An Exploration of Heterogeneity in Electronic Medical Record Use: Information Technology Use as Emergent and Driven by Values and Expertise

We explore heterogeneity in the use of an organization-wide information technology (IT) by both individuals and groups in a professional organization. We study electronic medical record use by physicians and clinic work groups in two medical practices operating within one multi-specialty health care clinic. Data collection methods include interviews, non-participant observations, and questionnaires. Drawing on theories of professional organizations and complex adaptive systems, we offer as an explanation of heterogeneity in IT use by individuals that IT use is a function of professional values and expertise and of heterogeneity of IT use in groups the insight that IT use at a collective level is an emergent property arising from the interactions of diverse, learning agents. This study contributes to information systems research by enriching current understandings of IT use and by providing new insights about heterogeneous IT use in professional organizations

Are We Putting the Cart Before the Horse? A Microcosm of Intended and Unintended Outcomes of Electronic Medical Record Implementation

Leaders in health care are calling for the implementation of electronic medical records (EMR) systems to help alleviate high costs of care delivery, high error rates, and uneven access to care. However, many of these leaders seem to be overlooking unintended outcomes of EMR implementation. Specifically, they may be overlooking the critical role physician beliefs and relationships play in the use of EMRs and in generating both intended and unintended outcomes. We studied a microcosm of the health care system through a qualitative field study examining EMR use in four clinics operating within a multi-specialty medical organization. We found that beliefs held by physicians about medical practice and the patterns of relationships in clinics influence EMR use behaviors in both expected and unexpected ways. Our contribution is to call attention to unintended outcomes of EMR implementation and to suggest that EMRs can be used as artifacts for learning

Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis

Polly H. Noel and Luci K. Leykum are with the South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA -- Polly H. Noel, Ray F. Palmer, Raquel L. Romero, Luci K. Leykum, Holly J. Lanham, and Krista W. Bowers are with the Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA -- Michael L. Parchman is with the MacColl Center for Healthcare Innovation, Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave 1600, Seattle, WA 98101, USA -- Holly J. Leykum is with the The McCombs School of Business, The University of Texas at Austin, 2110 Speedway, Stop B6000, Austin, TX 78712, USA -- John E. Zeber is with the Central Texas Veterans Health Care System, 1901 S. 1st St, Temple, TX 76504, USA and Scott and White Healthcare Center for Applied Health Research, 2401 S. 31st St, Temple, TX 76508, USABackground: Little is known as to whether primary care teams’ perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients’ own experience of chronic illness care. We examined the extent to which practice members’ perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients’ perceptions of the chronic illness care they have received. Methods: Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice “members” (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. Results: Two sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients’ perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak. Conclusions: The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care.Information, Risk, and Operations Management (IROM)[email protected]

Implementation research design: integrating participatory action research into randomized controlled trials

Luci K. Leykum and Jacqueline A. Pugh are with VERDICT, a VA HSRD REAP at the South Texas Veterans Health Care System, San Antonio, Texas, USA and the Department of Medicine, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA -- Joel Harmon is with the School of Business, Fairleigh Dickinson University, Madison, New Jersey, USA -- Holly J. Lanham and Reuben R. McDaniel Jr. are with the Department of Information, Risk and Operations Management, McCombs School of Business, The University of Texas at Austin, Austin, Texas, USABackground: A gap continues to exist between what is known to be effective and what is actually delivered in the usual course of medical care. The goal of implementation research is to reduce this gap. However, a tension exists between the need to obtain generalizeable knowledge through implementation trials, and the inherent differences between healthcare organizations that make standard interventional approaches less likely to succeed. The purpose of this paper is to explore the integration of participatory action research and randomized controlled trial (RCT) study designs to suggest a new approach for studying interventions in healthcare settings. Discussion: We summarize key elements of participatory action research, with particular attention to its collaborative, reflective approach. Elements of participatory action research and RCT study designs are discussed and contrasted, with a complex adaptive systems approach used to frame their integration. Summary: The integration of participatory action research and RCT design results in a new approach that reflects not only the complex nature of healthcare organizations, but also the need to obtain generalizeable knowledge regarding the implementation process.Information, Risk, and Operations Management (IROM)[email protected]

Ceci n’est pas une ville

Treballs Finals de Grau de Belles Arts. Facultat de Belles Arts. Universitat de Barcelona, Curs: 2015-16, Tutor: Bibiana Crespo[cat] El títol de l’obra d’aquest Treball Final de Grau, Ceci n’est pas une ville, fa al·lusió a la paradoxa proposada per René Magritte al quadre La Trahison des images (La traïció de les imatges), atès que la incapacitat de distingir realitat i ficció ha sobrepassat el territori de la mera representació, convertint-se en un dels dilemes més presents a la nostra contemporaneïtat, fent-se evident tant en les imatges i la informació que ens envolta com en els paisatges que habitem.La peça és un dibuix en el que es representa un paisatge de gran format, introduint l’espectador dins la vivència d’un lloc fictici, simulat. En el dibuix es presenta el carrer principal de La Roca Village, un centre comercial construït imitant l’arquitectura catalana del segle XIX i dedicat a la venda de grans marques de roba i altres complements. Amb més de 4 milions de visitants a l’any aquest “no-poble” ja és el més visitat de Catalunya. Mitjançant el suport d’un material transparent, pintura blanca i una il·luminació dirigida, es crea una projecció d’ombra del grafisme del dibuix a la paret que domina la visió, fet que suscita una confusió a l’espectador, ja que no sap si està veient el dibuix mateix o l’ombra que genera aquest. L’ obra constitueix una crítica al capitalisme cultural i convida a l’espectador a reflexionar sobre el paisatge que habita, tot considerant que els carrers de La Roca Village, habitats per marques i transitats per consumidors, podrien ser un model per una societat en potència, que amaga les seves diferències sota un espectacle dedicat exclusivament a vendre productes lluents i experiències fictícies.[eng] The work’s title of this Final Degree Dissertation project, Ceci n’est pas une ville, refers to René Magritte’s paradox proposed in his painting La Trahison des images (The image betrayal), since the inability to distinguish reality and fiction has exceeded the territory of the mere representation, becoming one of our most noticeable contemporary dilemmas, making itself evident both in images and information that surround us, as in the landscapes that we inhabit. This piece is a drawing representing a large landscape, aiming to introduce the viewer into the experience of a fictitious and simulated place. The drawing shows the main street of La Roca Village, a shopping center built imitating the Catalan architecture of the 19th Century, devoted to selling big clothing brands. With more than 4 million of visitors per year, this “no-village” is already the most visited one in Catalonia. Through a transparent material support, white painting and a directed light, the shadow of the graphism is projected onto the wall and dominates the vision, this fact causes a confusion to the viewer as he/she doesn’t know if is watching the drawing itself or the shadow that it generates. The work constitutes a critic to cultural capitalism and invites the viewers to think about the landscapes they inhabit. Considering that La Roca Village streets, inhabited by brands and crowded by consumers, could be a potential model for a society that hides its differences under a performance exclusively dedicated to sell shiny products and fictitious experiences

Reciprocal learning and chronic care model implementation in primary care: results from a new scale of learning in primary care

<p>Abstract</p> <p>Background</p> <p>Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in the health care literature, but may be related to the ability of primary care practices to improve the care they deliver.</p> <p>To better understand learning in primary care settings by developing a scale of learning in primary care clinics based on the literature related to learning across disciplines, and to examine the association between scale responses and chronic care model implementation as measured by the Assessment of Chronic Illness Care (ACIC) scale.</p> <p>Methods</p> <p>Development of a scale of learning in primary care setting and administration of the learning and ACIC scales to primary care clinic members as part of the baseline assessment in the ABC Intervention Study. All clinic clinicians and staff in forty small primary care clinics in South Texas participated in the survey.</p> <p>Results</p> <p>We developed a twenty-two item learning scale, and identified a five-item subscale measuring the construct of reciprocal learning (Cronbach alpha 0.79). Reciprocal learning was significantly associated with ACIC total and sub-scale scores, even after adjustment for clustering effects.</p> <p>Conclusions</p> <p>Reciprocal learning appears to be an important attribute of learning in primary care clinics, and its presence relates to the degree of chronic care model implementation. Interventions to improve reciprocal learning among clinic members may lead to improved care of patients with chronic disease and may be relevant to improving overall clinic performance.</p

The role of conversation in health care interventions: enabling sensemaking and learning

<p>Abstract</p> <p>Background</p> <p>Those attempting to implement changes in health care settings often find that intervention efforts do not progress as expected. Unexpected outcomes are often attributed to variation and/or error in implementation processes. We argue that some unanticipated variation in intervention outcomes arises because unexpected conversations emerge during intervention attempts. The purpose of this paper is to discuss the role of conversation in shaping interventions and to explain why conversation is important in intervention efforts in health care organizations. We draw on literature from sociolinguistics and complex adaptive systems theory to create an interpretive framework and develop our theory. We use insights from a fourteen-year program of research, including both descriptive and intervention studies undertaken to understand and assist primary care practices in making sustainable changes. We enfold these literatures and these insights to articulate a common failure of overlooking the role of conversation in intervention success, and to develop a theoretical argument for the importance of paying attention to the role of conversation in health care interventions.</p> <p>Discussion</p> <p>Conversation between organizational members plays an important role in the success of interventions aimed at improving health care delivery. Conversation can facilitate intervention success because interventions often rely on new sensemaking and learning, and these are accomplished through conversation. Conversely, conversation can block the success of an intervention by inhibiting sensemaking and learning. Furthermore, the existing relationship contexts of an organization can influence these conversational possibilities. We argue that the likelihood of intervention success will increase if the role of conversation is considered in the intervention process.</p> <p>Summary</p> <p>The generation of productive conversation should be considered as one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.</p

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial

Background Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. Methods INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides – non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides’ quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument – Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. Discussion INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. Trial registration ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 201