Article

Building a National Health IT System from the Middle Out

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Abstract

The top-down approach of many national programs for healthcare information technology (IT) may be at the heart of their current problems. The medical-industrial complex loves a big procurement, and the contracts do not get much bigger than for building nation-scale health information systems (NHIS). But do we really need government embedded in the process of IT implementation, something it so clearly and routinely struggles with? Or is it better for government to simply set the policy rules of the game, given that it is policy in which they are expert? As the new United States Administration has recently signalled a massive injection of funds into building a National Health Information infrastructure via the American Recovery and Reinvestment Act (ARRA), what lessons can be learned from the past, and what strategic shape should the Federal intervention take? The English National Health System (NHS) National Program for IT (NPfIT) in many ways serves as an international beacon for healthcare reform, because of its clear message that major restructuring of health services is not possible without a pervasive information infrastructure. The NPfIT is rolling out working systems and delivering tangible benefits to patients and caregivers. Yet no one could deny that there have been plenty of setbacks, misgivings, clinical unrest, delays, cost overruns, and paring back of promised functionality, culminating in demands from some political quarters to shut down the program.1 The NPfIT was bound to experience some difficulties purely on the basis of its scale and complexity.2 However, it is becoming apparent that there may be another, more foundational, cause of NPfIT's problems. The NHS remains one of the few nation-scale, single-payer health systems in the world. It thus has nation-scale management and governance structures to match, and these inevitably encourage a top-down system architecture, standards compliance, and procurement process. …

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... Taking our study further, we take a close look into one of the main influencers of user attitudes, user support, which can come from a number of different areas within the organisation (Lluch, 2011). Whereas a number of studies has showed the positive impact of user support on user attitudes (Coiera, 2009, MacFarlane et al., 2006, Callen et al., 2008, the implementation of HIS demands a sociotechnical perspective (Lluch, 2011, Herrmann et al., 2017. However, such an integrated perspective of the technological factors (related to the platform itself), organisational factors (related to the specific hospital context) and individual factors (that take into the different needs and beliefs of the users) that altogether facilitate or hinder the adoption is so far missing in literature. ...
... In this context, Borycki (2015) points to the common misconception that simply installing a new HIS will be sufficient to generate value. Further studies conclude that organisational dynamics, such as roles, tasks and work practices, are as important as technological design parameters when implementing HIS (Westbrook et al., 2007, Coiera, 2009, Herrmann et al., 2017. It is therefore essential to not try to get the organisation to adapt to the technology, as this can result in loss of expected value and suboptimal returns. ...
... It is therefore essential to not try to get the organisation to adapt to the technology, as this can result in loss of expected value and suboptimal returns. Misalignment between HIS and workflows is further likely to lead to misuse of the system as well as negative user attitudes (Coiera, 2009, Lluch, 2011. Research addressing the people side of HIS is especially focused on negative user attitude, user resistance and non-adoption as this is often believed to be the cause of the absent project benefits (Bhattacherjee and Hikmet, 2007, Kellermann and Jones, 2013, Phichitchaisopa and Naenna, 2013. ...
Conference Paper
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The implementation of Health Information Systems (HIS) has been heralded as bringing numerous benefits to the healthcare sector. When implementing a HIS, the attitudes of the various users (nurses, doctors, admin people) towards the HIS can be influenced by a number of different factors. User support has proved to be one of the most important ones. Most recently, Sundhedsplatformen, one of the largest public HIS in Denmark, is being implemented in 18 hospitals across Zealand. In this context, we conducted 21 interviews at one of the major hospitals, Rigshospitalet, and qualitatively coded them. This allowed us to explore three archetypical groups of user attitudes toward Sundhedsplatformen: 'Dedicated', 'Frustrated' and 'Despondent'. Further, we identified manifestations of insufficient user support on different levels. We clustered these elements into three levels of support: 'Individual', 'Technological' and 'Organisational'. Reflecting on the manifestations of insufficient user support enables us to achieve a nuanced and holistic understanding of user support as an important adoption factor and further how user attitudes can be addressed when implementing HIS.
... As discussed previously, due to the centralized view in NPfIT, in developing national systems with more focus on technology rather than the needs of the users, these four principles are disregarded. Similarly, Coiera (2009) indicated the weakness of NPfIT in his studies [91]. These guiding principles are also approved and accepted by more than one hundred health ministers, chiefs of international agencies and organizations [47,92]. ...
... As discussed previously, due to the centralized view in NPfIT, in developing national systems with more focus on technology rather than the needs of the users, these four principles are disregarded. Similarly, Coiera (2009) indicated the weakness of NPfIT in his studies [91]. These guiding principles are also approved and accepted by more than one hundred health ministers, chiefs of international agencies and organizations [47,92]. ...
... In other words, NHIN architecture in the US is formed by the connection of local networks including Health Information Exchanges (HIEs), Regional Health Information Organizations (RHIOs), integrated delivery networks, state-wide health information exchange programs, federal agencies and other healthrelated organizations [14]. This type of architecture in the literature is called the bottomup approach [91,93], while in the UK, the architecture of the N3 network (related to NPfIT) is centralized, which means that the governance, systems development and network members or nodes have been defined centrally [51,71]. This approach is known as top-down approach [91,93]. ...
Article
National Health Information Network (NHIN) is a network in which all healthcare organizations, government agencies and other health-related organizations are connected to each other in order to exchange information about health. Due to the necessity of a framework for NHIN development, in this paper, according to the literature review, a definition for NHIN framework was provided, and then the NHIN-related projects were reviewed in the United States of America (USA) and the United Kingdom (UK), NHIN and National Program for Information Technology in the NHS (NPfIT), respectively. The Review of NHIN framework in the countries studied show some similarities and differences in each dimension that are discussed in this framework. NHIN guiding principles in the NHS NPfIT were not regarded or were considered incomplete, compared to the US. NHIN architecture in the US is decentralized while it is centralized in the UK. Based on the review of NHIN framework, these two countries represent important points that can be used in many other countries. However, it can be said that the development of NHIN not only means the implementation of national system or systems, or the binding of local health information systems, but it also needs to build on a framework in which many of the issues related to the formation of NHIN would be considered, including the cooperation between government, private sector and stakeholders with regard to local, national and international needs.
... Therefore, open source EHRs can be an alternative (Evans, 2016). Other studies also identified variability in computer literacy, poor training, and lack of time as a barrier for implementing HIT successfully (Christensen and Grimsmo, 2008;Granlien et al., 2008;Buntin et al., 2011;Hayward-Rowse and Whittle, 2006;Mac-Farlane et al., 2006;Harrop, 2002;Coiera, 2009;Evans et al., 2008). Flynn et al. (Flynn et al., 2009) see, in addition to the positive effects training could have, that financial incentives would compensate for the time needed to invest to acquire the right skills and use the HIT application properly. ...
... According to these studies, users can get support not only from management and clinical leaders but also from colleagues and professional networks (MacFarlane et al., 2006). Finally, the authors see support at policy-making level as required for widespread HIT adoption beyond prototype stages (MacFarlane et al., 2006;Coiera, 2009). Staff skepticism, a lack of clinical leadership, a vendor whose products are not ready on time (Spetz and Keane, 2009), and unfulfilled expectations were also identified as barriers in other studies (Georgiou and Westbrook, 2009). ...
... That is in line with the work of Coiera (2009) and Westbrook et al. (2004Westbrook et al. ( , 2007. They stated that HIT development has to consider the importance of roles, tasks and workflows and that the HIT should be designed to adapt to or at least considering these. ...
Chapter
Electronic Health Records are designed for integrating patient health information recorded in multiple care settings. In the light of the demographic change and the medico-technical progress, an integrated health information exchange is necessary to improve quality and safety of care, and to provide patient-centered medical support. With the help of EHR data, the knowledge can be gained to increase efficiency of healthcare services and to support clinical or health services research adequately. Although many countries have now launched their own nationwide EHR initiatives and healthcare facilities have already powerful computer applications to manage and process patient data locally, the exchange of this data continues to work poorly. According to scientific literature, the main obstacles for establishing EHR systems are interoperability issues, security and privacy concerns, and a low uptake by physicians. In the past, many studies have been conducted on the use or acceptance of EHR applications that have been already operated as a prototype (Lluch, 2011; Gesulga et al., 2017). In addition, there are very few studies to date that consider the complex setting of using an EHR system within the network of different healthcare providers (McCarthy et al., 2014). Many challenges of implementing EHR systems, such as physician resistance, share important similarities across countries and therefore create an unprecedented opportunity for countries to learn from each other (Adler-Milstein et al., 2013). Finally, participatory design in developing and implementing EHR systems is a promising way to address appropriately practical needs of the end-users and to increase healthcare providers acceptance of EHR systems (Unertl et al., 2015).
... Similarly, the standardisation of health-based terminologies such as SNOMED CT, which covers areas including diseases, findings, procedures and anatomy, consists of more than 400,000 coded elements, which makes establishing such a clearly cumbersome process (KITH report 2009). Coiera (2009) questions the feasibility for large complicated top-down IT implementations. Based on a study of the English National Health System (NHS) National program for IT (NPfIT) he argues that the scale of and inertia of top-down efforts have a limited capacity to adapt quickly to the significant delivery challenges the health service will face in the next 20 years. ...
... Based on a study of the English National Health System (NHS) National program for IT (NPfIT) he argues that the scale of and inertia of top-down efforts have a limited capacity to adapt quickly to the significant delivery challenges the health service will face in the next 20 years. Taking into account both local and national needs, Coiera (2009) suggests a middle-out approach acknowledging that governments and providers all have different starting points, goals, and resources. It allows local healthcare institutions and service providers to make their information systems gradually meet national standards, based on their existing systems (Coiera 2009). ...
... Taking into account both local and national needs, Coiera (2009) suggests a middle-out approach acknowledging that governments and providers all have different starting points, goals, and resources. It allows local healthcare institutions and service providers to make their information systems gradually meet national standards, based on their existing systems (Coiera 2009). Still, exactly how to accomplish the standardisation process is an open question. ...
Article
Full-text available
In Norway, a national initiative is currently aiming at standardising the electronic patient record (EPR) content based on an openEHR framework. The openEHR architecture, offers users the capability to conduct standardisation and structuration of the EPR content in a distributed manner, through an internet-based tool. Systems based on this architecture, is expected to ensure universal (also internationally) interoperability among all forms of electronic data. A crude estimate is that it is necessary to define somewhere between 1000 and 2000 standardised elements or clinical concepts (so-called archetypes), to constitute a functioning EPR system. Altogether, the collection of defined archetypes constitutes a backbone of an interoperable EPR system lending on the openEHR architecture. We conceptualize the agreed-upon archetypes as a large-scale information infrastructure, and the process of developing the archetypes as a infrastructuring effort. With this as a backdrop, we focus on the following research question: What are the challenges of infrastructuring in a large-scale user-driven standardisation process in healthcare? This question is operationalized into three sub-questions: First, how are the openEHR-based archetypes standardised in practice? Second, what is the role of daily clinical practice, and existing systems in the process of developing archetypes? Third, how may related, but supposedly independent infrastructuring projects shape each other’s progress? We contribute with insight into how power relations and politics shape the infrastructuring process. Empirically, we have studied the formative process of establishing a national information infrastructure based on the openEHR approach in the period 2012–2016 in Norway.
... Considering the national scope of implementation of such technologies, this sort of venture comprises the government definition of policies and standards that encourage the convergence of public and private interests in the development of an effectively functional national system (Coiera, 2009). Coiera (2009) still proposes a typology for regulatory models of implementation of large-scale HIS (top-down, middle-out, bottom-up), categorizing them according to the level of influence of government authority and the level of autonomy experienced by provider institutions in the process of developing, implementing and using the systems. ...
... Considering the national scope of implementation of such technologies, this sort of venture comprises the government definition of policies and standards that encourage the convergence of public and private interests in the development of an effectively functional national system (Coiera, 2009). Coiera (2009) still proposes a typology for regulatory models of implementation of large-scale HIS (top-down, middle-out, bottom-up), categorizing them according to the level of influence of government authority and the level of autonomy experienced by provider institutions in the process of developing, implementing and using the systems. While the top-down approach is characterized by a centralized management accomplished by the government, in the bottom-up approach the health care institutions make their own decisions about the system to be implemented, following the minimum interoperability standards. ...
... While the top-down approach is characterized by a centralized management accomplished by the government, in the bottom-up approach the health care institutions make their own decisions about the system to be implemented, following the minimum interoperability standards. In an intermediate way, the middle-out approach combines elements of the other two approaches (Coiera, 2009. ...
Article
Purpose The study aims to analyze the previous literature on government initiatives to implement health information systems (HISs). Design/methodology/approach Proknow-C (Knowledge Development Process-Constructivist) was used in the selection of the literature and in the bibliometric and systematic analysis. Findings The research identified a portfolio composed of 33 articles aligned with the research theme and with scientific recognition, as well as periodicals, authors, papers and keywords that stood out the most. Amongst the government initiatives in the 24 identified countries, England has been the most studied nation, and there is a certain prominence of research arising from developed countries. Electronic health records (EHRs) have been the most explored technology. Efficiency and safety of health care delivery, integration of information and among health organizations, cost reduction and economicity are the most expected benefits from government programs. The difficulties found are related to the broader context in which the system is inserted, to the management of the program, to technology itself and to individuals. The most emphasized difficulties identified in most countries were previous context marked by a lack of standardization/interoperability, acceptance of providers and users and project financing. The findings of the present article provide a theoretical framework for future studies, in addition to yielding a replicable process for future use. Originality/value This research may be considered original as it analyzes – through a constructivism-structured process (Proknow-C) – the phenomenon under investigation by gathering bibliometric and systematic review data concomitantly. The countries and technologies reported emerge from the process itself.
... Huang et al. (2017) suggests that major health sector innovations typically 'emerge from negotiations between diverse stakeholders who compete to impose or at least prioritise their preferred version of that innovation' [29]. Instead of a top-down approach to technology deployment, Coiera (2009) advocates for a "Middle-Out" approach to developing national health IT systems, whereby technical goals are set to help achieve clinical/service standards [31]. These standards are not static and therefore a partnership approach is required between health care providers (clinicians and managers), government and the IT industry to constantly develop national health IT systems in line with health service priorities and the evolving potential of technology. ...
... Huang et al. (2017) suggests that major health sector innovations typically 'emerge from negotiations between diverse stakeholders who compete to impose or at least prioritise their preferred version of that innovation' [29]. Instead of a top-down approach to technology deployment, Coiera (2009) advocates for a "Middle-Out" approach to developing national health IT systems, whereby technical goals are set to help achieve clinical/service standards [31]. These standards are not static and therefore a partnership approach is required between health care providers (clinicians and managers), government and the IT industry to constantly develop national health IT systems in line with health service priorities and the evolving potential of technology. ...
... These standards are not static and therefore a partnership approach is required between health care providers (clinicians and managers), government and the IT industry to constantly develop national health IT systems in line with health service priorities and the evolving potential of technology. Under this approach, 'implementation never stops' [31] and implementing technical capability as an objective separate from a specific clinical or service target would not be pursued. ...
Article
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Background: Electronic referrals or e-referrals can be defined as the electronic transmission of patient data and clinical requests between health service providers. National electronic referral systems have proved challenging to implement due to problems of fit between the technical systems proposed and the existing sociotechnical systems. In seeming contradiction to a sociotechnical approach, the Irish Health Service Executive initiated an incremental implementation of a National Electronic Referral Programme (NERP), with step 1 including only the technical capability for general practitioners to submit electronic referral requests to hospital outpatient departments. The technology component of the program was specified, but any changes required to embed that technology in the existing sociotechnical system were not specified. Objective: This study aimed to theoretically frame the lessons learned from the NERP step 1 on the design and implementation of a national health information technology program. Methods: A case study design was employed, using qualitative interviews with key stakeholders of the NERP step 1 (N=41). A theory-driven thematic analysis of the interview data was conducted, using Barker et al's Framework for Going to Full Scale. Results: The NERP step 1 was broadly welcomed by key stakeholders as the first step in the implementation of electronic referrals-delivering improvements in the speed, completeness of demographic information, and legibility and traceability of referral requests. National leadership and digitalized health records in general practice were critical enabling factors. Inhibiting factors included policy uncertainty about the future organizational structures within which electronic referrals would be implemented; the need to establish a central referral office consistent with these organizational structures; outstanding interoperability issues between the electronic referral solution and hospital patient administration systems; and an anticipated need to develop specialist referral templates for some specialties. A lack of specification of the sociotechnical elements of the NERP step 1 inhibited the necessary testing and refinement of the change package used to implement the program. Conclusions: The key strengths of the NERP step 1 are patient safety benefits. The NERP was progressed beyond the pilot stage despite limited resources and outstanding interoperability issues. In addition, a new electronic health unit in Ireland (eHealth Ireland) gained credibility in delivering national health information technology programs. Limitations of the program are its poor integration in the wider policy and quality improvement agenda of the Health Service Executive. The lack of specification of the sociotechnical elements of the program created challenges in communicating the program scope to key stakeholders and restricted the ability of program managers and implementers to test and refine the change package. This study concludes that while the sociotechnical elements of a national health information technology program do not need to be specified in tandem with technical elements, they do need to be specified early in the implementation process so that the change package used to implement the program can be tested and refined.
... As with system implementation, ongoing high-level commitment is essential to ensure that sufficient resources are devoted to support optimization activities. [16][17][18][19][20] Such leadership needs to continuously and consistently drive improvements by following the transformational vision, determining medium-and long-term priority areas, and providing financial support and incentives for related initiatives. 1,21,22 At present, many organizations are trying to manage enormous numbers of requests for HIT changes, and if these are not actively addressed, value is not likely to be achieved, with the consequence that "sharp end" providers may become discouraged. ...
... 50 Multi-stakeholder consensus around key organizational, professional, and patient priorities is therefore a crucial step in any optimization strategy. 11,19 Specifying associated electronic data to address priority areas should follow. 51 Here, it is important to consider which data is actually needed to achieve the desired goal, otherwise there is a danger that efforts will be spent on collecting information that is ultimately not used. ...
Article
Implementation and adoption of complex health information technology (HIT) is gaining momentum internationally. This is underpinned by the drive to improve the safety, quality, and efficiency of care. Although most of the benefits associated with HIT will only be realized through optimization of these systems, relatively few health care organizations currently have the expertise or experience needed to undertake this. It is extremely important to have systems working before embarking on HIT optimization, which, much like implementation, is an ongoing, difficult, and often expensive process. We discuss some key organization-level activities that are important in optimizing large-scale HIT systems. These include considerations relating to leadership, strategy, vision, and continuous cycles of improvement. Although these alone are not sufficient to fully optimize complex HIT, they provide a starting point for conceptualizing this important area.
... 34 A prescriptive (top-down) approach has been reported to reduce their receptiveness to technological and healthcare delivery developments. 35 Second, it concentrated the risk by moving responsibility for realization of the strategy from local NHS organizations (monitored centrally) to a large-scale central program. Whereas predecessor initiatives can be regarded as strategic frameworks within which customized implementation programs (eg, for laboratory results reporting) were established, NPfIT had a strong emphasis on controlling systems delivery with considerable reshaping of earlier strategies. ...
... The fragmented and decentralized system in the United States, which favors a bottom-up approach to national systems, has been contrasted with the top-down approach adopted by NPfIT, and in Canada and Australia. 3,35 Based on experience in New Zealand, a "middle-out" approach to national systems has been proposed, characterized by central leadership, public-private sector collaboration, and local investment in solutions that achieve national goals. It has been suggested that the current NHS approach post-NPfIT, based on standards accreditation, a flexible sociotechnical change model, and a shared learning environment, now resembles that of New Zealand. ...
Article
Full-text available
Objective: There is global interest in implementing national information systems to support healthcare, and the National Health Service in England (NHS) has a troubled 25-year history in this sphere. Our objective was to chronicle structural reorganizations within the NHS from 1973 to 2017, alongside concurrent national information technology (IT) strategies, as the basis for developing a conceptual model to aid understanding of the organizational factors involved. Materials and methods: We undertook an exploratory, retrospective longitudinal case study by reviewing strategic plans, legislation, and health policy documents, and constructed schemata for evolving structure and strategy. Literature on multi-organizational forms, complexity, national-level health IT implementations, and mega-projects was reviewed to identify factors that mapped to the schemata. Guided by strong structuration theory, these factors were superimposed on a simplified structural schema to create the conceptual model. Results: Against a background of frequent NHS reorganizations, there has been a logical and emergent NHS IT strategy focusing progressively on technical and data standards, connectivity, applications, and consolidation. The NHS has a complex and hierarchical multi-organization form in which restructuring may impact a range of intra- and inter-organizational factors. Discussion: NHS-wide IT programs have generally failed to meet expectations, though evaluations have usually overlooked longer-term progress. Realizing a long-term health IT strategy may be impeded by volatility of the implementation environment as organizational structures and relationships change. Key factors influencing the strategy-structure dyad can be superimposed on the tiered NHS structure to facilitate analysis of their impact. Conclusion: Alignment between incremental health IT strategy and dynamic structure is an under-researched area. Lessons from organizational studies and the management of mega-projects may help in understanding some of the ongoing challenges.
... Maintenance of some local control, as opposed to full standardisation, was one theme resulting from a study of the roll-out of the NHS Care Records Service in England. 3 Some see the concept of HIEs as being more flexible over the long term. 4 Despite the increasing adoption rates of HIE systems across the healthcare industry, the actual use of HIE systems by users remains minimal, with usage statistics reported to be less than 5% in some cases. 1 A systematic review conducted by the Agency for Healthcare Research and Quality outlined many of the barriers that may explain the discrepancy between health information technology (HIT) availability and the adoption of users who have yet to embrace it. 1 HIE systems can (1) be plagued by usability deficiencies (eg, inundating the user with information), (2) fail to support clinical workflow (eg, requiring multiple log-ins) and (3) have technical deficiencies such as slow speed. ...
... HIEs are a relatively new tool in the USA, and relevant policies and technologies are still evolving. While HIEs have some downsides, such as varied and unknown costs and the need for well-defined interoperability standards, 4 they are the current model for making patient records Open access more readily available in many countries. This work is a first step in highlighting some issues encountered with clear messaging within one tool that serves to share data for use at point of care. ...
Article
Full-text available
Background The promise of Health Information Exchange (HIE) systems rests in their potential to provide clinicians and administrative staff rapid access to relevant patient data to support judgement and decision-making. However, HIE systems can have usability and technical issues, as well as fail to support user workflow. Objective Share the findings from a series of studies that address HIE system deficiencies for an Electronic Health Record (EHR) viewer which accesses multiple data sources. Methods A variety of methods were used, in a series of studies, to gain a better understanding of issues and their mitigation through use of promising EHR viewer features. Results The study series results are presented by the themes that underscore the importance for users to distinguish between data that are available but missing due to connection or system errors, data that are omitted entirely because they are not available and data that are excluded due to filtered search criteria. Conclusions The principal findings from this study series led to improvement recommendations for the EHR viewer, as well as citing areas that are ripe for further investigation and analysis.
... Therefore, the research discusses range of available approaches to formulate architecture of national health information system. Various approaches like middle out, top-down and bottom-up [3] are prevalent to engineer health systems. a) : The top-down approach focuses on integrated centralized systems to store and share sensitive information. ...
... The last middle-out approach addresses developing of set standards in order to interconnect government, IT industry and health providers [3]. Due to heterogeneity and complexity of health information system, some countries including Australia and Canada have also adopted such an approach. ...
... An Institute of Medicine report published in 2012 concluded that the present healthcare trajectory has become too complex and costly and that digital technology will be a key aspect of healthcare delivery [1]. Clinical Information systems (CISs) will play a critical role in helping health care authorities provide service delivery in the context of shrinking workforces and increased need for services [2,3]. However there is a need for ways of evaluating and monitoring the quality of CIS implementation. ...
... A further challenge to identifying the cause of CIS errors is the difficulty in defining the spaces within which CISs are used. Unlike technology designed for a closed environment (i.e. an airline cockpit, assembly line), CISs are often used in open systems, often referred to as 'spaces', which represent the interactive sociotechnical environment where CIS are used [3,14]. The dynamic nature of these spaces makes it hard to pinpoint how a CIS will automate a task. ...
Conference Paper
Clinical information systems (CISs) play an increasingly pivotal role in modern health care delivery. They are safety-critical as well as sensitive with respect to security and privacy concerns. In the light of ongoing reports on CISs failures and technology-induced adverse events, policy-makers and regulators have been struggling to identify effective ways to ensure the quality of these systems. Existing regulatory frameworks and controls do not readily apply to CISs. This paper identifies the shortcomings of existing regulatory controls and proposes a new framework for regulating CIS, based on a notion of continuous certification. We exemplify the application of the proposed framework with a real-world case study of a perioperative CIS.
... Another study , concerning the approaches used for an NEHR system implementation, has shown how different healthcare systems, national policy contexts and anticipated benefits have shaped the initial strategies. Coiera's (2009) typology of national programs ("top-down," "bottom-up" and "middle-out") was used in order to review EHR system implementation strategies in three representative countries: England, the USA and Australia. In England, a government-driven centralized national approach was applied and this approach is considered as a "top-down" approach. ...
Purpose The scope of this research is to identify the best practices applied during the implementation process of a national EHR system. Further, the main goal is to explore the knowledge gained by experts from leading countries in the field of nationwide EHR system implementation, focusing on some of the main success factors and difficulties, or failures, of the various implementation approaches. Design/methodology/approach To gather the necessary information, an international survey has been conducted with expert participants from 13 countries (Denmark, Austria, Sweden, Norway, the United Kingdom, Germany, Netherlands, Switzerland, Canada, USA, Israel, New Zealand and South Korea), who had been playing varying key roles during the implementation process. Taking into consideration that each system is unique, with each own (different) characteristics and many stakeholders, the methodological approach followed was not oriented to offer the basis for comparing the implementation process, but rather, to allow us better understand some of the pros and cons of each option. Findings Taking into account the heterogeneity of each country’s financing mechanism and health system, the predominant EHR system implementation option is the middle-out approach. The main reasons which are responsible for adopting a specific implementation approach are usually political. Further, it is revealed that the most significant success factor of a nationwide EHR system implementation process is the commitment and involvement of all stakeholders. On the other hand, the lack of support and the negative reaction to any change from the medical, nursing and administrative community is considered as the most critical failure factor. Originality/value A strong point of the current research is the inclusion of experts from several countries (13) spanning in 4 continents, identifying some common barriers, success factors, and best practices stemming from the experience obtained from these countries, with a sense of unification. An issue that should never be overlooked or underestimated is the alignment between the functionality of the new EHR system and users’ requirements
... Overall, there are many questions and challenges related to large-scale generic systems in healthcare, and the global/local gap may be hard to reconcile. In this regard, Coiera (2009) questions the feasibility for large, complicated top-down IT implementations due the scale and inertia of such systems, which will have a limited capacity to adapt quickly to the significant delivery challenges the health service will face in the next 20 years. Nonetheless, studies based on information infrastructure may be a way to increase our understanding of the challenges associated with the acquisition of generic systems. ...
Article
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Large-scale generic systems are typically adapted to local practice through configuration. This is especially important in healthcare, which involves a plurality of institutions and users. However, the decision to acquire a generic system in public healthcare is typically founded on regional and national health policy goals, which often are translated into various forms of standardization. As a result, national and regional health policy interests may stand in contrast to interests on the local level. Therefore, we analyze how national and local concerns are weighed against each other in the preparations for implementing large-scale generic systems in healthcare. We explore what role configuration plays and what the prospects are for long-term development. We contribute with insight into how the organizational consequences of generic systems are formed already in the preparation phase and point to how configuration easily results in standardization, thereby basically privileging national and regional health goals at the expense of local needs. Empirically, we focus on the preparations for implementing the Epic electronic health record in Central Norway.
... Some SEHRs are government-owned and operated. Other nations take a less-direct "middle-out" approach, emphasizing the development of interoperability standards and encouraging the IT industry to work directly with the healthcare system [3,4]. ...
Article
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Background The purpose of this study was to assess the impact of accessing primary care records on unscheduled care. Unscheduled care is typically delivered in hospital Emergency Departments. Studies published to December 2014 reporting on primary care record access during unscheduled care were retrieved. Results Twenty-two articles met inclusion criteria from a pool of 192. Many shared electronic health records (SEHRs) were large in scale, servicing many millions of patients. Reported utilization rates by clinicians was variable, with rates >20% amongst health management organizations but much lower in nation-scale systems. No study reported on clinical outcomes or patient safety, and no economic studies of SEHR access during unscheduled care were available. Design factors that may affect utilization included consent and access models, SEHR content, and system usability and reliability. Conclusions Despite their size and expense, SEHRs designed to support unscheduled care have been poorly evaluated, and it is not possible to draw conclusions about any likely benefits associated with their use. Heterogeneity across the systems and the populations they serve make generalization about system design or performance difficult. None of the reviewed studies used a theoretical model to guide evaluation. Value of Information models may be a useful theoretical approach to design evaluation metrics, facilitating comparison across systems in future studies. Well-designed SEHRs should in principle be capable of improving the efficiency, quality and safety of unscheduled care, but at present the evidence for such benefits is weak, largely because it has not been sought.
... It means that material changes in the behaviour and characteristics of the system, even modest ones, promote or facilitate rules and further changes, some of which can eventually be far-reaching. This is the so-called "Butterfly Effect" (Begun, Zimmerman and Dooley, 2003 (Coiera, 2009). The rules that matter may be, but are not necessarily (and often aren't), the formalised rules of the prescribed policy landscape, or reflective of the governance mechanisms depicted on boxes of organisational charts (Rouse, 2008). ...
Research
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Professor Jeffrey Braithwaite, and the Complexity Science Team in the Centre for Healthcare Resilience and Implementation Science (CHRIS), Australian Institute of Health Innovation (AIHI) have been leading work in the area of complexity science and have recently released a White Paper: Complexity Science in Healthcare – Aspirations, Approaches, Applications and Accomplishments.
... One common theme was the agreement that there needed to be a mixture between 'bottom-up' and 'top-down' approaches to implementation, ensuring a degree of central leadership and direction while also allowing for local input in decision-making. 26 This balance is crucial, as many existing 'failed' change initiatives such as the National Programme for Information Technology (NPfIT) have illustrated that national 'top-down' approaches alone are insufficient to realise the benefits associated with large-scale change in healthcare settings. In the NPfIT, 'top-down' strategies were superseded by locally driven strategies, and ultimately changed to a more 'middle-out' model, where national strategic direction aligns more closely with local strategy. ...
Article
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Context The Scottish Government has identified computerised decision support as a strategic priority in order to improve knowledge management in health and social care settings. A national programme to build a pilot Decision Support Platform was funded in 2015. Aims We undertook a formative evaluation of the Decision Support Platform to inform plans for its national roll-out in primary care. Methods We conducted a series of in-depth semistructured interviews and non-participant observations of workshops demonstrating decision support systems. Participants were policymakers and clinical opinion leaders from primary care. As the Platform was in its early stages of development at the time of data collection, we focused on exploring expectations and drivers of the pilot decision support system tested in primary care. Our methodological approach had to be tailored to changing circumstances and offered important opportunities for realising impact through ongoing formative feedback to policymakers and active engagement of key clinical stakeholders. We drew on sociotechnical principles to inform data analysis and coded qualitative data with the help of NVivo software. Findings We conducted 30 interviews and non-participant ethnographic observations of eight stakeholder engagement workshops. We observed a strong sense of support from all stakeholders for the Platform and associated plans to roll it out across NHS Scotland. Strategic drivers included the potential to facilitate integration of care, preventive care, patient self-management, shared decision-making and patient engagement through the ready availability of clinically important information. However, in order to realise these benefits, participants highlighted the need for strong national eHealth leadership to drive a coherent strategy and ensure sustained funding, system usability (which stakeholders perceived to be negatively affected by alert fatigue and integration with existing systems) and ongoing monitoring of potential unintended consequences emerging from implementations (eg, increasing clinical workloads). Conclusions and implications In order to address potential tensions between national leadership and local usability as well as unintended consequences, there is a need to have overall national ownership to support the implementation of the Platform. Potential local tensions could be addressed through allowing a degree of local customisation of systems and tailoring of alerts, and investing in a limited number of pilots that are carefully evaluated to mitigate emerging risks early.
... The overemphasis on top-down standardisation at the expense of local variation has been a poor policy choice in the realm of health information technology. 24 So it is too with clinical practices. Procedural variation in surgery seems to confer versatility that allows surgeons to vary their approach, depending on the specific needs of a patient. ...
Article
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Introduction: Forgetting shapes learning in two different ways. It impedes learning when important lessons are forgotten. Equally, it can be difficult to enact new lessons if we do not let go of old beliefs and practices that are no longer useful. A learning health system (LHS) that wishes to improve health service delivery will need to find ways to remember processes that shape quality and safety - using data that often resides beyond electronic health records. An LHS will also need to "forget", or programmatically decommission, obsolete practices, whose persistence otherwise leads to unnecessary system complexity and inertia to change. Discussion: New forms of data needed to improve health services include process metrics extracted from digital systems; human-level metrics that capture workflow patterns and clinician behaviors; and multivariate process patterns that can identify service "syndromes." To avoid inertia to change, system complexity must be reduced by retiring (or forgetting) inefficient or unhelpful work practices. Biological models of programmed cell death provide a rich set of mechanisms to decommission elements of health services. These models suggest health service elements should be able to detect the end of their useful life and should contain internal mechanisms to orchestrate decommissioning-in contrast to current service decommissioning, which is an externally initiated, top-down down-driven process. Conclusions: An LHS should take advantage of digital infrastructure to bring together people, sensors, analytics, and quasi-autonomous mechanisms for service adaptation. By drawing inspiration from biology, we can design LHSs that do not just remember but also actively forget.
... The term "electronic medical records" may be used to describe a wide variety of information technology applications, from files on single patients to national databases (Greenhalgh et al., 2009). An EMR may be cross-organizational, designed to be implemented across a whole health-care system or it may be more fragmented, bottom-up, introduced within a single organization (Coiera, 2009). Issues concerning leading implementation may, realistically, be expected to vary, depending on the scale and scope of the proposed system. ...
Article
Purpose Leaders in health-care organizations introducing electronic medical records (EMRs) face implementation challenges. The adoption of EMR by the emergency medical and ambulance setting is expected to provide wide-ranging benefits, but there is little research into the processes of adoption in this sector. The purpose of this study is to examine the introduction of EMR in a small emergency care organization and identify factors that aided adoption. Design/methodology/approach Semi-structured interviews with selected paramedics were followed up with a survey issued to all paramedics in the company. Findings The user interfaces with the EMR, and perceived ease of use, were important factors affecting adoption. Individual paramedics were found to have strong and varied preferences about how and when they integrated the EMR into their practice. As company leadership introduced flexibility of use, this enhanced both individual and collective ability to make sense of the change and removed barriers to acceptance. Research limitations/implications This is a case study of one small organization. However, there may be useful lessons for other emergency care organizations adopting EMR. Practical implications Leaders introducing EMR in similar situations may benefit from considering a sense-making perspective and responding promptly to feedback. Originality/value The study contributes to a wider understanding of issues faced by leaders who seek to implement EMRs in emergency medical services, a sector in which there has been to date very little research on this issue.
... In recent years, governments of industrialized countries have promoted the development of national programs for healthcare information technology. The approach followed and the results obtained have been different [28]: views of records, as abstracted or aggregated from regional systems. The expectation is that Regional HIEs will eventually aggregate into a nation-scale system. ...
Thesis
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The deployment of information systems in healthcare facilities has become widespread in recent decades and the main processes at Healthcare facilities are generally well supported. However, in spite of great advances in information and communication technologies domain during last years, current systems fail to provide true support to healthcare professionals in their daily practice and research activities. As a consequence of the variety of organizations providing healthcare and the heterogeneity of information systems used, current Electronic Health Record systems are not capable to show to healthcare professionals a conceptually consolidated view of the patients’ health state. Patient’s health data are fragmented inside information systems and over different information systems, and the professional should interpret and infer lacking relationships among them. In this scenario, semantic interoperability is pointed out by scientific community as an essential factor in achieving benefits from EHR systems to improve the quality and safety of patient care, public health, clinical research, and health service management. In this thesis we propose OntoEHR, a conceptual architecture for a new semantically interoperable EHR system, focused on the clinical process and driven by ontologies. Conceptual and structural elements of the system are explicitly defined in OWL ontologies, conforming a declarative metamodel that drive all the system. Clinical data coming from different sources are stored and integrated in a clinical repository conforming to CEN/ISO 13606 standard, which is able to communicate clinical data using CEN/ISO 13606 extracts. Lastly, we propose a Problem Oriented Medical Record model, founded on CEN/ISO 13940 standard, to represents patients’ clinical data, assuring a safe and efficient continuity of care. This thesis does not propose a specific and complete EHR system, but the foundation to build such systems.
... Whereas governmental providers may have different starting points, goals and resources, government might help in funding the development process and providing incentives that encourage clinical providers to acquire systems technically and legally compliant with interoperative health standards, suitable for building emergent national health information grids. 36 In human computing interaction (HCI), some have defined the middle-out design for urban HCI as 'the process to draw on the collective knowledge of all actors to provide greater opportunities for more inclusive and collaborative community engagement processes.' 37 Scholars describe their approach as following three stages of design, implementation and deployment, fostering the integration of the objectives defined by top-down decision makers with those of the everyday people represented by citizens and community groups. ...
Article
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All models of legal governance and most regulatory options have to do with ‘top-down’ solutions as an essential ingredient of the approach. Such models may include ‘bottom-up’ forms of self-regulation, such as in forms of ex post regulation, or unenforced self-regulation. This paper focuses on what lies in between such top-down and bottom-up approaches, namely, the middle-out interface of the analysis. Within the EU legal framework, this middle-out layer is mainly associated with forms of co-regulation, as defined by Recital 44 of the 2010 AVMS Directive and Article 5(2) of the GDPR. However, there are also additional models on how we should grasp the middle-out layer of legal regulation, as shown by the debates on the governance of AI and the Web of Data. For example, the debates on issues such as monitored self-regulation, coordination mechanisms for good AI governance, and ‘wind-rose’ models for the Web of Data make it clear that co-regulation is not the only alternative to both bottom-up and top-down approaches. From a methodological viewpoint, the middle-out approach sheds light on three different kinds of issues that regard (i) how to strike a balance between multiple regulatory systems; (ii) how to align primary and secondary rules of the law; and (iii) how to properly coordinate bottom-up and top-down policy choices. The increasing complexity of technological regulation recommends new models of governance that revolve around this middle-out analytical ground.
... Whilst it is widely recognised that technology implementation in healthcare requires a judicious mix of "topdown" [47], "bottom-up" [48], and "middle-out" approaches [49], the literature still lacks rich exemplar case studies of how such approaches may dovetail (or not) in practice. Whilst not the only way to approach complexity in technology implementation, NASSS can be used to generate multi-level accounts that incorporate the target health condition(s), the technology, the adopter system (patients, providers, managers), the organisational elements, and the broader system enablers (policy, financing, etc.). ...
Article
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Background: Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability)framework was developed to study unfolding technology programmes in real time—and in particular to identifyand manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. Methods: We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic DecisionSupport) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDOdataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, video taped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. Results: Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians’ experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. Conclusion: The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes,failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.
... Substantial investments into ever more complex Health Information Technologies (health IT) are currently actively being made in many countries across the world [1,2,3]. Despite significant monetary investments and some noteworthy implementation progress, particularly in relation to health IT infrastructures and bespoke technologies for discreet areas of care, a lot still remains to be desired [4][5][6]. ...
Chapter
Information systems can only reach their full potential if their implementation is effective, and there is much to be learned as to what makes an " effective " implementation. In light of the substantial investments in Health Information Technology internationally, implementation evaluations are a powerful tool to ensure that technologies are enabled to fulfil their potential in improving care, reducing cost and increasing efficiency. The most salient characteristics of such evaluations are outlined, considering how they can help to assess adoption processes and outcomes through a continuous cycle of scientific enquiry and learning. A brief description surrounding potential theoretical lenses that may be drawn on is given. Issues discussed will be illustrated with the help of a case study on the implementation and adoption of Electronic Health Records in English hospitals. Practical challenges encountered and potential ways to address these during the conduct of health IT implementation evaluations illustrated include: 1) ways to cope with the shifting nature of reality (e.g. changes in local implementation strategies need to be reflected in the methods), 2) the need to examine processes as well as outcomes, 3) researching implementation in context with attention to both local processes and wider (e.g. political) developments, and 4) the pragmatic use of theoretical lenses where different approaches can shed light on different aspects of the implementation and adoption process.
... The command structure that governs this will have aspects of top-down and bottom-up control, but will most likely need a flexible middle-out approach. 12 Highly specific strategies will complement these general ones. Rapid system reconfiguration and surge capacity will require a rapid response infrastructure to be in place. ...
... 53 The middle-out approach to implementation, which attempts to balance top-down and bottom-up implementation, might be one solution. 54 It acknowledges that governments and providers have different starting points, goals, and resources. At the earlier stages of development, govern ments predominantly focus on helping fund local innovation, rather than setting mandates. ...
Article
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Health information technology can support the development of national learning health and care systems, which can be defined as health and care systems that continuously use data-enabled infrastructure to support policy and planning, public health, and personalisation of care. The COVID-19 pandemic has offered an opportunity to assess how well equipped the UK is to leverage health information technology and apply the principles of a national learning health and care system in response to a major public health shock. With the experience acquired during the pandemic, each country within the UK should now re-evaluate their digital health and care strategies. After leaving the EU, UK countries now need to decide to what extent they wish to engage with European efforts to promote interoperability between electronic health records. Major priorities for strengthening health information technology in the UK include achieving the optimal balance between top-down and bottom-up implementation, improving usability and interoperability, developing capacity for handling, processing, and analysing data, addressing privacy and security concerns, and encouraging digital inclusivity. Current and future opportunities include integrating electronic health records across health and care providers, investing in health data science research, generating real-world data, developing artificial intelligence and robotics, and facilitating public-private partnerships. Many ethical challenges and unintended consequences of implementation of health information technology exist. To address these, there is a need to develop regulatory frameworks for the development, management, and procurement of artificial intelligence and health information technology systems, create public-private partnerships, and ethically and safely apply artificial intelligence in the National Health Service.
... Telesalud y telemedicina como estrategias para mejorar los servicios de salud Por ello, en pro de lograr un uso más eficiente tanto de los agentes prestadores de servicios como de las infraestructuras de salud, una estrategia que ha sido adoptada por algunos Estados, ha sido el rápido desarrollo de TIC en salud a escala nacional, con el propósito de enfrentar problemas como: fuerza de trabajo clínico disminuyendo, aumento de las cargas de trabajo y limitaciones de recursos físicos e infraestructuras (4,5). ...
... The study's findings conducted by Damanabi et al. (2014) are also consistent with the proposed components in this framework. She grouped the inputs of the Iranian NHIS into eight dimensions; data sources, coordination and leadership, information policies, human resources, financial resources, facilities, information and communication infrastructure, and, finally, the cultural and institutional aspects [37]. In general, based on the literature review, there are three approaches to NHIN architecture [34][35]. ...
Article
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Background: The National Health Information Network (NHIN) is one of the key issues in health information systems in any country. However, the development of this network should be based on an appropriate framework. Unfortunately, the conducted projects of health information systems in the Ministry of Health of Iran do not fully comply with the concept of NHIN. The present study was aimed to develop a general framework for NHIN in Iran. Materials and methods: In this study, in the first stage, the required information about the concept of the NHIN framework and related NHIN documents in the USA and the UK were collected based on a literature review. Then, according to the results of the first stage and with regards to the structure of the Iranian health system, a general framework for Iranian NHIN was proposed. The Delphi technique was conducted to verify the framework. Results: The proposed framework for Iranian NHIN includes three dimensions; components, principles, and architecture. Over 80% of experts have evaluated all three aspects of the framework at an acceptable scale. In total, the proposed framework has been evaluated by 83.8% of the experts at an acceptable scale. Conclusion: The proposed framework was expected to serve as the starting point for moving towards the design and creation of Iranian NHIN. At any rate, the framework could be criticized, and it could only be used for the countries whose health system is similar to the structure of the health system in Iran.
... 65 We could also envision a "middle-out" approach as described by Coiera in 2009, helping encourage or incentivize EHR developers and health systems to work together to improve EHR safety. 66 As this author suggests, payers, of which the US Federal government is the largest, have an important role in supporting health systems and could indirectly influence EHR usability by modifying reimbursement guidelines for evaluation and management services to reduce dependence on unnecessarily detailed structured documentation. 37 Payers could also provide incentives for health systems to participate in more information-sharing activities between organizations designed to address known safety issues and inform improvements in design of EHRs. ...
Article
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In 2011, an Institute of Medicine report on health information technology (IT) and patient safety highlighted that building health-IT for safer use is a shared responsibility between key stakeholders including: “vendors, care providers, healthcare organizations, health-IT departments, and public and private agencies”. Use of electronic health records (EHRs) involves all these stakeholders, but they often have conflicting priorities and requirements. Since 2011, the concept of shared responsibility has gained little traction and EHR developers and users continue to attribute the substantial, long list of problems to each other. In this article, we discuss how these key stakeholders have complementary roles in improving EHR safety and must share responsibility to improve the current state of EHR use. We use real-world safety examples and outline a comprehensive shared responsibility approach to help guide development of future rules, regulations, and standards for EHR usability, interoperability and security as outlined in the 21st Century Cures Act. This approach clearly defines the responsibilities of each party and helps create appropriate measures for success. National and international policymakers must facilitate the local organizational and socio-political climate to stimulate the adoption of shared responsibility principles. When all major stakeholders are sharing responsibility, we will be more likely to usher in a new age of progress and innovation related to health IT.
... Three major approaches (i.e., top-down, bottom-up and middle-out) have been adopted in constructing nationwide interoperability [12]. Recent study results indicate that, irrespective of the initial development strategy, more and more countries have adopted or switched to the middle-out approach that facilitates interests of multiple stakeholders in healthcare between local constituencies and national government to achieve nationwide connectivity [13]. ...
Article
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Objectives: China has set up an ambitious goal to complete the construction of a nationwide interoperable health information system (HIS) by the end of 2020. This paper provides a policy analysis, from the perspective of a province, on how China achieves nationwide interoperability through integrating Population Health Information Platforms (PHIP), developed by healthcare authorities at different levels, with HIS implemented by healthcare institutions. Methods: An analytical framework, with a focus on interoperability between PHIPs and healthcare institutions' HIS, is proposed and used to analyze Sichuan Province's interoperable HIS to shed light on China's approach. To assure the validity of our research, this study analyzed data collected from multiple sources including literature review, web-based search, and interviews with staff from healthcare institutions. Results: China's approach to constructing a nationwide HIS offers great potential and flexibility through delegating PHIP construction to healthcare authorities at different levels. Our findings reveal that developed PHIPs have strong capacities for health information exchange. China's approach provides clear guidelines and standards such that healthcare authorities able to complete the construction of PHIPs on time. However, remedial policies are needed to improve the effective use and sustainability of completed systems. Conclusions: To maximize use of developed systems, China government should: a) define a monitoring policy to ensure full observation of construction guidelines; b) promote a new payment mechanism to motivate information sharing; c) clarify the role of PHIPs, at different levels, to assure their effective use; d) provide incentives for non-public institutions to participate in EMR adoption.
... Many countries worldwide see large-scale system-wide health information technology (HIT) programmes as a means to tackle existing health and care challenges [1][2][3]. For example, the United States (US) federal government's estimated $30 billion national stimulus package promotes the adoption of electronic health records (EHRs) through the Health Information Technology for Economic and Clinical Health (HITECH) Act [4]. ...
Article
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Background: Attempts to achieve digital transformation across the health service have stimulated increasingly large-scale and more complex change programmes. These encompass a growing range of functions in multiple locations across the system and may take place over extended timeframes. This calls for new approaches to evaluate these programmes. Main body: Drawing on over a decade of conducting formative and summative evaluations of health information technologies, we here build on previous work detailing evaluation challenges and ways to tackle these. Important considerations include changing organisational, economic, political, vendor and markets necessitating tracing of evolving networks, relationships, and processes; exploring mechanisms of spread; and studying selected settings in depth to understand local tensions and priorities. Conclusions: Decision-makers need to recognise that formative evaluations, if built on solid theoretical and methodological foundations, can help to mitigate risks and help to ensure that programmes have maximum chances of success.
... Such work could include the question of how small-scale, homegrown, modularized systems that support effective collaborative clinical care in local settings can be interfaced with other small-scale systems so as to achieve multiple objectives (local information sharing, local research, and also secondary uses of data at the regional and national levels). [171] suggests a way forward. ...
Article
Changes in technology sometimes raise important public policy choices and require that we clarify key values and reexamine legal concepts. Such is the case with the development of electronic medical records (EMRs), which facilitate obtaining patient data from provider and insurer records. EMRs expand our ability to tap patient data and thereby create great potential benefits as well as risks. This new technology requires that we clarify the ambiguous property interests in patient data. How the law defines ownership of patient data will shape whether its benefits can be developed and also affects patient confidentiality. EMRs make it feasible to collect aggregate patient data that can be used to vastly improve medical knowledge, patient safety and public health. Researchers have long used patient data from clinical trials to evaluate the benefits and risks of drugs and medical therapy, compare their relative effectiveness, and analyze health care cost and quality.
Book
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El impacto del uso de tecnologías de la información y de las comunicaciones (TIC) en la seguridad de la atención a los pacientes puede ser muy positivo pero requiere educación, capacitación y un cuidadoso diseño para ayudar a reducir los eventos adversos en el proceso de atención a la salud. Un aporte muy significativo para mejorar la seguridad del paciente es el registro medico electrónico, que permite una mejor evidencia sobre las prestaciones que se otorgan al paciente.
Article
Purpose The purpose of this paper is to describe the recent efforts of a large publicly funded healthcare organisation in Sydney, Australia to implement integrated care (IC) “at scale and pace” in the messy, real-world context of a District Health Service. Design/methodology/approach The paper outlines the theoretical and practical considerations used to design and develop a localised IC Strategy informed by the “House of Care” model (NHS England, 2016). Findings The need for cross-agency partnership, a shared narrative, joint leadership and an IC Strategy underpinned by proven theoretical models model is described. Originality/value This paper highlights key factors relating to implementation and evaluation of a local IC Strategy in the real world.
Chapter
Technical artefacts should exist to bring added value and quality to people’s lives. HTI design should, therefore, be considered in a much broader context than merely the usage of technology. It should be based on an understanding of people’s lives and well-grounded design methods and tools, which can investigate life and apply this knowledge to the design work. The conceptual model of life-based design (LBD) is based on segregating unified systems of actions called forms of life. Investigating the structure of actions and related facts relevant to particular forms of life, in addition to the values that people follow, is the core tool of LBD. The knowledge produced constitutes a template for human requirements, which serves as a basis for design ideas and technological solutions.
Technical Report
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The research, funded by the Italian Ministry of Health, was carried out between Nov 2012 and May 2016. Principal Investigator: Stefania Rodella. Participating Units: 1) Emilia-Romagna Region, Agency for Health and Social Care; 2) University Hospital Policlinico di Modena; 3) Forlì Hospital - Romagna Local Health Unit; 4) Research and Care Institute - Rizzoli Orthopedics Institute, Bologna. The general purpose of the research was to explore the impact of Health Information Technology (HIT) on patient safety in surgical care. Four specific objectives were defined: a) carry out an extensive literature review of available evidence on HIT on effectiveness, safety and efficiency; b) conceptualize and analyze the surgical process in some hospitals, in order to identify main hazards, risks and controls; c) describe the level of HIT achieved in the selected hospitals; d) explore the impact of different “HIT products” on safety in surgery.
Article
Purpose – This study attempts to understand the factors that influence clinician resistance to the implementation of health information technology in a mandatory setting. Design/methodology/approach – A survey study was conducted with 202 clinicians regarding their perceptions of the implementation of electronic medication management systems (eMMS) in an Australian hospital. The data was collected during the initial roll-out of eMMS for model validation and quantitative analysis. Findings – The overall results indicated that performance expectancy, switching costs, and facilitating conditions are direct predictors of clinician resistance, whereas effort expectancy and social influence showed indirect effects on clinician resistance through performance expectancy or switching costs. Theoretical implications – The study is among the first study that investigates passive clinician resistance to the implementation of health information technology in a health organisation. This study also focused on opposition behaviour among under-examined degrees of resistance. Practical implications – This study provides some insights to the hospital management on how to mitigate clinician resistance in the implementation of health information technology. Research limitations/Future directions – Other types of clinician resistance, such as postponement and rejection, are not examined in this study. Future research on postponement behaviour and rejection behaviour is needed to have a more comprehensive view of clinician resistance.
Chapter
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Health information technology (HIT) offers great potential for supporting healthcare delivery, particularly collaborative care delivery that is provided across multiple settings and providers. To date much of HIT design has focused on digitizing data or processes on a departmental or healthcare provider basis. However, this bounded approach has not scaled well for supporting community based care across disparate providers or settings because of the lack of boundaries (e.g. disprate data and processes) that exist in community based care. Cloud computing approaches that leverage mobile form applications for developing integrated HIT solutions have the potential to support collaborative healthcare delivery in the community. However, to date there is a shortage of methods that describe how to develop integrated cloud computing solutions to support community based care delivery. In particular there is a need for methods that identify how to incorporate boundaries into cloud computing systems design. This paper uses a three year case study of the design of the Palliative Care Information System (PAL-IS) to provide system design insight on cloud computing approaches that leverage mobile forms applications to support community care management.
Conference Paper
The engineering of health information technology (HIT) often focuses on clinical or hospital focused tasks. As more care is provided in the community there is an increasing need to monitor goals of care related to patient care delivery. These goals are often measured through performance metrics. Before we can track performance metrics we need to articulate the data and processes that define the metrics. However, the data sources are often varied and the processes ill-defined making it hard to engineer systems to collect and analyze metrics. Further, the ability to share data between organizations is impacted by culture, technology and privacy issues. To date there are few methodological approaches for modeling a health system from the perspective of metrics, data sources, and touch points to enable performance management of community based healthcare delivery. This paper addresses those shortcomings and presents a methodology for modeling goals, metrics and data to enable engineering of business intelligence applications for performance management of community based care.
Conference Paper
Co-design projects often include multiple partners from diverse organisations in a Quadruple Helix model for innovation. While literature on co-design and participatory design (PD) projects often focus on how to co-design with end-users or citizens, our paper discusses collaboration issues among citizen, industrial, public and academic partners in a living lab-based co-design project. Through analysis of end-project interviews with these partners, we identify a number of tensions that were negotiated in the course of the project, and identify team management, collaboration and facilitation strategies for putting PD to work among this group of citizen, industrial, public and academic partners. We discuss the conflicting discourses of the Quadruple Helix model and the co-design approach to innovation as a possible reason for such tensions. We understand tensions in PD projects organized in a Quadruple Helix model for innovation as both unavoidable and in some cases even productive in driving forward innovative design.
Article
Background: In dentistry, the use of electronic patient records for research is underexplored. The aim of this paper is to describe a case study process of obtaining research data (sociodemographic, clinical and workforce) from electronic primary care dental records, and outlining data cleaning and validation strategies. This study was undertaken at the University of Portsmouth Dental Academy (UPDA), which is a centre of education, training and provision of state funded services (National Health Services). UPDA's electronic patient management system is R4/Clinical +. This is a widely used system in general dental practices in the UK. Method: A two-phase process, involving first Pilot and second Main data extraction were undertaken. Using System Query Language (SQL), data extracts containing variables related to patients' demography, socio-economic status and dental care received were generated. A data cleaning and validation exercise followed, using a combination of techniques including Maletic and Marcus's (2000) general framework for data cleaning and Rahm and Haido's (2010) principles of data cleaning. Results: The findings of the case study support the use of a two-phase data extraction process. The data validation processes highlighted the need for both manual and analytical strategies when cleaning these data. Finally, the process demonstrated that electronic dental records can be validated and used for epidemiological and heath service research. The potential to generalise findings is great due to the large number of records. There are, however, limitations to the data which need to be considered, relating to quality (data input), database structure and interpretation of data codes. Conclusion: Electronic dental records are useful in health service research, epidemiological studies and skill mix research. Researchers should work closely with clinicians, managers and software developers to ensure that the data generated are accurate, valid and generalisable. Following data extraction the researchers need to adapt stringent validation and data cleaning strategies to guarantee that the extracted electronic data are accurate.
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This article discusses eHealth evaluation leadership in terms of the need, key characteristics, and means to cultivate this leadership. It is well known that health leaders with technical informatics skills and prior eHealth adoption experience are more likely to commit to a long-term eHealth vision, are highly motivated, and can navigate through complex adoption issues. However, much less attention is paid to leadership when it comes to electronic health evaluation. The aim here is to engage the eHealth and broader health leadership communities in a dialogue about eHealth evaluation leadership in terms of its importance, the issues involved, and ways to build capacity in Canada and abroad.
Article
Nowadays, information technology tools are widely used in the healthcare industry to record and integrate medical data so as to provide complete access to patients' information for coordinated healthcare delivery. Yet, the efficacy of these technologies depends on their successful implementation for, adoption by and/or adaptation to support health professional workers such as physicians and nurses. This study addresses the impact of specific factors including result observability, autonomy, perceived barriers, task structure, privacy and security anxiety on the nurses' perception of their performance using health information technologies. Additionally, the effects of nurses' personality factors are examined as moderating factors on the relationships between the organizational factors and nurses' perception of performance. Multiple linear regression was applied to validate the proposed research model and professional autonomy, result observability, privacy and security anxiety were found to be key factors predicting the nurses' perception of performance.
Article
Health information technology (HIT) offers great potential for supporting healthcare delivery, particularly collaborative care delivery that is provided across multiple settings and providers. To date much of HIT design has focused on digitizing data or processes on a departmental or healthcare provider basis. However, this bounded approach has not scaled well for supporting community based care across disparate providers or settings because of the lack of boundaries (e.g. disprate data and processes) that exist in community based care. Cloud computing approaches that leverage mobile form applications for developing integrated HIT solutions have the potential to support collaborative healthcare delivery in the community. However, to date there is a shortage of methods that describe how to develop integrated cloud computing solutions to support community based care delivery. In particular there is a need for methods that identify how to incorporate boundaries into cloud computing systems design. This paper uses a three year case study of the design of the Palliative Care Information System (PAL-IS) to provide system design insight on cloud computing approaches that leverage mobile forms applications to support community care management.
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Communication and information sharing is an important aspect of healthcare information technology and mHealth management. A main requirement in the quality of patient care is the ability of all health care participants to communicate. Research illustrates that the complexity of communicating within the health care system hinders the quality of health care service delivery. Health informatics have been touted as a way to improve communication deficiencies, which has led to the exponential growth of health informatics integration. However, research still lags in understanding how health informatics affects patient care, health professional work routines, and the overall health care system. This study investigates the extent to which mHealth technologies influence communication information sharing patterns between interdisciplinary health care providers in the delivery of health care services. This study was conducted at Hamilton Health Sciences and through a sociotechnical approach, focuses on both the end user’s experiences with mHealth in daily work communication scenarios, and the extent to which mHealth use affects interdisciplinary communication. Results indicate that there are several mitigating factors which influence communication patterns using mHealth technologies, including: information sharing, mobility, ergonomic and system design.
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Nowadays, information technology tools are widely used in the healthcare industry to record and integrate medical data so as to provide complete access to patients' information for coordinated healthcare delivery. Yet, the efficacy of these technologies depends on their successful implementation for, adoption by and/or adaptation to support health professional workers such as physicians and nurses. This study addresses the impact of specific factors including result observability, autonomy, perceived barriers, task structure, privacy and security anxiety on the nurses' perception of their performance using health information technologies. Additionally, the effects of nurses' personality factors are examined as moderating factors on the relationships between the organizational factors and nurses' perception of performance. Multiple linear regression was applied to validate the proposed research model and professional autonomy, result observability, privacy and security anxiety were found to be key factors predicting the nurses' perception of performance.
Thesis
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This research aimed to discover the difficulties and limitations of Healthcare Information Technology (HIT) solutions and their stakeholders; where the investigation for the potential solutions by the Next Generation Information Technology was a further objective of this study. The IT systems that are developed to store, manage and disseminate the healthcare data were called the HIT (Chaudhry et al, 2006). And the Next Generation IT was addressed to cloud and ubiquitous computing solution (Young, 2012). A systematic literature review was conducted to search for the literature regarding the cited aims; with a part of this study researched through the principles of a critical incident technique to reflect the potential anthropologic hazard that might rise in future. A diversity of problems regarding quality of services, marketing, finance and sovereignty were reviewed in accordance with HIT and its adoption by the private sector. Potential solutions provided by Next Generation Information Technology have been reviewed; where both the advantages and disadvantages that were brought to other industries were investigated. The socio-reflection to capitalism was analyzed; thus HIT was considered to be a significant role player in future’s information economy, as an enhanced public administration service Moreover further research in problems with HIT and potential solutions was recommended, as far as this study was limited to time, scope and publication nations. Additional recommendations were likewise provided to persuade the goals of this study within security, sovereignty, immigration and socio-interaction concerns.
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The vision of EHR environments, located within multiple adaptive digital health ecosystems, provided the foundation for this road map. Planning and implementing desired strategic directions and implementation strategy are described. This includes a list of top-down and bottom-up responsibilities. The current state and enabling environment is summarised to provide a foundation for future directions. Each of the many interdependent ecosystem components requires strong leadership, a commitment to collaborative cross-sectoral practices, and niche expertise. Key ecosystem architectural components to be standardised are open platform architecture, data types, terminology, concept representation and definitions, unique identifiers, and governance and domain information models. This may need a new coordinating standards body charged with the global responsibility to create a coherent set of health standards that will support a fully functional global digital health ecosystem. A successful digital health ecosystem needs to be built using a solid engineering methodology, compliant with scientific evidence, and underpinned by extensive implementation experience by a capable workforce.
Article
Electronic Personal Health Record systems are providing health consumers with greater access and control to their health records by shifting these records from being a health provider-centred Electronic Health Record, to a patient-centred, Electronic Personal Health Record (ePHR). Based on the delivery system, ePHR systems are classified into standalone, tethered, and integrated or unified ePHRs. While national approaches of implementing integrated ePHR vary, the middle out method has been recognised as the ideal approach. It is worth considering the adoption of ePHRs has been slow due to several factors, including technical, individual, environmental, social, and legal factors. This paper provides a representative overview of an ePHR system, outlining its definition, types, architectures, and nationwide approaches of its implementation. Additionally, the drivers and hindrances to health consumer adoption are discussed.
Book
Despite a strong commitment to delivering quality health care, persistent problems involving medical errors and ineffective treatment continue to plague the industry. Many of these problems are the consequence of poor information and technology (IT) capabilities, and most importantly, the lack cognitive IT support. Clinicians spend a great deal of time sifting through large amounts of raw data, when, ideally, IT systems would place raw data into context with current medical knowledge to provide clinicians with computer models that depict the health status of the patient. Computational Technology for Effective Health Care advocates re-balancing the portfolio of investments in health care IT to place a greater emphasis on providing cognitive support for health care providers, patients, and family caregivers; observing proven principles for success in designing and implementing IT; and accelerating research related to health care in the computer and social sciences and in health/biomedical informatics. Health care professionals, patient safety advocates, as well as IT specialists and engineers, will find this book a useful tool in preparation for crossing the health care IT chasm. © 2009 by the National Academy of Sciences. All rights reserved.
Article
Pressure on the NHS in England to abandon or radically reform its £13bn (€14bn; $18bn) scheme to computerise all patients’ records reached a new peak this week with the publication of a critical parliamentary report. The Committee of Public Accounts’ second investigation into the NHS national programme for IT says that the health service may never adopt the programme’s core systems for acute hospitals but will end up paying for them anyway. Although the 7 year old programme has notched up some achievements, risks remain “as serious as ever,” said the committee’s chairman, the Conservative MP Edward Leigh. The committee’s report says that the main point of concern is the installation of electronic records in secondary care. Originally the …
Article
The Massachusetts eHealth Collaborative (MAeHC) was formed to improve patient safety and quality of care by promoting the use of health information technology through community-based implementation of electronic health records (EHRs) and health information exchange. The Collaborative has recently implemented EHRs in a diverse set of competitively selected communities, encompassing nearly 500 physicians serving over 500,000 patients. Targeting both EHR implementation and health information exchange at the community level has identified numerous challenges and strategies for overcoming them. This article describes the formation and implementation phases of the Collaborative, focusing on barriers identified, lessons learned, and policy issues.
Article
Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.
Article
Improving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII). To help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003. Attendees favored a public-private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.
Article
As patients store their personal health information in online repositories, the entities holding this information may be able to use it for a variety of purposes. This article explains the challenges and problems associated with a small number of companies holding large numbers of individual health records.
Available at: http:// www.nehta.gov.au/. Accessed: 3/31/09
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National E-Health Transition Authority. Available at: http:// www.nehta.gov.au/. Accessed: 3/31/09. Journal of the American Medical Informatics Association Volume 16 Number 3 May / June 2009 273
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National E-Health Transition Authority. Available at: http:// www.nehta.gov.au/. Accessed: 3/31/09.