Health Information Technology Implementation Strategies in Zimbabwe

The adoption rate of health information technology (HIT) remains low in developing countries, where healthcare institutions experience high operating costs and loss of revenue, which are related to systems and processes inefficiency. The purpose of this case study was to explore strategies leaders in Zimbabwe used to implement HIT. The conceptual framework of the study was Davis\u27s technology acceptance model (TAM). Data were gathered through observations, review of organizational documents (i.e., policies, procedures, and guidelines), and in-depth interviews with a purposive sample of 10 healthcare leaders and end-users from hospitals in Zimbabwe who had successfully implemented HIT. Transcribed interview data were coded and analyzed for emerging themes. Implementation strategies, overcoming barriers to adoption, and user acceptance emerged as the themes most healthcare leaders associated with successful HIT projects. Several subthemes also emerged, including: (a) the importance of stakeholder involvement, (b) the importance of management buy-in, and (c) the low level of IT literacy among healthcare workers. The strategies identified in this study may provide a foundation on which healthcare leaders in developing countries can successfully adopt and implement HIT. The recommendations from this study could lead to positive social change by providing leaders with knowledge and skills to use information technology strategies to deliver better healthcare at lower costs while creating employment for local communities

Information Management during Care Transitions of Older Adults receiving Skilled Home Healthcare Services after Hospital Discharge

Background: Older adults who require skilled home health care (SHHC) services following hospital discharge are among those at highest risk of experiencing suboptimal outcomes during care transitions. Information management (IM) refers to the ability of skilled home healthcare providers (SHHCP) to collect, organize, and communicate older adults’ care plans to key stakeholders. Optimal IM is critical to ensure patient safety during a care transition from hospital to home, yet little is known about IM during this care transition. Human factors engineering (HFE), a systems science that investigates factors affecting human performance, may be used to understand risks and outcomes experienced by older adults receiving SHHC services after hospital discharge. Objectives: We used a HFE approach to: 1) identify key components of IM from the perspectives of SHHCPs directly responsible for executing older adults’ transitions; and 2) describe IM-related process failures during the SHHC admissions process and initial home visit after hospital discharge. Methods: This was a qualitative study primarily guided by the HFE-informed Information Chaos framework, which groups IM-related process failures (i.e., information problems that may contribute to errors) that contribute to suboptimal IM into five categories: information overload (too much information), information underload (too little information), information scatter (information in many places), information conflict (information not matching other information), and erroneous information (incorrect information). We interviewed 33 SHHC administrative staff to obtain contextual information about the SHHC admissions process (~24 hours after hospital discharge) and initial home visit (~48-72 hours after hospital discharge). We directly observed interactions among SHHCPs, older adults, and informal caregivers during the initial home visit after hospital discharge (n=60 visits). Following each visit, we interviewed the older adults (n=60), informal caregivers (n=40), and SHHCPs (n=46) involved. Participants were admitted to SHHC at five sites associated with three SHHC agencies in rural and urban sites across the US. Both field notes and audiotapes of interviews were transcribed, coded, and analyzed. Themes, subthemes, and information flow diagrams were generated. Results: We identified four action steps involved in the flow of information during the SHHC admissions process primarily taking place in the hospital and at the SHHC agency: 1) prepare referral and inform agency; 2) verify insurance; 3) contact older adult; and 4) review case to schedule visit. We subsequently identified four action steps involved in the flow of information during the initial start-of-care (SOC) home visit: 1) assess appropriateness for SHHC and obtain consent for treatment; 2) manage expectations; 3) ensure safety; and 4) develop contingency plans and recovery scenarios. Within each of these action steps, we identified examples of IM-related process failures: too much information for older adults to process upon hospital discharge (information overload); SHHCPs without access to complete information during the SOC visit (information underload); SHHC coordinators needing to access information from multiple places to prepare the initial referral (information scatter); older adult and informal caregivers’ mismatched expectations regarding what SHHC services they will actually receive, compared with what they were told in the hospital (information conflict); and SHHCPs encountering wrong diagnoses or medication lists during the SOC visit (erroneous information). We also identified important characteristics of IM during hospital/SHHC transitions: overlap among roles, tasks, information sources, and information targets; propagation of IM-related process failures over time; and variation in IM across study sites. Conclusions: Understanding IM during hospital/SHHC transitions elicited factors influencing the quality of care delivered during this particularly high-risk transition. IM required a high reliance on others (e.g., hospital staff, SHHC staff, older adults, informal caregivers) for success to reduce the risk of propagating IM-related process failures throughout the care transition. However, SHHCP often did not have access to complete and correct information during the SOC visit, nor did they have easy access to the sources of that information. This suggests that clinical and organizational infrastructure was not in place to adequately support IM during the hospital/SHHC transition

Factors affecting progress of the National e-Health Strategy in the NHS in England: A Socio-technical Evaluation.

Background: This is a formative socio-technical study of the “middle out” NHS e-health strategy in England. It began in 2015 with an objective to become “paperless at the point of care by 2020”, focussing nationally on the “electronic glue”, (interoperability), to facilitate the inter-organisational exchange digital communications of patient data and leaving the choice of EHRs to local organisations. No academic research has been published into the strategy and similar studies rarely include sample groups of suppliers or IT consultants. So this study seeks to fill both gaps in knowledge. Such strategies are prevalent across westernised developed countries and can consume large sums of government funding and local resources. In consequence, their failure can be very costly. This study seeks to mitigate that risk whilst recognising that, as they operate in highly complex environments, choosing any particular type of “bottom up”, “middle out” or “top down” strategy construct does not guarantee success. Their outcome is dependent upon the successful navigation through a mix of factors, known and unknown, across technical, human and social, organisational, macro-environmental and wider socio-political dimensions through time. Findings: The “middle out” strategy is broadly more appropriate, rather than “bottom up” or “top down”, but the target, of becoming “paperless by 2020”, is unattainable. Major cultural barriers include resistance by powerful clinicians, who can perceive such strategies as threats to the moral order and their traditional role as gatekeepers of access to patient data. Other barriers include inadequate and delayed national funding; disruption caused by government reorganisations; major premature programme re-structuring and a shift away from the original intent, resulting in the inappropriate selection of single organisation pilot sites rather than multi-organisational community wide ones to promote interoperability. New factors found include: the threats of cyber security incidents and the need for protective measures; the mismatch between strategy timescales and local procurement cycles; the quality of IT suppliers and the competing demands of similar change management programmes for scarce local NHS resources. Proposition: To reflect those findings a new socio-technical model is proposed that incorporates those additional factors as well as two further cross cutting dimensions to reflect “Lifecycle” and “Purpose”, drawing on elements of both Change Management and Technology Lifecycle Theory. “Lifecycle” reflects the “passage of time” as the evidence suggests that factors affecting progress may vary in their presence and impact over time as a strategy moves though its lifecycle. The addition of a “Purpose” dimension supports a reflection on the “why”. Some support is found for the proposal that a “middle out” strategy is more likely to facilitate progress than “bottom up” or “top down” ones. However a shift in approach is advocated. It is proposed that “middle out” e-health strategies are more likely to be successful if their “purpose” shifts away from promoting EHRs, per se, like with single organisation pilot sites, towards inter-organisational clinical and social care workflow improvement across health and social care economies. To achieve that, the focus should shift towards interoperability and cyber security programmes. Those should promote and mandate the use of national interoperability infrastructure, national systems and national standards. They should also provide national funding support to health economy wide clinical and social care workflow improvement pilots and initiatives that span those economies