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

Public health platforms: an emerging informatics approach to health professional learning and development

Health informatics has a major role to play in optimising the management and use of data, information and knowledge in health systems. As health systems undergo digital transformation, it is important to consider informatics approaches not only to curriculum content but also to the design of learning environments and learning activities for health professional learning and development. An example of such an informatics approach is the use of large-scale, integrated public health platforms on the Internet as part of health professional learning and development. This article describes selected examples of such platforms, with a focus on how they may influence the direction of health professional learning and development

Time for change: a new training programme for morpho-molecular pathologists?

The evolution of cellular pathology as a specialty has always been driven by technological developments and the clinical relevance of incorporating novel investigations into diagnostic practice. In recent years, the molecular characterisation of cancer has become of crucial relevance in patient treatment both for predictive testing and subclassification of certain tumours. Much of this has become possible due to the availability of next-generation sequencing technologies and the whole-genome sequencing of tumours is now being rolled out into clinical practice in England via the 100 000 Genome Project. The effective integration of cellular pathology reporting and genomic characterisation is crucial to ensure the morphological and genomic data are interpreted in the relevant context, though despite this, in many UK centres molecular testing is entirely detached from cellular pathology departments. The CM-Path initiative recognises there is a genomics knowledge and skills gap within cellular pathology that needs to be bridged through an upskilling of the current workforce and a redesign of pathology training. Bridging this gap will allow the development of an integrated 'morphomolecular pathology' specialty, which can maintain the relevance of cellular pathology at the centre of cancer patient management and allow the pathology community to continue to be a major influence in cancer discovery as well as playing a driving role in the delivery of precision medicine approaches. Here, several alternative models of pathology training, designed to address this challenge, are presented and appraised

Bringing Anglo-governmentality into public management scholarship : the case of evidence-based medicine in UK health care

The field of public administration and management exhibits a limited number of favored themes and theories, including influential New Public Management and Network Governance accounts of contemporary government. Can additional social science–based perspectives enrich its theoretical base, in particular, analyzing a long-term shift to indirect governance evident in the field? We suggest that a variant of Foucauldian analysis is helpful, namely “Anglo-governmentality.” Having reviewed the literatures, we apply this Anglo-governmentality perspective to two case studies of “post hierarchical” UK health care settings: first, the National Institute for Health and Clinical Excellence (NICE), responsible for producing evidence-based guidelines nationally, and the second, a local network tasked with enacting such guidelines into practice. Compared with the Network Governance narrative, the Anglo-governmentality perspective distinctively highlights (a) a power–knowledge nexus giving strong technical advice; (b) pervasive grey sciences, which produce such evidence-based guidelines; (c) the “subjectification” of local governing agents, herein analyzed using Foucauldian concepts of the “technology of the self” and “pastoral power”; and (d) the continuing indirect steering role of the advanced neoliberal health care State. We add to Anglo-governmentality literature by highlighting hybrid “grey sciences,” which include clinical elements and energetic self-directed clinical–managerial hybrids as local governing agents. These findings suggest that the State and segments of the medical profession form a loose ensemble and that professionals retain scope for colonizing these new arenas. We finally suggest that Anglo-governmentality theory warrants further exploration within knowledge-based public organizations

Reducing prescribing errors through creatinine clearance alert redesign

Background Literature has shown that computerized creatinine clearance alerts reduce errors during prescribing, and applying human factors principles may further reduce errors. Our objective was to apply human factors principles to creatinine clearance alert design and assess whether the redesigned alerts increase usability and reduce prescribing errors compared with the original alerts. Methods Twenty Veterans Affairs (VA) outpatient providers (14 physicians, 2 nurse practitioners, and 4 clinical pharmacists) completed 2 usability sessions in a counterbalanced study to evaluate original and redesigned alerts. Each session consisted of fictional patient scenarios with 3 medications that warranted prescribing changes because of renal impairment, each associated with creatinine clearance alerts. Quantitative and qualitative data were collected to assess alert usability and the occurrence of prescribing errors. Results There were 43% fewer prescribing errors with the redesigned alerts compared with the original alerts (P = .001). Compared with the original alerts, redesigned alerts significantly reduced prescribing errors for allopurinol and ibuprofen (85% vs 40% and 65% vs 25%, P = .012 and P = .008, respectively), but not for spironolactone (85% vs 65%). Nine providers (45%) voiced confusion about why the alert was appearing when they encountered the original alert design. When laboratory links were presented on the redesigned alert, laboratory information was accessed 3.5 times more frequently. Conclusions Although prescribing errors were high with both alert designs, the redesigned alerts significantly improved prescribing outcomes. This investigation provides some of the first evidence on how alerts may be designed to support safer prescribing for patients with renal impairment

Conceptual, sociological and materialistic view of innovation-translation dynamics in medicine: The need and directions for a novel multi-pronged initiative

The recent decades have witnessed overwhelming advancements in medical technologies and the quality of healthcare. A vast majority of the advancements which are capable of revolutionising healthcare still remain dormant within laboratories which is certainly due to the tardive translation and assimilation of these innovations. Innovation-translation is explained by an over-simplified linear model which provides the users with just two option- either to adopt or not. The translation of medical innovation is a cyclical and dynamic process which includes the conception of novel ideas, generation of proof of concept, adoption, post-adoption analysis and emergence of new innovations. Conceptual factors like principle, validity, contextual appropriateness and performance; sociological factors like political climate, professional involvement, interdisciplinary interaction and investment policies; and materialistic factors like resource availability, affordability and apt human resource management are the chief determinants of innovation translation. Loose knit configuration of national policies favour innovation translation than close knit configuration. India suffers from lack of drive for local innovation, lack of succinct aptitude, inadequate local investment and lack of efficient regulation. Innovation studies expose the determinants of successful and failed innovations. Ensuring a favourable political and financial environment that provides systematic innovation assessment, evaluation and regulation, valid operational guidelines, encourage local innovation, and promote intellectual aptitude can drive further innovation. Competitively promoting sustaining and disruptive innovation will enable remarkable advancements. Post-adoption analysis and feedback and Precision medicine are significant tools. Efforts should be made to introduce and ensure meticulous innovation surveillance. Keywords: Innovation-translation dynamics; Cyclic dynamic model; Innovation surveillance; Regulation

Conceptual, sociological and materialistic view of innovation-translation dynamics in medicine: The need and directions for a novel multi-pronged initiative

The recent decades have witnessed overwhelming advancements in medical technologies and the quality of healthcare. A vast majority of the advancements which are capable of revolutionising healthcare still remain dormant within laboratories which is certainly due to the tardive translation and assimilation of these innovations. Innovation-translation is explained by an over-simplified linear model which provides the users with just two option- either to adopt or not. The translation of medical innovation is a cyclical and dynamic process which includes the conception of novel ideas, generation of proof of concept, adoption, post-adoption analysis and emergence of new innovations. Conceptual factors like principle, validity, contextual appropriateness and performance; sociological factors like political climate, professional involvement, interdisciplinary interaction and investment policies; and materialistic factors like resource availability, affordability and apt human resource management are the chief determinants of innovation translation. Loose knit configuration of national policies favour innovation translation than close knit configuration. India suffers from lack of drive for local innovation, lack of succinct aptitude, inadequate local investment and lack of efficient regulation. Innovation studies expose the determinants of successful and failed innovations. Ensuring a favourable political and financial environment that provides systematic innovation assessment, evaluation and regulation, valid operational guidelines, encourage local innovation, and promote intellectual aptitude can drive further innovation. Competitively promoting sustaining and disruptive innovation will enable remarkable advancements. Post-adoption analysis and feedback and Precision medicine are significant tools. Efforts should be made to introduce and ensure meticulous innovation surveillance. Keywords: Innovation-translation dynamics; Cyclic dynamic model; Innovation surveillance; Regulation

Review and Analysis of the Digital Health Sector and Skills for Scotland : A Report by the Digital Health and Care Institute in Partnership with Skills Development Scotland

This report has been produced by the Digital Health and Care Institute (DHI), as commissioned by Skills Development Scotland to investigate and analyse the Digital Health sector and its skills issues in Scotland. The digital health sector is characterised as emerging from the conjunction of health and care services, mobile health and ICT, and it is one of the fastest growing economic sectors globally, hungry for skilled staff. In this report 'digital health' encompasses companies that produce, provide and service digital health solutions on the one hand, and health and care service providers that utilize and implement digital healthcare solutions and tools in the delivery of their services on the other. As the health and care sector catches up with the other economic sectors in digitization, the need for personnel in digital health and care both in the private and the public sectors increases exponentially. Digital health is a diverse, interdisciplinary sector, something that is reflected in the skills required in the field, ranging from higher level computing, such as software development and software engineering to project management and business-related skills. There is a specific lack of personnel who are proficient in ICT but also have an understanding of health and care. However, while the sector is finding it hard to find suitably skilled graduates, and to offer them competitive salaries, the unemployment among ICT graduates is higher than in other disciplines. Furthermore, currently there are only a handful of courses, and these only on post-graduate level, offering digital health education in Scotland. The biggest single factor restricting economic growth in the sector is the lack of suitably skilled personnel. Digital health is going to face severe challenges in the near future, if the disparity between what the education and training provision offers and what the digital health sector needs is not bridged. Currently, companies are using all available means to attract skilled employees, ranging from recruiting from other sectors to offering in-house training, internships, modern apprenticeships and industrial placements to students and graduates. In order for Scotland to capitalize on the expanding digital health market, it is vital to ensure that there is a sufficient supply of skilled workers entering into the sector. Based on the research discussed in this report the DHI have made several recommendations that focus on: * Reviewing the existing education and training provision with digital health in mind; * involving digital health employees more closely in the development of the curricula in computing and health and care; and * Raising the profile of digital health sector in Scotland

A Systematic Approach for Using DICOM Structured Reports in Clinical Processes: Focus on Breast Cancer

The final publication is available at Springer via http://dx.doi.org/10.1007/s10278-014-9728-6.This paper describes a methodology for redesigning the clinical processes to manage diagnosis, follow-up, and response to treatment episodes of breast cancer. This methodology includes three fundamental elements: (1) identification of similar and contrasting cases that may be of clinical relevance based upon a target study, (2) codification of reports with standard medical terminologies, and (3) linking and indexing the structured reports obtained with different techniques in a common system. The combination of these elements should lead to improvements in the clinical management of breast cancer patients. The motivation for this work is the adaptation of the clinical processes for breast cancer created by the Valencian Community health authorities to the new techniques available for data processing. To achieve this adaptation, it was necessary to design nine Digital Imaging and Communications in Medicine (DICOM) structured report templates: six diagnosis templates and three summary templates that combine reports from clinical episodes. A prototype system is also described that links the lesion to the reports. Preliminary tests of the prototype have shown that the interoperability among the report templates allows correlating parameters from different reports. Further work is in progress to improve the methodology in order that it can be applied to clinical practice.We thank the subject matter experts for sharing their insights through this study. We are especially appreciative of the efforts of the Radiology Unit and Medical Oncology Unit teams at the University Hospital Dr. Peset. 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