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

Mutual Shaping of Tele-Healthcare Practice: Exploring Community Perspectives on Telehealth Technologies in Northern and Indigenous Contexts

In Canada, northern and Indigenous communities face well documented challenges to accessing healthcare services prompting the urgent need to adopt alternative and innovative solutions to overcome barriers of limited access due to geographic distance, physician shortages, limited resources, and high cost of service delivery. Telehealth – the means of delivering health care services and information across distance – promises to augment services to address some of these barriers and has been increasingly relied upon to bridge healthcare service gaps. Despite the promise of telehealth, notable utilization barriers and structural constraints remain that challenge long-term sustainability. Little is known about how well these technologies work from community telehealth users’ perspectives. Current work in the area has tended to focus on the increased efficiency and cost effectiveness of telehealth in facilitating healthcare services, with less focus on users’ perspectives obscuring the important roles played by users and technologies. In sum, more work needs to be done to present a complete picture of users’ experiences and community needs – a gap this dissertation aims to tackle. In doing so, this research captures a snapshot of community perspectives from four Northern Saskatchewan communities, drawing attention to users’ experiences in relation to the social and technical factors shaping telehealth use. Working in partnership with the communities of Hatchet Lake Denesuline First Nation, the Northern Villages of Île-à-la-Crosse and Pinehouse Lake, and the Town of La Ronge, and external stakeholders/knowledge users working directly with these communities, this work resulted in valuable insights into the user-technology interface. Emerging from community concerns with accessing healthcare services and education/training, the goal of this project was to better understand strengths and barriers for telehealth use. Methodologically, the personal accounts and lived experiences of telehealth users were explored using qualitative methods grounded in Community-Based Participatory Research (CBPR) and decolonizing methodologies utilizing Constructivist Grounded Theory (CGT) that is drawn from interpretive-constructivist epistemological frameworks. In-depth, semi-structured qualitative interviews/focus groups with 24 telehealth users, field notes and general observations provided the basis for data collection, and NVivo 12 was used to organize, iteratively code and analyze community insights. Thematic analysis and socio-technical mapping explored themes across community contexts and provided understanding of the interrelationship of shared and unique insights whereby community telehealth users’ voices guided interpretations. This dissertation highlights the importance of community collaborations and identifies the strengths and barriers for utilizing telehealth within northern and Indigenous contexts. Using theoretical frameworks drawn from Science and Technology Studies (STS), this dissertation makes the argument that users and technologies play significant roles in shaping tele-healthcare practice – a mutually co-constitutive relationship embedded within larger socio-structural systems that pose varying constraints. Analysis revealed that users and technologies mutually shape tele-healthcare practices and care experiences – i.e. technologies shape patients’ and local/remote providers’ use of the system in enabling/constraining ways and users shape technologies through reconfiguration or “tinkering”. A mutual shaping approach following the relational/performative view of socio-technical agency serves as a pathway for examining socio-cultural factors shaping how technologies are designed, implemented, and used, and alternatively how technologies shape practice and meanings of socio-technical spaces. Further, it is argued that understanding the context in which telehealth technologies are situated and experienced will be increasingly critical as technological systems play greater roles in service delivery

Health Information System Implementation in a Complex Acute Care Environment: A Sociotechnical Analysis

With the increase of information systems in health care, there is a growing need to better understand factors that contribute to the implementation and use of such technology. This secondary analysis explored the implementation of a health information system in a large acute care hospital from the perspective of hospital leadership and the health information system developers. The purpose of this study was to: (a) explore a group of interprofessional leaders’ perceptions of social and technical factors which impacted an HIS implementation within an acute care hospital organization; and, (b) uncover how the various social and technical forces contributed to, or prevented, successful implementation of the HIS in relation to nursing practice and education. A directed content analysis approach was used to obtain an understanding of participants’ perceptions regarding health information system implementation and use. Sittig and Singh’s (2010) sociotechnical framework was chosen as a theoretical framework to guide the analysis of focus group (n=17, in 3 separate groups) and interview data (n=10) from a longitudinal study at an acute care hospital in Ontario, Canada. Several benefits of the health information system implementation were realized including increased organizational transparency regarding patient flow and improved communication among managers and directors. Findings also indicated that implementation was compromised by problems with inaccurate data stemming from poor interoperability with other health information systems, insufficient training, and turnover of leadership during the implementation process. This type of research is important to support future implementation of information and communication technologies and contribute to a growing body of knowledge regarding the implementation of health information systems in complex healthcare environments. The consolidated evidence generated from this content analysis also has implications for the nursing profession and development of clinical practice. Further evaluation measures must be undertaken to more fully understand the role of nurses in health information systems implementation and optimize the use of these technologies in supporting nursing practice and improving patient care

Mentorship: A Powerful Tool for IPG Success

Because Canada espouses principles of diversity and multiculturalism, many international pharmacy graduates (IPGs) immigrate to Canada expecting to find employment using skills for which they trained in their home country. Upon arrival, they often face challenges in credential recognition and licensure. Barriers include systemic discrimination, socio-psychological isolation, the precipitous decline in social status, and financial challenges of navigating the steps that bridge the training received in their home countries to the scopes of practice in Canada. The problem of practice (PoP) explored in this organizational improvement plan (OIP) focuses on the lack of opportunity that IPGs have to access clinical workplace settings prior to being assessed for entry to practice competencies. Health Alliance is an organization that works in the regulatory space for internationally educated healthcare professionals, and that provides a service that facilitates the IPG path to licensure in Canada. This OIP proposes housing a mentorship program at Health Alliance, to specifically address the experiential learning, and knowledge and skill gaps that have been identified as barriers to success for international pharmacy graduates pursuing licensure, and ultimately, gainful employment as pharmacists in Canada. This OIP examines the PoP through the lenses of sense of community theory and critical race theory to explore how the lived experiences of diverse internationally educated skilled immigrants are impacted by the process of seeking credential recognition and licensure. Change at the leadership, cultural and operational levels will be facilitated through Kotter’s eight stage change model and will be evaluated using an empowerment evaluation approach

Exploring the impact of telehealth videoconferencing services on work systems for key stakeholders in New Zealand : a sociotechnical systems approach : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Management at Massey University, Albany, New Zealand

Figure 2.9 is re-used under a Creative Commons Attribution 4.0 International (CC BY 4.0) license. Figures 2.11 and 2.13 are re-used with the publishers' permission.This thesis explores how the impacts of telehealth videoconferencing services (THVCS) on work systems are perceived by key stakeholders in New Zealand. Telehealth - the use of information and communications technologies to deliver healthcare when patients and providers are not in the same physical location - exemplifies how technological developments are changing the ways in which healthcare is provided and experienced. With the objectives of improving access, quality, and efficiencies of financial and human resources, THVCS use real time videoconferencing to provide healthcare services to replace travel to a common location. Despite the benefits of telehealth reported in the extant literature, there continues to be difficulties with developing and sustaining services. The aim of this inquiry is to understand how THVCS impact key stakeholders in the work system. Specifically, it seeks to examine the characteristics of THVCS in the New Zealand context, identify the facilitators and barriers to THVCS, and understand how the work system can adapt for THVCS to be sustained practice. The research design is framed by a post-positivist approach and underpinned by sociotechnical systems (STS) theory. STS theory and a human factors/ergonomics design approach inform the methodology, including the use of the SEIPS 2.0 model. Forty semi-structured qualitative interviews and contextual observations in a two-phase methodology explore the perceptions of an expert telehealth group, and providers, receivers, and decliners of THVCS. These data are analysed using the framework method of thematic analysis. The key findings suggest that to enable sustained THVCS in New Zealand, factors such as new ways of working; change; human connection; what is best for patient; and equity need to be recognised and managed in a way that balances costs and consequence and ensures fit across the work system. Theoretical contributions to knowledge are made through the development of a conceptual model from the literature, exploring THVCS with an STS theory lens and developing SEIPS 2.0. Methodologically, this inquiry contributes a theory-based, qualitative approach to THVCS research and draws on the perceptions of unique groups of participants. Significantly, the findings make practical contributions to the design of the THVCS in the New Zealand context

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

Background: The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement. Methods: We used a scoping review methodology drawing on Arksey and O’Malley’s methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 – April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills. Results: We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking. Conclusions: We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers

Why is it difficult to implement e-health initiatives? A qualitative study

<b>Background</b> The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers - the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.<p></p> <b>Methods</b> We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).<p></p> <b>Results</b> Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.<p></p> <b>Conclusions</b> Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning

Virtual Reality in Residential Aged Care: a study of adoption and system complexity.

Virtual Reality (VR) has been increasingly adopted by residential aged care facilities (RACFs) for enriching residents’ experiences. RACFs are sensitive settings with complex sociocultural elements, thus aged care providers might experience challenges when introducing new technologies. This paper presents findings from a descriptive analysis of survey responses exploring the complexity brought about by adopting VR in RACFs. By understanding technology-in-use as socio-technical systems, this study draws on the work of Greenhalgh et al. to understand how the adoption of health-care technologies is influenced by complexity across seven domains: condition, technology, value proposition, adopter(s), organization(s), wider system, and adaptation over time. The paper details the design of a new survey instrument. Results indicate that it is challenging to sustain a VR program within RACFs due to the complexity arising from residents’ conditions and the technology itself, and the complicated challenges involving staff who facilitate VR activities and those who provide training

Inviting a Hospital Healthcare Team to Change : A Framework for Building Capacity to Provide Intersectional, Trauma-Informed Care

This Organizational Improvement Plan is designed for Open Doors (a pseudonym), a Canadian hospital invested in providing stigma-free, social, and structural determinants-based care to patients who are marginalized from healthcare vis-à-vis previous experiences of exclusion and institutional trauma at healthcare settings. In the context of deepening scrutiny on healthcare institutions for their role in perpetuating systemic oppression and for failure to mitigate inequitable health outcomes for marginalized populations, Open Doors’ commitment to justice-centered care offers a compelling case study in hospital-based strategies for addressing health inequity. The specific Problem of Practice (PoP) addressed is the hospital’s care team’s limited capacity for providing trauma-informed care for patients from diverse communities who face complex, intersecting, and systemic barriers to hospital-based care. Broader systemic failures and contextual factors shaping this PoP are discussed and situated using organizational theory and the recent groundswell in literature on socially conscious caregiving. The need to instigate transformative, adaptive third order change to address the PoP is highlighted using transformative and adaptive leadership theories. Critical appreciative inquiry and dialogic change models are blended to propose a change framework that can mobilize such change within Open Doors’ context. Guided by the change framework and an evaluation-driven design process, a specific solution is detailed, namely, a patient-centered design and learning hub. A detailed change plan is presented, whereby patients, staff, community representatives and leaders are invited into a knowledge-based, dialogic process of co-creating intersectional, trauma informed practices to address a high-priority intersectional area of need for Open Doors. Keywords: healthcare change management; transformative leadership; health professions education; critical reflexivity; critical appreciation; evaluative thinkin

Strategies Rural Hospital Leaders Use to Implement Electronic Health Record

The Centers for Medicare and Medicaid Services issued over 144,000 payments totaling $7.1 billion to medical facilities that have adopted and successfully demonstrated meaningful use of certified electronic health record (EHR). Hospital organizations can increase cost savings by using the electronic components of EHRs to improve medical coding and reduce medical errors and transcription costs. Despite the incentives, some rural health care facilities are failing to progress. The purpose of this multiple case study was to explore the strategies rural hospital leaders used to implement an EHR. The target population consisted of rural hospital leaders who were involved in the successful implementation of an EHR in South Texas. The conceptual framework chosen for this study was the sociotechnical systems theory. Data were collected through telephone interviews using open-ended semistructured interviews with 5 participants from 4 rural hospitals who were involved in the EHR implementation. Data analysis occurred using Yin\u27s 5-step process which includes compiling, disassembling, reassembling, interpreting, and concluding. Data analysis included collecting information from government websites, company documents, and open-ended information to develop recurring themes. Several themes emerged including ongoing training, provider buy-in, constant communication, use of super users, and workflow maintenance. The findings could influence social change by making the delivery of health care more efficient and improving quality, safety, and access to health care services for patients