Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Haywards Heath College: report from the Inspectorate (FEFC inspection report; 116/95 and 63/99)

Comprises two Further Education Funding Council (FEFC) inspection reports for the periods 1994-95 and 1998-9

Croydon College: report from the Inspectorate (FEFC inspection report; 26/96 and 96/00)

Comprises two Further Education Funding Council (FEFC) inspection reports for the periods 1995-96 and 1999-200

Will the development of Web 2.0 technology result in a preference for quantity over quality?

Over the last decade the world has experienced a rapid increase in the number of people using the internet for health information seeking and interaction. This increased demand for internet heath information has led to the emergence of large volumes of unstructured and unregulated medical information found on the web. This web-based information is seldom the subject of systematic investigation for its accuracy and appropriateness for patients, highlighting the need for additional research into the field. The rapid development of the internet as a communication tool, and the accumulation of large volumes of information, makes locating valid information extremely difficult especially for those who lack ability to use computers and technology efficiently. A 1997 study examining 40 websites providing advice on the management of a feverish child found that only four of the websites adhered to published guidelines. These high volumes of unregulated internet health information are partly due to there being no agreed standard for the assessment and to ensure accuracy of information presented on the web. This paper addresses the issue of quality of online health information, and asks, as we move forward and develop technologies which emphasise content creation, will the issue of quality of online health information be exacerbated? The emergence of Web 2.0 has facilitated many new online activities which could not have previously been achieved by the world wide web (Web 1.0) technology. Often referred to as the 'social web', it looks to increase social interaction by sharing content which is more easily generated and published by users. Many researchers believe this has implications for the future of healthcare, by enhancing the connection between patients, clinicians and health information. The use of blogs, podcasts and wikis can help to both communicate health information, and increase social support by providing a potentially anonymous space within which online interaction can take place. It also allows the information seeker to rapidly become the information provider, and share healthcare knowledge and experiences quickly and easily. However, this benefit of Web 2.0 technology may also be seen as a limitation when discussing information quality. For example, although health related Wiki's and blogs are an excellent way to share health information, their content can be added and edited by anyone, with a significant number being fuelled by lay users, most often with no professional experience of the health topic they are writing about. This paper aims to discuss that while the benefits of using Web 2.0 to develop communication in healthcare and health education are clear, it is also necessary to consider potential issues, such as quality, which may be more present in Web 2.0's application to healthcare than other uses. This issue is made relevant due to the possibility of high volumes of inaccurate and misleading information being potentially disastrous within a health care setting, as it can be extremely distressing and potentially damaging for some health information seeke

The impact of using computer decision-support software in primary care nurse-led telephone triage:Interactional dilemmas and conversational consequences

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care

Applications and Uses of Dental Ontologies

The development of a number of large-scale semantically-rich ontologies for biomedicine attests to the interest of life science researchers and clinicians in Semantic Web technologies. To date, however, the dental profession has lagged behind other areas of biomedicine in developing a commonly accepted, standardized ontology to support the representation of dental knowledge and information. This paper attempts to identify some of the potential uses of dental ontologies as part of an effort to motivate the development of ontologies for the dental domain. The identified uses of dental ontologies include support for advanced data analysis and knowledge discovery capabilities, the implementation of novel education and training technologies, the development of information exchange and interoperability solutions, the better integration of scientific and clinical evidence into clinical decision-making, and the development of better clinical decision support systems. Some of the social issues raised by these uses include the ethics of using patient data without consent, the role played by ontologies in enforcing compliance with regulatory criteria and legislative constraints, and the extent to which the advent of the Semantic Web introduces new training requirements for dental students. Some of the technological issues relate to the need to extract information from a variety of resources (for example, natural language texts), the need to automatically annotate information resources with ontology elements, and the need to establish mappings between a variety of existing dental terminologies

Linked Data - the story so far

The term “Linked Data” refers to a set of best practices for publishing and connecting structured data on the Web. These best practices have been adopted by an increasing number of data providers over the last three years, leading to the creation of a global data space containing billions of assertions— the Web of Data. In this article, the authors present the concept and technical principles of Linked Data, and situate these within the broader context of related technological developments. They describe progress to date in publishing Linked Data on the Web, review applications that have been developed to exploit the Web of Data, and map out a research agenda for the Linked Data community as it moves forward

An evaluation of the role of the Admiral Nurse : a systematic evidence synthesis to inform service delivery and research

Two thirds of people with dementia live in the community and receive support from family members. There is a great deal of evidence to suggest that caring for a person with dementia impacts on the health and wellbeing of family carers. Despite this the provision of funded support for family carers is often limited or inadequate. Admiral Nurses, developed in the 1990s, were specifically designed by the charity for dementia (now Dementia UK) to support the family carers of people with dementia. Admiral Nurses are mental health nurses specialising in the care of people with dementia. They are mainly employed by local providers of care for people with dementia but dementia UK is involved in setting up new posts and providing ongoing practice development. There are currently around 100 Admiral Nurses employed in England. In addition the charity has a national helpline provided by experienced Admiral Nurses. The evidence synthesis presented here was commissioned by Dementia UK in order to establish what is currently known about the scope, nature and effectiveness of Admiral Nurse