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

LZAP Inhibits p38 MAPK (p38) Phosphorylation and Activity by Facilitating p38 Association with the Wild-Type p53 Induced Phosphatase 1 (WIP1)

LZAP (Cdk5rap3, C53) is a putative tumor suppressor that inhibits RelA, Chk1 and Chk2 and activates p53. LZAP is lost in a portion of human head and neck squamous cell carcinoma and experimental loss of LZAP expression is associated with enhanced invasion, xenograft tumor growth and angiogenesis. p38 MAPK can increase or decrease proliferation and cell death depending on cellular context. LZAP has no known enzymatic activity, implying that its biological functions are likely mediated by its protein-protein interactions. To gain further insight into LZAP activities, we searched for LZAP-associated proteins (LAPs). Here we show that the LZAP binds p38, alters p38 cellular localization, and inhibits basal and cytokine-stimulated p38 activity. Expression of LZAP inhibits p38 phosphorylation in a dose-dependent fashion while loss of LZAP enhances phosphorylation and activation with resultant phosphorylation of p38 downstream targets. Mechanistically, the ability of LZAP to alter p38 phosphorylation depended, at least partially, on the p38 phosphatase, Wip1. Expression of LZAP increased both LZAP and Wip1 binding to p38. Taken together, these data suggest that LZAP activity includes inhibition of p38 phosphorylation and activation

Partnership disengagement from primary community care networks (PCCNs): A qualitative study for a national demonstration project

<p>Abstract</p> <p>Background</p> <p>The Primary Community Care Network (PCCN) Demonstration Project, launched by the Bureau of National Health Insurance (BNHI) in 2003, is still in progress. Partnership structures in PCCNs represent both contractual clinic-to-clinic and clinic-to-hospital member relationships of organizational aspects. The partnership structures are the formal relationships between individuals and the total network. Their organizational design aims to ensure effective communication, coordination, and integration across the total network. Previous studies have focused largely on how contractual integration among the partnerships works and on its effects. Few studies, however, have tried to understand partnership disengagement in PCCNs. This study explores why some partnerships in PCCNs disengage.</p> <p>Methods</p> <p>This study used a qualitative methodology with semi-structured questions for in-depth interviews. The semi-structured questions were pre-designed to explore the factors driving partnership disengagement. Thirty-seven clinic members who had withdrawn from their PCCNs were identified from the 2003-2005 Taiwan Primary Community Care Network Lists.</p> <p>Results</p> <p>Organization/participant factors (extra working time spend and facility competency), network factors (partner collaboration), and community factors (health policy design incompatibility, patient-physician relationship, and effectiveness) are reasons for clinic physicians to withdraw or change their partnerships within the PCCNs.</p> <p>Conclusions</p> <p>To strengthen partnership relationships, several suggestions are made, including to establish clinic and hospital member relationships, and to reduce administrative work. In addition, both educating the public about the concept of family doctors and ensuring well-organized national health policies could help health care providers improve the integration processes.</p

Quality of human-computer interaction - results of a national usability survey of hospital-IT in Germany

<p>Abstract</p> <p>Background</p> <p>Due to the increasing functionality of medical information systems, it is hard to imagine day to day work in hospitals without IT support. Therefore, the design of dialogues between humans and information systems is one of the most important issues to be addressed in health care. This survey presents an analysis of the current quality level of human-computer interaction of healthcare-IT in German hospitals, focused on the users' point of view.</p> <p>Methods</p> <p>To evaluate the usability of clinical-IT according to the design principles of EN ISO 9241-10 the IsoMetrics Inventory, an assessment tool, was used. The focus of this paper has been put on suitability for task, training effort and conformity with user expectations, differentiated by information systems. Effectiveness has been evaluated with the focus on interoperability and functionality of different IT systems.</p> <p>Results</p> <p>4521 persons from 371 hospitals visited the start page of the study, while 1003 persons from 158 hospitals completed the questionnaire. The results show relevant variations between different information systems.</p> <p>Conclusions</p> <p>Specialised information systems with defined functionality received better assessments than clinical information systems in general. This could be attributed to the improved customisation of these specialised systems for specific working environments. The results can be used as reference data for evaluation and benchmarking of human computer engineering in clinical health IT context for future studies.</p

Using text messages to support recovering substance misusers

YesBackground: The use of digital technology in health and social care is developing rapidly. It is promoted in UK policy and research which suggests varied results surrounding its implementation and outcomes. Introduction: This article aimed to test the implementation and outcomes of a short messaging service sent to a dedicated phone. The target cohort were drug treatment clients in two sites in Northern England. Materials and methods: Through staff focus groups and interviews with a small cohort of clients, the implementation and perceptions of the system were examined. Results: Nineteen participants were recruited to site 1 (15 male, 4 female, average age=37.7 years) and 12 participants were recruited to site 2 (9 male, 3 female, average age=40.3 years). One outcome that was of interest was well-being in treatment which, in this study, was described as an overall sense of feeling better rather than just focusing on the rehabilitation aspect of the programme. Other outcomes included: the successful completion of treatment and any relapse or associated reported drug use. Discussion: The system shows some evidence of its ‘social actor’ role; however, its implementation was hindered by staff citing that it called for increased resources. For future implementation the use of client’s own phones may be considered which may help to embed the system more fully in recovery planning and targeting clients at a different treatment stage. Conclusions: Despite some indications of positive results for clients and a perception that the system may have value as an addition to existing clinical interventions, more evaluation is required to determine whether this system can be implemented in a drug treatment setting

Mobile health apps to facilitate self-care: a qualitative study of user experiences

Objective: Consumers are living longer, creating more pressure on the health system and increasing their requirement for self-care of chronic conditions. Despite rapidly-increasing numbers of mobile health applications (‘apps’) for consumers’ self-care, there is a paucity of research into consumer engagement with electronic self-monitoring. This paper presents a qualitative exploration of how health consumers use apps for health monitoring, their perceived benefits from use of health apps, and suggestions for improvement of health apps. Materials and Methods: ‘Health app’ was defined as any commercially-available health or fitness app with capacity for self-monitoring. English-speaking consumers aged 18 years and older using any health app for self-monitoring were recruited for interview from the metropolitan area of Perth, Australia. The semi-structured interview guide comprised questions based on the Technology Acceptance Model, Health Information Technology Acceptance Model, and the Mobile Application Rating Scale, and is the only study to do so. These models also facilitated deductive thematic analysis of interview transcripts. Implicit and explicit responses not aligned to these models were analyzed inductively.Results: Twenty-two consumers (15 female, seven male) participated, 13 of whom were aged 26–35 years. Eighteen participants reported on apps used on iPhones. Apps were used to monitor diabetes, asthma, depression, celiac disease, blood pressure, chronic migraine, pain management, menstrual cycle irregularity, and fitness. Most were used approximately weekly for several minutes per session, and prior to meeting initial milestones, with significantly decreased usage thereafter. Deductive and inductive thematic analysis reduced the data to four dominant themes: engagement in use of the app; technical functionality of the app; ease of use and design features; and management of consumers’ data. Conclusions: The semi-structured interviews provided insight into usage, benefits and challenges of health monitoring using apps. Understanding the range of consumer experiences and expectations can inform design of health apps to encourage persistence in self-monitoring

Integration of a nationally procured electronic health record system into user work practices

BACKGROUND: Evidence suggests that many small- and medium-scale Electronic Health Record (EHR) implementations encounter problems, these often stemming from users' difficulties in accommodating the new technology into their work practices. There is the possibility that these challenges may be exacerbated in the context of the larger-scale, more standardised, implementation strategies now being pursued as part of major national modernisation initiatives. We sought to understand how England's centrally procured and delivered EHR software was integrated within the work practices of users in selected secondary and specialist care settings. METHODS: We conducted a qualitative longitudinal case study-based investigation drawing on sociotechnical theory in three purposefully selected sites implementing early functionality of a nationally procured EHR system. The complete dataset comprised semi-structured interview data from a total of 66 different participants, 38.5 hours of non-participant observation of use of the software in context, accompanying researcher field notes, and hospital documents (including project initiation and lessons learnt reports). Transcribed data were analysed thematically using a combination of deductive and inductive approaches, and drawing on NVivo8 software to facilitate coding. RESULTS: The nationally led "top-down" implementation and the associated focus on interoperability limited the opportunity to customise software to local needs. Lack of system usability led users to employ a range of workarounds unanticipated by management to compensate for the perceived shortcomings of the system. These had a number of knock-on effects relating to the nature of collaborative work, patterns of communication, the timeliness and availability of records (including paper) and the ability for hospital management to monitor organisational performance. CONCLUSIONS: This work has highlighted the importance of addressing potentially adverse unintended consequences of workarounds associated with the introduction of EHRs. This can be achieved with customisation, which is inevitably somewhat restricted in the context of attempts to implement national solutions. The tensions and potential trade-offs between achieving large-scale interoperability and local requirements is likely to be the subject of continuous debate in England and beyond with no easy answers in sight

Structural insight into the membrane targeting domain of the Legionella deAMPylase SidD

AMPylation, the post-translational modification with adenosine monophosphate (AMP), is catalyzed by effector proteins from a variety of pathogens. Legionella pneumophila is thus far the only known pathogen that, in addition to encoding an AMPylase (SidM/DrrA), also encodes a deAMPylase, called SidD, that reverses SidM-mediated AMPylation of the vesicle transport GTPase Rab1. DeAMPylation is catalyzed by the N-terminal phosphatase-like domain of SidD. Here, we determined the crystal structure of full length SidD including the uncharacterized C-terminal domain (CTD). A flexible loop rich in aromatic residues within the CTD was required to target SidD to model membranes in vitro and to the Golgi apparatus within mammalian cells. Deletion of the loop (??loop) or substitution of its aromatic phenylalanine residues rendered SidD cytosolic, showing that the hydrophobic loop is the primary membrane-targeting determinant of SidD. Notably, deletion of the two terminal alpha helices resulted in a CTD variant incapable of discriminating between membranes of different composition. Moreover, a L. pneumophila strain producing SidD??loop phenocopied a L. pneumophila ??sidD strain during growth in mouse macrophages and displayed prolonged co-localization of AMPylated Rab1 with LCVs, thus revealing that membrane targeting of SidD via its CTD is a critical prerequisite for its ability to catalyze Rab1 deAMPylation during L. pneumophila infection