdc.gov/hai/prevent/resource-limited/index.html and http://www.icanetwork.co.za/icanguideline2019/CS314156-Aenvironmental-cleaning-RLS-H.pdf20191061