Meaningful Use of Electronic Health Records for Physician Collaboration: A Patient Centered Health Care Perspective

EHRs (Electronic Health Records), can contribute greatly to improving care and managing the rising costs of healthcare. The use and the integration of EHRs (Electronic Health Records) in supporting collaboration to increase the efficiency and effectiveness of healthcare remains a challenge. It appears that the physicians are at the center of this bottleneck. As healthcare is provided by interdisciplinary teams of clinicians and collaboration and coordination are key to success. Literature suggests reasons for the limited use relate to policy, financial and usability considerations, but it does not provide an understanding of reasons for physicians\u27 limited interaction and adaptation of EHR. This paper investigates how meaningful use of EHRs by physicians enable patient centered healthcare to be achieved. Following an analysis of qualitative data, collected in a case study at a hospital using interviews, this research shows how a collaborative technology architecture can enable the reduction in the costs of healthcare and improvements in the quality of care by enabling more patient centered health care

Adoption of Computerised Health Information System Focusing on Kenya’s Health Facilities

Although the benefits of information technology are clear adapting new information systems to health care has proven difficult globally and rates of use have been limited. With the challenge of inadequate health workers and low quality of service delivery, Information Communication Technology is essential to ensure availability of Information to multiple users and multiple settings. It is also important for Integration of variable types of data media, data legibility, reduced medical errors, complete and quality data. It also enable structured data entry, accurate calculation of processes, provision of tools for decision support and data based analysis. Although Kenya as a developing country has invested in Information Communication Technology with the aim of improving patient care, all indications have shown slow adoption of technology in healthcare industry. Therefore it is important to focus on means of hastening adoption of HIS in order to enhance service delivery in the health sector and hence effective service delivery for Kenyan people. Keywords: Adoption, Health Information Systems, ICT Infrastructure

The Development and Evaluation of Hospital Pay-for-Performance in Lebanon: Casemix, Readmissions and Patient Perspectives.

Background: Pay-for-performance (P4P) has been widely used in healthcare, but there are few experiences of hospital-based P4P at scale. The evidence of impact from these has been mixed, and there has been increased recognition of the importance of different contexts, designs, incentives and other factors. In 2014, the Lebanese Ministry of Public Health integrated a P4P model for determining hospital reimbursement tiers. In 2018, this model was updated to include a readmissions component, in addition to the preexisting components such as casemix and patient satisfaction. The impact of these interventions was previously undetermined. This also provided an opportunity to contribute to some of the known knowledge gaps regarding hospital P4P. The purpose of this thesis was to describe the development and evaluate the impact of hospital P4P in Lebanon, and ultimately to contribute more broadly to improved design and implementation of value-based healthcare, particularly in limited resource settings.Methods: This thesis uses a mixed methods approach, combining quantitative and qualitative study designs, to conduct four research investigations. The first paper uses descriptive analysis to address how and why hospital P4P was developed in Lebanon. The second and third papers both use an interrupted time series design on data collected from the Ministry hospitalization database. The former uses Newey-OLS regression, and the latter uses Autoregressive Integrated Moving Average models. The second paper analyzes the impact of the 2014 P4P integration on casemix index, and the third paper analyzes the impact of the 2018 model update on readmissions. The fourth paper uses qualitative content analysis on data collected from eight focus groups discussions with patient participants.Results: The Ministry developed hospital P4P after recognizing the limitations of the previous model that had been solely based on accreditation status. Casemix index was included in the P4P model, to improve the appropriateness and fairness of the Ministry-hospitals relation. The analysis of P4P integration impact on casemix included 1,353,025 hospitalizations between 2011 and 2016. This revealed an abrupt increase in casemix among short-stay cases, and a gradual increase in medium-stay cases. Code-level analysis suggested this was attributable to a decrease in unnecessary hospitalizations and improved coding practices. The analysis of P4P impact on readmissions included 1,333,691 hospitalizations across 2011-2019. An abrupt decrease of cholecystectomy and stroke readmissions was found, but not of general and pneumonia readmissions. Our qualitative investigation allowed us to identify six patient perspectives, including satisfaction, health status, perceptions on each of quality, access and health system, and valuing of health, all of central relevance to health systems performance.Conclusion: Hospital P4P in Lebanon led to several positive impacts, including improving the relation between hospitals and the Ministry of Public Health, and providing a tool for continuous development of the health system. The 2014 and 2018 P4P interventions improved system effectiveness and related patient outcomes, by decreasing unnecessary hospitalizations and decreasing some types of readmissions. The Ministry should develop its P4P model to capture the entire spectrum of hospital visits. Using appropriate interrupted time series analysis on readily available data is a useful way to evaluate the effects of health system interventions in contexts with limited resources. Patients in Lebanon highly valued health and supported improving public hospitals and measures to counter the influence of personal connections and money. Health systems canmore widely engage people for their perspectives, and patients can have a fundamental role in shaping the values and functions of a health system

The practice of integrated healthcare and the experiences of people in Ghana’s Ashanti region

Background: The Ghanaian government has implemented interventions that integrate traditional medicine (TM) into its national health system in response to the high prevalence of TM use. However, empirical evidence of the experiences of service users and the practice of integrated health in Ghana is scanty. Therefore, this study explored the experiences of people with TM integration into the formal health system in Ashanti region using an adapted TM integration framework. Methods: A sequential explanatory mixed methods study design comprising survey administration and in-depth interviews for data collection was utilised to address the research objective. Framework analysis was used in analysing the qualitative data and for triangulation of results. Results: Participants were aware of licensing and training of TM practitioners in a science-based university in Ghana. However, knowledge of the existence of TM units in selected hospitals in the region was minimal. Integration knowledge was largely influenced by sex, marital status, household size and residential status, where males and urban dwellers were more familiar with the process than females and rural dwellers. Low patronage of integrated health services in the region was attributable to weak cross referrals. However, service users who had engaged with the integrated system recounted a satisfactory outcome. Conclusion: Service users’ unfamiliarity with the presence of integrated facilities in Ghana could be an impediment to the practice of integrated healthcare. Sensitisation of the public about the practice of an integrated system could refine the Ghanaian integrated system. Regular evaluation of patient satisfaction and outcome measures might also serve as an effective strategy for improving health services delivery since evaluation is becoming an important component of health service design and implementation. There is the need for future studies to focus on exploring the perceptions and experiences of health practitioners and hospital administrators regarding the practice of integrated health in Ghana

Online tool for monitoring adverse events in patients with cancer during treatment (eRAPID): field testing in a clinical setting

Objectives: Electronic patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is an online system developed to support patient care during cancer treatment by improving the detection and management of treatment-related symptoms. Patients can complete symptom reports from home and receive severity-based self-management advice, including notifications to contact the hospital for severe symptoms. Patient data are available in electronic records for staff to review. Prior to the commencement of a randomised controlled trial (RCT), field testing of the intervention was undertaken to troubleshoot practical issues with intervention integration in clinical practice. Design: Observational clinical field testing. Setting: Medical oncology breast service in a UK cancer centre. Participants: 12 patients receiving chemotherapy for early breast cancer and 10 health professionals (oncologists and specialist nurses). Intervention: Patients were asked to use the eRAPID intervention and complete weekly online symptom reports during four cycles of chemotherapy. Clinical staff were invited to access and use patient data in clinical assessments. Analysis: Descriptive data on the frequency of online symptom report completion and severe symptom notifications were collated. Verbal and written feedback was collected from patients and staff and semistructured interviews were conducted to explore patient experiences. Interviews were transcribed and analysed thematically. Results: The testing ran from January 2014 to March 2014. Feedback from patients and staff was largely positive. Patients described eRAPID as ‘reassuring’ and ‘comforting’ and valued the tailored management advice. Several changes were made to refine eRAPID. In particular, improvement of the clinical notification, patient reminder systems and changes to patient and staff training. Conclusions: The field testing generated valuable results used to guide refinement of eRAPID prior to formal intervention evaluation. Feedback indicated that eRAPID has the potential to improve patients’ self-efficacy, knowledge and confidence with managing symptoms during treatment. A large-scale RCT is underway with data collection due to finish in October 2018

Healthcare professional and manager perceptions on drivers, benefits, and challenges of telemedicine: results from a cross-sectional survey in the Italian NHS

Background: The Covid-19 pandemic provided new challenges and opportunities for patients and healthcare providers while accelerating the trend of digital healthcare transformation. This study explores the perspectives of healthcare professionals and managers on (i) drivers to the implementation of telemedicine services and (ii) perceived benefits and challenges related to the use of telemedicine across the Italian National Health Service. Methods: An online cross-sectional survey was distributed to professionals working within 308 healthcare organisations in different Italian regions. Quantitative and qualitative data were collected through a self-administered questionnaire (June-September 2021). Responses were analysed using summary statistics and thematic analysis. Results: Key factors driving the adoption of telemedicine have been grouped into (i) organisational drivers (reduce the virus spread-80%; enhance care quality and efficiency-61%), (ii) technological drivers (ease of use-82%; efficacy and reliability-64%; compliance with data governance regulations-64%) and (iii) regulatory drivers (regulations’ semplification-84%). Nearly all respondents perceive telemedicine as useful in improving patient care (96%). The main benefits reported by respondents are shorter waiting lists, reduced Emergency Department attendance, decreased patient and clinician travel, and more frequent patient-doctor interactions. However, only 7% of respondents believe that telemedicine services are more effective than traditional care and 66% of the healthcare professionals believe that telemedicine can’t completely substitute in-person visits due to challenges with physical examination and patient-doctor relationships. Other reported challenges include poor quality and interoperability of telemedicine platforms and scarce integration of telemedicine with traditional care services. Moreover, healthcare professionals believe that some groups of patients experience difficulties in accessing and using the technologies due to socio-cultural factors, technological and linguistic challenges and the absence of caregivers. Conclusions: Respondents believe that telemedicine can be useful to complement and augment traditional care. However, many challenges still need to be overcome to fully consider telemedicine a standard of care. Strategies that could help address these challenges include additional regulations on data governance and reimbursements, evidence-based guidelines for the use of telemedicine, greater integration of tools and processes, patient-centred training for clinicians, patient-facing material to assist patients in navigating virtual sessions, different language options, and greater involvement of caregivers in the care process

Operational Modeling with Health Economics to Support Decision Making for COPD Patients

© Health Research and Educational Trust. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1111/1475-6773.13652Objective: To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis. Data sources: We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programmes. Study Design: The COPD pathway was modelled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions. Data Collection/Extraction methods: A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature. Principal Findings: The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions and bed days decreased (i.e. by 3.56 patients, 4.90 admissions, 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (i.e. by 5.53 QALY among 1540 patients for the 30% increase). Conclusions: No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention.Peer reviewedFinal Accepted Versio

Ideas and Enhancements Related to Mobile Applications to Support Type 1 Diabetes

Background: Mobile devices have become increasingly important to young people who now use them to access a wide variety of health-related information. Research and policy related to the integration of health information and support with this technology do not effectively consider the viewpoint of a younger patient. Views of young people with type 1 diabetes are vital in developing quality services and improving their own health-related quality of life (HRQOL), yet research on their lifestyle and use of Web and mobile technology to support their condition and in non–health-related areas is sparse. Objective: To develop insight into young people with type 1 diabetes and their current use of Web and mobile technology and its potential impact on HRQOL. This can be achieved by constructing an in-depth picture of their day-to-day experiences from qualitative interviewing and exploring how they make use of technology in their lives and in relation to their condition and treatment. The goal was then to build something to help them, using the researcher’s technical expertise and seeking users’ opinions during the design and build, utilizing sociotechnical design principles. Methods: Data were collected by semistructured, in-depth qualitative interviews (N=9) of young people with type 1 diabetes aged 18-21. Interviews were transcribed and loaded onto NVivo for theme identification. Data analysis was undertaken during initial interviews (n=4) to locate potential ideas and enhancements for technical development. Latter interviews (n=5) assisted in the iterative sociotechnical design process of the development and provided additional developmental ideas. Results: Six themes were identified providing an understanding of how participants lived with and experienced their condition and how they used technology. Four technological suggestions for improvement were taken forward for prototyping. One prototype was developed as a clinically approved app. A number of ideas for new mobile apps and enhancements to currently existing apps that did not satisfactorily cater to this age group’s requirements for use in terms of design and functionality were suggested by interviewees but were not prototyped. Conclusions: This paper outlines the nonprototyped suggestions from interviewees and argues that young people with type 1 diabetes have a key role to play in the design and implementation of new technology to support them and improve HRQOL. It is vital to include and reflect on their suggestions as they have a radically different view of technology than either their parents or practitioners. We need to consider the relationship to technology that young people with type 1 diabetes have, and then reflect on how this might make a difference to them and when it might not be a suitable mechanism to use

The nursing contribution to chronic disease management: a whole systems approach: Report for the National Institute for Health Research Service Delivery and Organisation programme

Background Transforming the delivery of care for people with Long Term Conditions (LTCs) requires understanding about how health care policies in England and historical patterns of service delivery have led to different models of chronic disease management (CDM). It is also essential in this transformation to analyse and critique the models that have emerged to provide a more detailed evidence base for future decision making and better patient care. Nurses have made, and continue to make, a particular contribution to the management of chronic diseases. In the context of this study, there is a particular focus on the origins of each CDM model examined, the processes by which nursing care is developed, sustained and mainstreamed, and the outcomes of each case study as experienced by service users and carers. Aims To explore, identify and characterise the origins, processes and outcomes of effective CDM models and the nursing contribution to such models using a whole systems approach Methods The study was divided into three phases: Phase 1: Systematic mapping of published and web-based literature. Phase 2: A consensus conference of nurses working within CDM. Sampling criteria were derived from the conference and selected nurses attended a follow up workshop where case study sites were identified. Phase 3: Multiple case study evaluation Sample: 7 case studies representing 4 CDM models. These were: i) public health nursing model; ii) primary care nursing model; iii) condition specific nurse specialist model; iv) community matron model. Methods: Evaluative case study design with the unit of analysis the CDM model (Yin, 2003): • semi-structured interviews with practitioners, patients, their carers, managers and commissioners • documentary analysis • psycho-social and clinical outcome data from specific conditions • children and young people: focus groups, age-specific survey tools. Benchmarking outcomes: Adults benchmarked against the Health Outcomes Data Repository (HODaR) dataset (Currie et al, 2005). Young people were benchmarked against the Health Behaviour of School aged Children Survey (Currie et al, 2008). Cost analysis: Due to limitations in the available data, a simple costing exercise was undertaken to ascertain the per patient cost of the nurse contribution to CDM in each of the models, and to explore patterns of health and social care utilisation. Analysis: A whole system methodology was used to establish the principles of CDM. i) The causal system is a “network of causal relationships” and focuses on long term trends and processes. ii) The data system recognises that for many important areas there is very little data. Where a particular explanatory factor is important but precise data are lacking, a range of methods should be employed to illuminate each factor as much as possible. iii) The organisational whole system emphasises how various parts of the health and social care system function together as a single system rather than as parallel systems. iv) The patient experience recognises that the whole system comes together and is embodied in the experience of each patient. Key findings While all the models strove to be patient centred in their implementation, all were linked at a causal level to disease centric principles of care which dominated the patient experience. Public Health Model • The users (both parents and children) experienced a well organised and coordinated service that is crossing health and education sectors. • The lead school nurse has provided a vision for asthma management in school-aged children. This has led to the implementation of the school asthma strategy, and the ensuing impacts including growing awareness, prevention of hospital admissions, confidence in schools about asthma management and healthier children. Primary Care Model • GP practices are providing planned and routine management of chronic disease, tending to focus on single diseases treated in isolation. Care is geared to the needs of the uncomplicated stable patient. • More complex cases tend to be escalated to secondary care where they may remain even after the patient has stabilised. • Patients with multiple diagnoses continue to experience difficulty in accessing services or practice that is designed to provide a coherent response to the idiosyncratic range of diseases with which they present. This is as true for secondary care as for primary care. • While the QOF system has clearly been instrumental in developing and sustaining a primary care nursing model of CDM, it has also limited the scope of the model to single diseases recordable on a register, rather than focus on patient centred care needs. Nurse Specialist Model • The model works under a disease focused system underpinned by evidence based medicine exemplified by NICE guidelines and NSF’s. • The model follows a template drawn from medicine and sustainability is significantly dependent on the championship and protectionism offered by senior medical clinicians. • A focus on self-management in LTCs gives particular impetus to nurse-led enablement of self-management. • The shift of LTC services from secondary care to primary care has often not been accompanied by a shift in expertise. Community Matron Model • The community matron model was distinctive in that it had been implemented as a top down initiative. • The model has been championed by the community matrons themselves, and the pressure to deliver observable results such as hospital admission reductions has been significant. • This model was the only one that consistently resulted in open access (albeit not 24 hours) and first point of contact for patients for the management of their ongoing condition. Survey Findings Compared to patients from our case studies those within HODaR visited the GP, practice nurse or NHS walk-in centres more, but had less home visits from nurses or social services within the six weeks prior to survey. HODaR patients also took significantly more time off work and away from normal activities, and needed more care from friends/ relatives than patients from our study within the last six weeks. The differences between the HODaR and case study patients in service use cannot easily be explained but it could be speculated when referring to the qualitative data that the case study patients are benefiting from nurse-led care. Cost analysis – The nurse costs per patient are at least ten times higher for community matrons conducting CDM than for nurses working in other CDM models. The pattern of service utilisation is consistent with the focus of the community matron role to provide intensive input to vulnerable patients. Conclusions Nurses are spearheading the kind of approaches at the heart of current health policies (Department of Health, 2008a). However, tensions in health policy and inherent contradictions in the context of health care delivery are hampering the implementation of CDM models and limiting the contribution nurses are able to make to CDM. These include: ? data systems that were incompatible and recorded patients as a disease entity ? QOF reinforced a disease centric approach ? practice based commissioning was resulting in increasing difficulties in cross health sector working in some sites ? the value of the public health model may not be captured in evaluation tools which focus on the individual patient experience. Recommendations Commissioners and providers 1. Disseminate new roles and innovations and articulate how the role or service fits and enhances existing provision. 2. Promote the role of the nurses in LTC management to patients and the wider community. 3. Actively engage with service users in shaping LTC services to meet patients’ needs. 4. Improve the support and supervision for nurses working within new roles. 5. Develop training and skills of nurses working in the community to enable them to take a more central role in LTC management. 6. Develop organisations that are enabling of innovation and actively seek funding for initiatives that provide an environment where nurses can reach their potential in improving LTC services. 7. Work towards data systems that are compatible between sectors and groups of professionals. Explore ways of enabling patients to access data and information systems for test results and latest information. 8. Promote horizontal as well as vertical integration of LTC services. Practitioners 1. Increase awareness of patient identified needs through active engagement with the service user. 2. Work to develop appropriate measures of nursing outcomes in LTC management including not only bureaucratic and physiological outcomes, but patient-identified outcomes. Implications of research findings 1. Investment should be made into changing patient perceptions about the traditional division of labour, the nurses’ role and skills, and the expertise available in primary care for CDM. 2. Development and evaluation of patient accessible websites where patients can access a range of information, their latest test results and ways of interpreting these. 3. Long-term funding of prospective evaluations to enable identification of CDM outcomes. 4. Mapping of patient experience and patient satisfaction so that the conceptual differences between these two related ideas can be demonstrated. 5. Development of appropriate measures of patient experience that can be used as part of the quality outcome measures. 6. Cost evaluation/effectiveness studies carried out over time that includes national quality outcome indicators and valid measures of patient experience. 7. The importance of whole system working needs to be identified in the planning of services. 8. Research into the role of the health visitor in chronic disease management within a public health model