The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study

BackgroundNursing homes are increasingly introducing electronic health record (EHR) systems into nursing practice; however, there is limited evidence about the effect of these systems on nursing staff time. Aims To investigate the effect of introducing an EHR system on time spent on activities by nursing staff in a nursing home. MethodAn observational work sampling study was undertaken with nursing staff between 2009 and 2011 at 2 months before, and at 3, 6, 12, and 23 months after implementation of an EHR system at an Australian nursing home. An observer used pre-determined tasks to record activities of the nursing staff at 9-minute intervals.ResultsThere was no significant change in registered nurses and endorsed enrolled nurses’ time on most activities after implementation. Personal carers’ time on oral-communication reduced, and time on documentation increased at most measurement periods in the first 12 months after implementation. At 23 months, time on these activities had returned to pre-implementation levels. Nursing staff time on direct care remained stable after implementation. No considerable change was observed in time spent on other activities after implementation.ConclusionFindings suggest that successful introduction of an EHR system in a nursing home may not interfere with nursing staff time on direct care duties. However, there is scope for improving the support provided by EHR systems through incorporation of functions to support collaborative nursing care

Einsatz und Evaluierung eines evolutionären IT-Konzepts für ein integriertes klinisches Informationssystem

Der erfolgreiche Einsatz von Informationstechnologie (IT) ist von wachsender Bedeutung für den Erfolg eines Unternehmens wie einem Universitätsklinikum. IT-Systeme im klinischen Umfeld sind jedoch Teil eines komplexen soziotechnischen Systems und haben nur nachhaltigen Erfolg, wenn sie sich eng an den Bedürfnissen der Endanwender orientieren und schnell auf geänderte Anforderungen reagieren können. Für die Neueinführung wesentlicher Komponenten des Marburger Krankenhausinformationssystems (KIS) wurde ab 1997 ein IT-Konzept erarbeitet. Dieses Konzept wird im ersten Teil der vorliegenden Arbeit vorgestellt. Aus Zeit- und Kostengründen musste zunächst eine sogenannte "Big-Bang"-Vorgehensweise für die schnelle klinikumsweite Einführung wichtiger Basisfunktionen gewählt werden. Um das damit verbundene hohe Projektrisiko zu minimieren wurde die "Big-Bang"-Phase auf das Nötigste begrenzt und für den weiteren Ausbau des KIS ein inkrementeller Ansatz zur bedarfsorientierten Softwareevolution verfolgt. Er soll die Möglichkeit bieten, neue und geänderte Anforderungen schnell und effektiv unter enger Einbeziehung der Endanwender umzusetzen. Ziel der vorliegenden Arbeit ist es, den Erfolg und die Tragfähigkeit dieses Ansatzes im praktischen Einsatz zu bewerten. Dazu wurde ausgehend von den wesentlichen Faktoren für den Erfolg eines IT-Systems ein Evaluationskonzept erarbeitet, das verschiedene qualitative und quantitative Methoden kombiniert. Dazu gehören: die Messung von Kennzahlen zum Ausbau des KIS (Umfang von Infrastruktur, Funktionalität und Nutzung, Projektierungsaufwand sowie Systemantwortzeiten), quantitative Vergleiche der Anwenderzufriedenheit vor und nach der Verwendung des inkrementellen Vorgehensmodells, Interviews mit Anwendern sowie kontinuierliche Analysen zu Bedienbarkeit, Prozess- und Dokumentationsqualität als Teil der Softwareentwicklung. Diese Untersuchungen wurden in den Jahren 2000 bis 2005 begleitend zu klinischen Teilprojekten der KIS-Einführung vorgenommen. Da die Evaluierung von IT-Maßnahmen innerhalb einer Organisation eng mit der Anwendungsentwicklung und der Schulung der Benutzer verwoben ist, wurde die Evaluierung des IT-Konzepts durch eine Reihe sozialer und organisatorischer Faktoren erschwert. Diese Hindernisse und mögliche Schwächen der einzelnen Methoden werden dargestellt und diskutiert. Die Evaluierungsergebnisse bestätigen weitgehend die Hypothesen. Der "Big-Bang"-Ansatz zeigte die erwarteten Nachteile: funktionale Defizite, eine unzureichende Anpassung an die Prozesse und die persönliche Arbeitsweise der Nutzer sowie eine mäßige Anwenderzufriedenheit. Der für den weiteren Ausbau des KIS verfolgte inkrementelle Ansatz zur bedarfsorientierten Softwareevolution führte zu messbaren Verbesserungen. Die Kombination dieser Ansätze erwies sich als praktikabel. Es war mit relativ geringen Ressourcen möglich, ein KIS aufzubauen, das flächendeckend ein breites Spektrum an klinischer Funktionalität bereitstellt und dabei sowohl die Vorteile eines integrierten Systems als auch eine hohe Flexibilität und Anpassbarkeit aufweist. Dies spiegelt sich auch in einer signifikant gesteigerten Anwenderzufriedenheit nach Verwendung des inkrementellen Vorgehensmodells wider. Dabei erhöhten sich nur die Werte derjenigen Zufriedenheitsfaktoren, bei denen ein direkter kausaler Zusammenhang zur partizipativen, bedarfsorientierten Softwareentwicklung vermutet wird. Auch der Abgleich mit den gemessenen Systemantwortzeiten und den Ergebnissen aus den Interviews und Anwenderrückmeldungen scheint die Annahme zu bestätigen, dass diese positiven Effekte weitgehend durch das verwendete Vorgehensmodell und nicht durch mögliche Störgrößen wie eine erhöhte Systemperformanz oder eine intensivere Betreuung durch das IT-Personal zu erklären sind. Die Erfahrungen aus klinischen Teilprojekten zeigen außerdem, dass es auf der Basis des Marburger IT-Konzepts möglich ist, klinische Prozesse effektiv und bedarfsorientiert zu unterstützen. Mittels einer kontinuierlichen, projektbezogenen Beobachtung von Qualitätsindikatoren als Teil eines iterativen, partizipativen Softwareentwicklungsprozesses, der in einen umfassenden "Change-Management"-Prozess eingebettet ist, können zudem mögliche negative Auswirkungen einer IT-Intervention frühzeitig erkannt und schnell beseitigt werden. Abschließend werden Defizite des zum Einsatz gekommenen Werkzeugs diskutiert und es werden ausgehend vom Marburger IT-Konzept internationale Forschungsbestrebungen hin zu mehrschichtigen Service-orientierten Architekturen skizziert. Solche Architekturen und die konsequente Trennung verschiedener Belange der Softwareentwicklung stellen einen vielversprechenden Ansatz zur entwicklungsfähigen, organisationsübergreifenden IT-Unterstützung von Prozessen in "Gesundheitsnetzen" dar

Evaluating ICT Applications in Health Care

This thesis is about evaluation of ICT applications in health care. How can information systems for patients and health care professionals best be evaluated? How to take into account that one - in practice - is often confronted with limited resources? The author describes the difficulties in designing information systems that are supposed to replace and add surplus value to existing forms of information exchange. For information systems to become and remain successful, one needs to have a thorough understanding of the needs of the users and the practical, social and political context in which these systems are used

Evaluating Evaluations of Clinical Decision Support Systems: Case Studies From NHS Clinical Settings

The NHS is under increasing pressure to cut costs while delivering high quality care. At the same time, the demand for healthcare services has grown, driven in part by the increasing number of older people in the population. NHS Trusts are adopting clinical decision support systems (CDSSs) to help decision making at the point of care. CDSSs are said to bring benefits such as improvements in guideline adherence, clinical processes and user performance but evidence of these benefits is not always available and their effectiveness in terms of improving patient outcomes is often open to question. This thesis presents research that was carried out in a large teaching NHS Trust looking at the evaluations of three CDSSs. Semi structured interviews were carried out with key informants who were involved in their adoption, use and evaluations. Documentary analysis and observations were also used to augment the interviews. Most evaluations were carried out informally by the developers and were primarily driven by external regulatory pressures rather than patient outcomes and organisational needs. Evaluation documentation was inadequate or missing, thus making it difficult to systematically assess these evaluations. This thesis contends that evaluations are important to provide decision makers in NHS Trusts with adequate information to make decisions about CDSSs and computerised healthcare information technologies in general. NHS Trusts need to build organisational capacity and readiness to enable them to effectively carry out evaluations that will provide meaningful information to gain better understanding of CDSSs and to inform their successful adoption, implementation, usage and to justify the resource allocation. This research shows that CDSS evaluations investigated took a predominantly narrow view. It thus provides evidence for the need for a more systemic approach to evaluation

Developing eSexual Health within the NHS How can we optimally design, implement and evaluate an internet-based clinical pathway for remote testing, diagnosis, clinical assessment, antibiotic prescribing and partner management of sexually transmitted infections?

PhD (md res)Over the past 20 years, the incorporation of eHealth within health services in England has expanded organically in diverse ways, usually in response to local perceived need, interest or funding. UK government policy and strategies have taken an optimistic view of how eHealth can revolutionise publically funded health care provision and implementation lags far behind expectations. Although there are some excellent examples of how eHealth has been incorporated into NHS practice in a beneficial manner, there is also a concerning lack of evidence to support many of the interventions and new models of service delivery. This largely reflects a disparate and fragmented evidence base within current eHealth literature, particularly in relation to methods for developing online care pathways. This doctoral research is focused on developing and implementing an online automated clinical care pathway for people with genital chlamydia infection, and developing a robust framework for its evaluation. The care pathway is a core component of an eSexual Health Clinic, also developed as part of this work, which is fully integrated within an NHS specialist sexual health service. An online clinical pathway taking a person from diagnosis of a new condition, through an automated clinical consultation, partner notification and collection of antibiotics from a community pharmacy via an electronic prescription has never been done before in the UK. The novelty of the work and paucity of literature in this field at times necessitated a different approach from conventional research practice. I started by conducting a scoping review to identify the legal, regulatory, ethical and perceptual barriers to introducing such a pathway into the NHS. Electronic prescribing across the secondary and primary care interface stood out as a barrier to implementation. There was also a clear lack of evidence in terms of the content and accuracy of sexual health mobile medical applications. I went on to conduct detailed reviews of both of these areas. 3 In the absence of any relevant guidance on developing online clinical care pathways, I then developed my own methods, underpinned by evidence adapted from guidance aimed at traditional clinical care, existing protocols and practice, eHealth and sexual health literature and questionnaires, and created a new eClinical Care Pathway Framework. I then applied this framework to guide my development of the online clinical care pathway for people with genital chlamydia. We then needed to demonstrate that the Chlamydia online clinical care pathway was feasible, acceptable and safe to take forward into a large scale trial, and potentially implement into clinical practice. There are no accepted methods for evaluation of this type of online clinical care pathway and my final piece of work focussed on developing a set of evaluation techniques and activities, which would assess all these elements to determine whether the online pathway was fit for purpose. Outputs of this doctoral work include: a comprehensive review of contemporary sexually transmitted infection and sexual health mobile applications (apps); a comprehensive review of electronic prescribing in the UK; a method for developing complex online clinical care pathways based on a novel framework; UK’s first automated online clinical care pathway for people with genital chlamydia, and finally a method for evaluation of online clinical care pathways

Digital diffusion in the clinical trenches : findings from a Telemedicine Needs Assessment

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Architecture, 2002.Includes bibliographical references (leaves 105-110).Broadly stated, this dissertation focuses on how practitioners and provider organizations integrate the computer and web into healthcare delivery. The opportunity that afforded this research was a Telemedicine Needs Assessment commissioned by a Massachusetts-based provider organization, consisting of two hospitals and 29 community group practices (CGP). The Telemedicine Needs Assessment incorporated qualitative and quantitative research programs to include: 1. cross-sectional, institution-wide, in-depth interviews; 2. participant observation at administrative and clinical day-to-day operations, and lastly, 3. a 68 item, closed-ended survey distributed to all 586 clinical practitioners to assess the access, use, and perceived needs of current computer, web, and telemedicine technologies. Data from the survey, (72% response rate), established a computer and web enablement baseline against which the success, failure, or potential usefulness of any future medical informatics implementation would be evaluated. Findings included: 1. Computer and web enablement within the organization is not ubiquitous. Access is high, use is low; 2. Practitioner status, practice location, and gender affect enablement. Non-MDs, CGP-based practitioners, and female practitioners report lowest access and use. 3. No differences were reported specific to home access to computers and use of e-mail. 4. Hospital-based practitioners report greater access and use. CGP-based practitioners report greater perceived needs for teletechnologies.(cont.) 5. Hospital-based and CGP-based male MDs emerge as the most polarized subgroups due to differences in computer and web use and perceived needs. 6. Female practitioners are more successful than male practitioners securing tech support at home and at work. 7. With regard to technology uptake, female MDs constitute a more homogeneous group than male MDs. Also, four products emerged from the Telemedicine Needs Assessment: 1. a needs assessment theory and methodology derived from Process Architecture which promulgates that discussions specific to the end users' work must always be inextricably linked with their work practice; 2. a typology of barriers to the integration of computer and web-based technologies into healthcare delivery stratified by practitioner, administration, organization, and industry; 3. a framework which defines and integrates real and virtual healthcare delivery services, products, and technologies, and finally; 4. a systems-based model of clinical and telecommunications integrated delivery networks providing IS, IT, and administrative infrastructure support for the framework.by Verlé Margaret Harrop.Ph.D