Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems:England, the USA and Australia

As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera's typology of national programmes - ‘top-down’, ‘bottom-up’ and ‘middle-out’ - to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy

Impact of computerized physician order entry (CPOE) system on the outcome of critically ill adult patients: a before-after study

<p>Abstract</p> <p>Background</p> <p>Computerized physician order entry (CPOE) systems are recommended to improve patient safety and outcomes. However, their effectiveness has been questioned. Our objective was to evaluate the impact of CPOE implementation on the outcome of critically ill patients.</p> <p>Methods</p> <p>This was an observational before-after study carried out in a 21-bed medical and surgical intensive care unit (ICU) of a tertiary care center. It included all patients admitted to the ICU in the 24 months pre- and 12 months post-CPOE (Misys^®) implementation. Data were extracted from a prospectively collected ICU database and included: demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, admission diagnosis and comorbid conditions. Outcomes compared in different pre- and post-CPOE periods included: ICU and hospital mortality, duration of mechanical ventilation, and ICU and hospital length of stay. These outcomes were also compared in selected high risk subgroups of patients (age 12-17 years, traumatic brain injury, admission diagnosis of sepsis and admission APACHE II > 23). Multivariate analysis was used to adjust for imbalances in baseline characteristics and selected clinically relevant variables.</p> <p>Results</p> <p>There were 1638 and 898 patients admitted to the ICU in the specified pre- and post-CPOE periods, respectively (age = 52 ± 22 vs. 52 ± 21 years, p = 0.74; APACHE II = 24 ± 9 vs. 24 ± 10, p = 0.83). During these periods, there were no differences in ICU (adjusted odds ratio (aOR) 0.98, 95% confidence interval [CI] 0.7-1.3) and in hospital mortality (aOR 1.00, 95% CI 0.8-1.3). CPOE implementation was associated with similar duration of mechanical ventilation and of stay in the ICU and hospital. There was no increased mortality or stay in the high risk subgroups after CPOE implementation.</p> <p>Conclusions</p> <p>The implementation of CPOE in an adult medical surgical ICU resulted in no improvement in patient outcomes in the immediate phase and up to 12 months after implementation.</p

Group differences in physician responses to handheld presentation of clinical evidence: a verbal protocol analysis

<p>Abstract</p> <p>Background</p> <p>To identify individual differences in physicians' needs for the presentation of evidence resources and preferences for mobile devices.</p> <p>Methods</p> <p>Within-groups analysis of responses to semi-structured interviews. Interviews consisted of using prototypes in response to task-based scenarios. The prototypes were implemented on two different form factors: a tablet style PC and a pocketPC. Participants were from three user groups: general internists, family physicians and medicine residents, and from two different settings: urban and semi-urban. Verbal protocol analysis, which consists of coding utterances, was conducted on the transcripts of the testing sessions. Statistical relationships were investigated between staff physicians' and residents' background variables, self-reported experiences with the interfaces, and verbal code frequencies.</p> <p>Results</p> <p>47 physicians were recruited from general internal medicine, family practice clinics and a residency training program. The mean age of participants was 42.6 years. Physician specialty had a greater effect on device and information-presentation preferences than gender, age, setting or previous technical experience. Family physicians preferred the screen size of the tablet computer and were less concerned about its portability. Residents liked the screen size of the tablet, but preferred the portability of the pocketPC. Internists liked the portability of the pocketPC, but saw less advantage to the large screen of the tablet computer (F[2,44] = 4.94, p = .012).</p> <p>Conclusion</p> <p>Different types of physicians have different needs and preferences for evidence-based resources and handheld devices. This study shows how user testing can be incorporated into the process of design to inform group-based customization.</p

High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement.

BACKGROUND: High performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement. METHODS: Methods used to collect and summarise the evidence contributing to this review followed the 'enhancing transparency in reporting the synthesis of qualitative research' protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes. RESULTS: A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued. CONCLUSIONS: This review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance

Assessing influences on speleothem dead carbon variability over the Holocene: Implications for speleothem-based radiocarbon calibration

Recently, it has been shown that U-Th dated speleothems may provide a valuable archive of atmospheric radiocarbon (14C), but the reliability of these records is dependent upon the stability of the dead carbon proportion (DCP) derived from the soil and bedrock. In order to assess climatic influences on speleothem DCP, we have investigated DCP variability over the Holocene interval where atmospheric 14C is well known based on dendrochronologically dated tree rings by conducting 14C measurements on a U-Th dated stalagmite (HS4) from Heshang Cave, Hubei Province, China (30°27 'N, 110°25 'E; 294 m) spanning 0.5-9.6 ka. We investigated climatic controls on DCP, and found that DCP in HS4 has an average value over the Holocene of 10.3 ± 1.5%, with an average age offset from atmospheric radiocarbon of 875 ± 130 years, and displays a response to both precipitation increases and decreases. HS4 DCP increases during the wetter mid-Holocene interval (~5.5-7.1 ka), likely reflecting a shift to more closed-system dissolution in response to increased soil moisture. DCP decreases during the 8.2 ka event, a time period of dry conditions at Heshang Cave, though the lower amplitude of this shift indicates that DCP may be less sensitive to dry events. Speleothems are potentially valuable archives of atmospheric radiocarbon, especially in older portions of the 14C calibration curve where knowledge of atmospheric 14C is limited, however minor climatic influences on DCP could introduce uncertainties of several hundred years to calibrated ages. © 2014 Elsevier B.V

A new look at old carbon in active margin sediments

Recent studies suggest that as much as half of the organic carbon (OC) undergoing burial in the sediments of tectonically active continental margins may be the product of fossil shale weathering. These estimates rely on the assumption that vascular plant detritus spends little time sequestered in intermediate reservoirs such as soils, freshwater sediments, and river deltas, and thus only minimally contributes to the extraneously old 14C ages of total organic matter often observed on adjacent shelves. Here we test this paradigm by measuring the Δ14C and δ13C values of individual higher plant wax fatty acids as well as the δ13C values of extractable alkanes isolated from the Eel River margin (California). The isotopic signatures of the long chain fatty acids indicate that vascular plant material has been sequestered for several thousand years before deposition. A coupled molecular isotope mass balance used to reassess the sedimentary carbon budget indicates that the fossil component is less abundant than previously estimated, with pre-aged terrestrial material instead composing a considerable proportion of all organic matter. If these findings are characteristic of other continental margins proximal to small mountainous rivers, then the importance of petrogenic OC burial in marine sediments may need to be reevaluated. © 2009 The Geological Society of America