How to Avoid Common Pitfalls of Health IT Implementation

The stories in this guide were based on case studies about a specific intensive care IT system that integrates information from bedside monitors into a single intuitive display to provide better real-time information for clinicians

Use of electronic patient records and encrypted email patient communication among Swiss chiropractors: a population-based cross-sectional study

BACKGROUND The implementation of electronic health information technologies is a key target for healthcare quality improvement. Among Swiss chiropractors, reliable data on the use of electronic heath information technologies and distribution of the health workforce was lacking. OBJECTIVES To estimate the prevalence of electronic patient record (EPR) and encrypted email communication use among Swiss chiropractors and describe the geographic distribution of chiropractors in Switzerland. METHODS Population-based cross-sectional study of all active practising members of the Swiss Chiropractic Association (ChiroSuisse) between 3 December 2019 and 31 January 2020. We asked about clinician and practice characteristics, EPR use for clinical record keeping, use of encrypted email for patient communication, and information on EPR and encrypted email communication products used. Multivariable logistic regression analyses assessed the associations between clinician and practice characteristics and (1) EPR use, and (2) encrypted email use. RESULTS Among 286 eligible Swiss chiropractors (193 [68%] men; mean age, 51.4 [SD, 11.2] years), 217 (76%) completed the survey (140 [65%] men; mean age 50.7 [11.2] years). Among respondents, 47% (95% confidence interval [CI], 40-54%) reported using an EPR in their practice, while 60% (95% CI, 54-67%) endorsed using encrypted email technology. Chiropractors aged ≥ 60 (versus those ≤ 39) years were 74% less likely to use an EPR system (OR 0.26, 95% CI 0.08 to 0.77), while clinicians from practices with 4 or more chiropractors (versus those from solo practices) were over 5 times more likely to report EPR use (OR 5.6, 2.1 to 16.5). Findings for factors associated with encrypted email use were similar. The density of chiropractors in Switzerland was 3.3 per 100,000 inhabitants. CONCLUSIONS As of January 2020, 286 duly licensed chiropractors were available to provide musculoskeletal healthcare in Switzerland - just under 50% of responding Swiss chiropractors used an EPR system in clinical practice, while 60% used encrypted email technology. Better implementation of EPR and electronic health information technologies in Swiss chiropractic practice is possible and encouraged for the purpose of musculoskeletal healthcare quality improvement

Routinedaten – das ungenutzte Potenzial in der Versorgungsforschung

Routinedaten entstehen als Nebenprodukt des normalen Betriebsalltags. Diese ohne Zusatzaufwand massenhaft generierten Daten lassen sich mit ökonomischen oder im Falle der Medizin auch mit gesundheitlichen Fragestellungen auswerten. Durch die nicht-kontrollierte Art der Sammlung von Routinedaten sowie aufgrund der uneinheitlichen Handhabung von elektronischen Krankengeschichten ergeben sich aber je nach Fragestellung Grenzen der Aussagekraft von Resultaten. Dieser Artikel widmet sich den Fragen rund um Herkunft, Verarbeitung, Interpretation und Nutzen von Routinedaten. Dabei werden auch Machine Learning und Big Data kritisch in den Kontext gebracht, sowie die Aspekte Datenschutz und Ethik. Hinsichtlich des Schweizer Gesundheitssystems zeigt der Artikel die notwendigen Voraussetzungen, damit das Potential von Routinedaten auch hierzulande zugunsten einer besseren medizinischen Versorgung genutzt werden kann. Today, a huge amount of data is created when medical care is provided, either in a hospital setting or in ambulatory care. Even if those data are not collected with the purpose to answer scientific questions, they can be used to this effect. The fact that data collection differs in quality and extent from setting to setting and no standardization regarding the documentation exists, means that the use of these data is often limited. Switzerland is one of the countries with the highest variety regarding Electronic Medical Records (EMR), nevertheless, routine data can be used if some standardization is used in aggregating and summarizing these data. They can provide important information about the extent as well as the quality of care and contribute to improve the health care system

Plausible Pictures For Data Governance: A Narrative Network Approach

Workaround-centric data activities (WCDA) can impact data integrity/quality. Despite this, one can view WCDA as an enhancement to organisational Data Governance (DG) maturity. However, these WCDA are primarily undocumented and poorly understood. Therefore, we need a means of creating plausible pictures for DG – by modelling WCDA visually. This study draws on the theory of organisational routines to develop WCDA modelling rules. It is the first study to leverage the Narrative Network (NN) approach as a conceptual lens to model WCDA visually. We identify five WCDA modelling rules: 1) a narrative fragment must come from a process actor, 2) a narrative fragment has three attributes: actor, action & resource, 3) all attributes in a narrative fragment establish the action type, 4) a narrative fragment must contain a data activity, and 5) a narrative fragment data activity must follow a standard naming convention. In conclusion, we discuss the advantages of our approach

Plausible pictures for data governance: A narrative network approach

Workaround-centric data activities (WCDA) can impact data integrity/quality. Despite this, one can view WCDA as an enhancement to organisational Data Governance (DG) maturity. However, these WCDA are primarily undocumented and poorly understood. Therefore, we need a means of creating plausible pictures for DG â by modelling WCDA visually. This study draws on the theory of organisational routines to develop WCDA modelling rules. It is the first study to leverage the Narrative Network (NN) approach as a conceptual lens to model WCDA visually. We identify five WCDA modelling rules: 1) a narrative fragment must come from a process actor, 2) a narrative fragment has three attributes: actor, action & resource, 3) all attributes in a narrative fragment establish the action type, 4) a narrative fragment must contain a data activity, and 5) a narrative fragment data activity must follow a standard naming convention. In conclusion, we discuss the advantages of our approach

Undirected health IT implementation in ambulatory care favors paper-based workarounds and limits health data exchange

BACKGROUND: The adoption and use of health information technology (IT) continues to grow around the globe. In Switzerland, the government nor professional associations have to this day provided incentives for health IT adoption. OBJECTIVE: We aim to assess the proportion of physicians who are routinely working with electronic health data and describe to what extent physicians exchange electronic health data with peers and other health care providers. Additionally, we aim to estimate the effect of physicians' attitude towards health IT on the adoption of electronic workflows. METHODS: Between May and July 2013, we conducted a cross-sectional survey of 1200 practice based physicians in Switzerland. Respondents were asked to report on their technical means and where applicable their paper-based workarounds to process laboratory data, examination results, referral letters and physician's letters. Physicians' view of barriers and facilitators towards health IT use was determined by a composite score. RESULTS: A response rate of 57.1% (n=685) was reached. The sample was considered to be representative for physicians in Swiss ambulatory care. 35.2% of the respondents documented patients' health status with the help of a longitudinal semi-structured electronic text record generated by one or more encounters in the practice. Depending on the task within a workflow, around 11-46% of the respondents stated to rely on electronic workflow practices to process laboratory and examination data and dispatch referral notes and physician's letters. The permanent use of electronic workflow processes was infrequent. Instead, respondents reported paper-based workarounds affecting specific tasks within a workflow. Physicians' attitude towards health IT was significantly associated with the adoption of electronic workflows (OR 1.04-1.31, p<0.05), but the effect sizes of factors related to the working environment (e.g., regional factors, medical specialty, type of practice) were larger. CONCLUSION: At present, only a few physicians in Swiss ambulatory care routinely work with electronic health data. Until more of their peers participate in electronic exchange of structured clinical information, most physicians will continue to stay in paper-based systems and workarounds. The survey found that physicians with a positive attitude towards health IT were more likely to adopt electronic workflows, but the impact is minor. It will likely be necessary to introduce financial incentives and develop national standards in order to promote the adoption by a critical mass of practicing clinicians

Inércia do conhecimento e seu efeito no comportamento workaround : um estudo na capacidade de improvisação organizacional no contexto do trabalho remoto

Muitas organizações são rígidas e resistentes às mudanças, tornando seus procedimentos de trabalho ultrapassados e impossibilitando a adoção de novas alternativas que possam auxiliar na execução das tarefas com eficiência. É nesse aspecto que surge o conceito da inércia do conhecimento que reflete na falta de atualização de conhecimentos necessários para melhorias na estrutura organizacional. Tal falta pode impactar diretamente em como os funcionários irão executar seu trabalho, recorrendo ao comportamento workaround que consiste na decisão de adaptar uma tarefa e numa reação de insatisfação com os processos de trabalho, para que seja possível concluir suas tarefas de maneira completa e efetiva. Assim, o comportamento workaround pode influenciar a capacidade de improvisação organizacional por meio da criação de novos conhecimentos e soluções criativas que podem refletir em melhorias para a organização como um todo. Diante disso, o objetivo deste trabalho é investigar o efeito da inércia do conhecimento no comportamento workaround e seu impacto na capacidade de improvisação organizacional no contexto do trabalho remoto, o qual possibilita exercer seu trabalho fora de um escritório convencional, sendo este contexto escolhido devido ao seu crescimento significativo. O método utilizado é definido por uma pesquisa quantitativa e a coleta de dados foi realizada através de uma survey online. O estudo contém uma amostra de 138 respondentes. A análise dos dados foi feita por meio dos softwares estatísticos SPSS e SmartPLS. Analisando os dados, foi verificado que a inércia da experiência e a inércia da aprendizagem possuem um efeito significativo com o comportamento workaround e que este também impacta a capacidade de improvisação organizacional.Many organizations are rigid and resistant to change, making their work procedures outdated and making it impossible to adopt new alternatives that can assist in performing tasks efficiently. It is in this aspect that the concept of knowledge inertia emerges, which reflects the lack of updating of knowledge necessary for improvements in the organizational structure. Such a lack can directly impact on how employees will perform their work, resorting to workaround behavior that consists of the decision to adapt a task and a reaction of dissatisfaction with the work processes, so that it is possible to complete their tasks in a complete and effective way. Thus, workaround behavior can influence the capacity for organizational improvisation through the creation of new knowledge and creative solutions that can reflect in improvements for the organization as a whole. Therefore, the objective of this work is to investigate the effect of inertia of knowledge with workaround behavior and its impact on the ability of organizational improvisation in the context of remote work, which makes it possible to exercise your work outside a conventional office, this context being chosen due to significant growth. The method used is defined by a quantitative survey and the data collection was carried out through an online survey. The study contains a sample of 138 respondents. Data analysis was performed using SPSS and SmartPLS statistical software. Analyzing the data, it was found that the inertia of the experience and the inertia of the learning have a significant effect with the workaround behavior and that this also impacts the capacity for organizational improvisation. In this way, three hypotheses were developed and supported

DEFINING THE CHARACTERISTICS AND INSTRUMENT DEVELOPMENT OF NURSE WORKAROUNDS DURING MEDICATION ADMINISTRATION

AbstractBackground. Nurses may use workarounds when they circumvent or eliminate a task during the medication administration process. Environmental, technological, and systemic barriers to following medication administration protocols are some of the reasons that nurses use workarounds. There is substantial qualitative research supporting the type of workarounds nurses use during medication administration, but currently there are no instruments available to quantify the type and frequency of workarounds that nurses use during medication administration. Aim. The purposes of this study were to: (a) complete a comprehensive literature review to understand the state of the science related to nursing workarounds and medication administration; (b) conduct a concept analysis of workarounds during the medication administration process; (c) use the findings of the concept analysis to develop an instrument to quantify the type and frequency of workarounds; and (d) to conduct initial psychometric testing of the newly developed instrument. Design and methods. A comprehensive literature search was conducted to understand workarounds and medication administration. A concept analysis, using the Walker and Avant (2005) method, was used to define the concept, and to identify defining characteristics, antecedents, and consequences of nursing workarounds during medication administration. Using the concept analysis findings, an instrument was developed and administered to a sample of acute care registered nurses. Content validity and face validity were assessed. Preliminary psychometric analysis was conducted through exploratory factor analysis. Construct validity was assessed with comparison to the Halbesleben, Rathert and Bennett instrument, a previously validated instrument measuring the construct of nursing workarounds. Results. Study results were reported in three manuscripts to be submitted for publication in peer-reviewed journals. Presented in the first manuscript, the results of the review determined that there is a need for continued research of nursing workarounds and a lack of a validated instrument to measure the type and frequency of workarounds when administering medications. The second manuscript included findings from a concept analysis that elucidated antecedents, eight defining characteristics, and consequences of workarounds. Eight defining characteristics were identified as either human factors or system factors that described workarounds: (a) goal driven adaptation or improvisation of a current policy or process; (b) inconsistent practice with policy; (c) staff actions that do not follow explicit or implicit rules, assumptions, workflow regulations, or intentions of system designers; (d) intentional action outside of the process; (e) nonstandard method for accomplishing work; (f) informal or temporary practice adaptation; (g) bypassed work procedures; and (h) out of sequence or omission of one or more steps in a process. Included antecedents were poorly designed workflows and knowledge of expected policies and practices. Consequences included achieving efficiency, personal satisfaction, process revisions and possible patient harm. The final manuscript presented the initial psychometric analysis of a newly created instrument containing three subscales that measured the type and frequency of workarounds. Based on exploratory factor analysis using principal axis factoring of eighteen items, twelve items were retained comprising three subscales: (a) defining characteristics, (b) type of workarounds, and (c) frequency of workarounds. Cronbach’s alpha ranged from .83 to .92 for the three subscales. As hypothesized, convergent validity was supported by the Spearman Rho correlations ranging from .27 to .47 with the Halbesleben, Rathert and Bennett instrument total and subscales. Divergent validity was supported with Spearman Rho correlations ranging from -.09 to .15 with the Halbesleben, Rathert and Bennett subscales. Conclusion. The three studies provided a psychometric evaluation of an instrument measuring the type and frequency of workarounds that registered nurses may use when administering medications. Initial testing of the three subscales of the Savage Workaround Instrument demonstrated good reliability and initial evidence of validity. Future research should be conducted on a larger sample size to verify the testing results

Le secret médical

Medical secrecy is going through a troubled period today. The multiplication of health care providers, technological progress and the pressure of financial policies tend to put pressure on this institution and to redefine its contours. In Swiss law, medical secrecy is now governed by an abundance of legal provisions whose implementation has become complex and unpredictable. After a first part dealing with the historical origins of medical secrecy, its main current factors of influence and its ethical justifications, the book systematically analyzes the multiple duties of confidentiality that may apply to caregivers, their respective limits and their articulation. The study concludes with an analysis of several scenarios for the future of medical confidentiality

Digitale Vernetzung und Qualitätsmessung Ausgangslage und Ergebnisse in der Schweizer Grundversorgung

Die stete Zunahme chronisch kranker und multimorbider Menschen stellt traditionelle Gesundheitssysteme weltweit vor eine grosse Herausforderung. Insbesondere hochspezialisierte, multisektorielle Gesundheitssysteme wie in der Schweiz stossen an ihre Grenzen, weil geeignete Infrastrukturen und Betreuungsressourcen für die proaktive, koordinierte Versorgung dieser Menschen fehlen. Allen diesbezüglich entwickelten neuen Ansätzen für die Versorgung sind zwei Kernelemente gemein: 1) Die Vernetzung aller an einer Behandlung beteiligten Leistungserbringer über traditionelle Grenzen der Versorgungssektoren und -ebenen hinweg und 2) kontinuierliches Qualitätsmanagement. Implizite Voraussetzung für beides ist die Verfügbarkeit und standardisierte Nutzung von Informationstechnologie (IT) im Praxisalltag der Leistungserbringer. Digitale Vernetzung und Qualitätsmessung werden damit einerseits zum Schlüsselfaktor für die Umsetzung neuer Versorgungsmodelle, andererseits für ihre Evaluation. Die verfügbaren Daten ermöglichen Versorgungsforschung zur Beurteilung der tatsächlichen Effekte neuer Behandlungsformen, und liefern damit evidenzbasierte Entscheidungsgrundlagen für die Restrukturierung des Gesundheitswesens. In dieser Habilitationsschrift werden drei Arbeiten vorgestellt, die die Ausgangslage für die digitale Vernetzung und Qualitätsmessung in der ambulanten medizinischen Grundversorgung der Schweiz untersuchen und erste klinische Qualitätsmessungen im Rahmen eines Forschungsnetzwerks in der Hausarztmedizin darstellen. Zunächst eine Querschnittsstudie, in der der aktuelle Stand der IT-Implementierung in der ambulanten Gesundheitsversorgung der Schweiz untersucht wurde. Besonderer Fokus lag auf der Nutzung strukturierter elektronischer Daten im Vergleich zu unstrukturierten elektronischen Einträgen und papierbasierter Dokumentation. Dies, weil strukturierte elektronische Daten die Voraussetzung für die Erfassung von Prozess- und Outcomeindikatoren für die Qualitätsmessung darstellen. Die Ergebnisse dieser Studie zeigen konkret auf, wo Implementierungsdefizite bestehen. Dann folgen zwei Analysen von Daten aus dem FIRE («Family medicine ICPC Research using Electronic medical records») Projekt, einem hausärztlichen Forschungsnetzwerk, in dessen Datenbank seit 2009 anonymisierte strukturierte elektronische Daten aus der hausärztlichen Routineversorgung der Schweiz gesammelt werden. 3 Die erste Analyse untersucht, ob die verfügbaren strukturierten Daten geeignet sind, um die Qualität der Diabetesversorgung in der Hausarztpraxis mit Indikatoren nach dem Vorbild des britischen «Quality and Outcomes Frameworks» zu messen. Die Diabetesversorgung wurde mit Vorsatz gewählt, weil es sich dabei um eine epidemiologisch relevante Erkrankung handelt, die häufig in der Hausarztpraxis behandelt wird. Die Ergebnisse liefern eine Baseline-Messung der Qualität und zeigen die heute bestehenden Limiten der Qualitätsbeurteilung auf. Die zweite Analyse ist ein Beispiel für Versorgungsforschungsprojekte in der Hausarztmedizin, die mit Hilfe von vollständigen strukturierten elektronischen Datensätzen durchgeführt werden können und zur besseren Adaption von Behandlungsempfehlungen an die Versorgungsrealität der Grundversorgung beitragen. Es wird gezeigt, in welchen Merkmalen sich Hausarzt-Patienten, die eine Langzeittherapie mit Vitamin-K-Antagonisten erhalten, von entsprechenden Patienten in randomisiert-kontrollierten Studien unterscheiden und wie die Qualität der erreichten Antikoagulation (gemessen am International Normalized Ratio [INR]-Wert) differiert. Somit ermöglichen die drei Arbeiten eine Einschätzung darüber, wie bereit die Schweizer Grundversorgung für die nachhaltige Implementierung neuer Versorgungsmodelle ist und welches Qualitätsniveau es in Zukunft zu erhalten, resp. zu erhöhen gilt. In der Habilitationsschrift besprochene Arbeiten 1. Djalali S, Ursprung N, Rosemann T, Senn O, Tandjung R: Undirected health IT implementation in ambulatory care favors paper-based workarounds and limits health data exchange. International Journal of Medical Informatics 2015; 15(84): 920−932. DOI: 10.1016/j.ijmedinf.2015.08.001. 2. Djalali S, Frei A, Tandjung R, Baltensperger A, Rosemann T: Swiss Quality and Outcomes Framework: Quality Indicators for Diabetes Management in Swiss Primary Care based on Electronic Medical Records. Gerontology 2014; 60(3): 263−273. DOI: 10.1159/000357370. 3. Djalali S, Valeri F, Gerber B, Meli D, Senn O: Anticoagulation control in Swiss primary care: Time in therapeutic range percentages exceed benchmarks of phase III trials. Clinical and Applied Thrombosis/Homeostasis 2016; E-Pub first. DOI: 10.1177/107602961664251