Improving the interoperability of drugs terminologies: Infusing local standardization with an international perspective.

OBJECTIVES: The objective of this study is to describe how OCRx (Canadian Drug Ontology) has been built to address the dual need for local drug information integration in Canada and alignment with international standards requirements. METHODS: This paper delves into (i) the implementation efforts to meet the Identification of Medicinal Product (IDMP) requirements in OCRx, alongside the ontology update strategy, (ii) the structure of the ontology itself, (iii) the alignment approach with several reference Knowledge Organization Systems, including SNOMED CT, RxNorm, and the list of "Code Identifiant de Spécialité" (CIS-Code), and (iv) the look-up services developed to facilitate its access and utilization. RESULTS: Each OCRx release contains two distinct versions: the full and the up-to-date version. The full version encompasses all drugs with a DIN code sanctioned by Health Canada, while the up-to-date version is limited to drugs currently marketed in Canada. In the last release of OCRx, the full version comprises 162,400 classes; meanwhile, the up-to-date version consists of 36,909 classes. In terms of mappings with OCRx, substances in RxNorm and SNOMED CT fall below 40%, registering at 37% and 22% respectively. Meanwhile, mappings for CIS-Code achieve coverage of 61%. The strength mappings are notably low for RxNorm at 40% and for CIS-code at 28%. This affects the mapping of clinical drugs, which are predominantly alignable through post-coordinated expressions: 56% for RxNorm, 80% for SNOMED CT, and 35% for CIS-Code. The main support service of OCRx is a look-up service known as PaperRx that displays OCRx's entities based on description logic queries (DL-queries) performed through the classified structure of OCRx. The look-up services also contain a SPARQL endpoint, an OCRx OWL file downloader, and a RESTful API. DISCUSSION: The OCRx ontology demonstrates a significant effort towards integrating Canadian drug information with international standards. However, there are areas for improvement. In the future, our focus will be on refining the structure of OCRx for better classification capability and improvement of dosage conversion. Additionally, we aim to harness OCRx in constructing an ontology-based annotator, setting our sights on its deployment in real-world data integration scenarios.

Cross-Sector Collaboration to Improve Access to Community Services for People Living With Diabetes: Contributions From Actor-Network Theory.

Diabetes is a global public health issue. The Public Health Agency of Canada published a Diabetes Framework 2022 which recommends collaborative work across sectors to mitigate the impact of diabetes on health and quality of life. Since 2020, the INMED-COMMUNITY pathway has been implemented in Laval, Québec developing collaboration between healthcare and community sectors through a participatory action research approach. The aim of this article is to gain a better understanding of the INMED-COMMUNITY pathway implementation process, based on the mobilization of network actor theory. Qualitative analysis of semi-structured interviews conducted from January to March 2023 with 12 participants from 3 different sectors (community, health system, research), were carried out using actor-network theory. The results explored the conditions for effective intersectoral collaboration in a participatory action research approach to implement the INMED-COMMUNITY pathway. These were: (1) contextualization of the project, (2) a consultation approach involving various stakeholders, (3) creation of new partnerships, (4) presence of a project coordinator, and (5) mobilization of stakeholders around a common definition of diabetes. Mediation supported by a project coordinator contributed to the implementation of an intersectoral collaborative health intervention, largely due to early identification of controversies.

Trajectories of opioid consumption as predictors of patient-reported outcomes among individuals attending multidisciplinary pain treatment clinics.

PURPOSE: This study aimed to identify opioid consumption trajectories among persons living with chronic pain (CP) and put them in relation to patient-reported outcomes 6 months after initiating multidisciplinary pain treatment. METHODS: This study used data from the Quebec Pain Registry (2008-2014) linked to longitudinal Quebec health insurance databases. We included adults diagnosed with CP and covered by the Quebec public prescription drug insurance plan. The daily cumulative opioid doses in the first 6 months after initiating multidisciplinary pain treatment were transformed into morphine milligram equivalents. An individual-centered approach involving principal factor and cluster analyses applied to longitudinal statistical indicators of opioid use was conducted to classify trajectories. Multivariate regression models were applied to evaluate the associations between trajectory group membership and outcomes at 6-month follow-up (pain intensity, pain interference, depression, and physical and mental health-related quality of life). RESULTS: We identified three trajectories of opioid consumption: "no or very low and stable" opioid consumption (n = 2067, 96.3%), "increasing" opioid consumption (n = 40, 1.9%), and "decreasing" opioid consumption (n = 39, 1.8%). Patients in the "no or very low and stable" trajectory were less likely to be current smokers, experience polypharmacy, use opioids or benzodiazepine preceding their first visit, or experience pain interference at treatment initiation. Patients in the "increasing" opioid consumption group had significantly greater depression scores at 6-month compared to patients in the "no or very low and stable" trajectory group. CONCLUSION: Opioid consumption trajectories do not seem to be important determinants of most PROs 6 months after initiating multidisciplinary pain treatment.

AI maturity in health care: An overview of 10 OECD countries.

BACKGROUND: Artificial Intelligence (AI) and its applications in health care are on the agenda of policymakers around the world, but a major challenge remains, namely, to set policies that will ensure wide acceptance and capture the value of AI while mitigating associated risks. OBJECTIVE: This study aims to provide an overview of how OECD countries strategize about how to integrate AI into health care and to determine their actual level of AI maturity. METHODS: A scan of government-based AI strategies and initiatives adopted in 10 proactive OECD countries was conducted. Available documentation was analyzed, using the Broadband Commission for Sustainable Development's roadmap to AI maturity as a conceptual framework. RESULTS: The findings reveal that most selected OECD countries are at the Emerging stage (Level 2) of AI in health maturity. Despite considerable funding and a variety of approaches to the development of an AI in health supporting ecosystem, only the United Kingdom and United States have reached the highest level of maturity, an integrated and collaborative AI in health ecosystem (Level 3). CONCLUSION: Despite policymakers looking for opportunities to expedite efforts related to AI, there is no one-size-fits-all approach to ensure the sustainable development and safe use of AI in health. The principles of equifinality and mindfulness must thus guide policymaking in the development of AI in health care.

Building a Logic Model to Foster Engagement and Learning Using the Case of a Province-Wide Multispecies Antimicrobial Use Monitoring System.

Successfully designing and implementing a program is complex; it requires a reflexive balance between the available resources and the priorities of various stakeholders, both of which change over time. Logic models are theory-based evaluation approaches used to identify and address key challenges of a program. This article describes the process of building a logic model on advanced theories in complexity studies. The models aim to support a province-wide multispecies monitoring system of antimicrobial use (AMU), designed in collaboration with the animal health sector in Quebec (Canada). Based on a rigorous theoretical foundation, the logic model is built in three steps: (1) mapping, a narrative review of literature on similar programs in other jurisdictions; (2) framing, iterative consultations with project members to elaborate the logic model; (3) shaping, hypotheses based on the logic model. The model emerges from the reflexive balancing of current scientific knowledge and empirical insights to gather relevant information about stakeholders from interdisciplinary experts that led a 3-year consensus-building process within the community. Recognizing the challenge of unpacking theories for practical use, we illustrate how the process of an "open" logic model building could enable governance coordination in complex processes. Logic models are useful for evaluating public, private, and academic partnerships in One Health programs that characterize an adaptive governance process.

Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol.

INTRODUCTION: Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients' barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec's 18 administrative regions to implement single points of access for unattached patients (Guichets d'accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients' experiences of navigation, access and service utilisation. METHODS AND ANALYSIS: A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients' experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases. ETHICS AND DISSEMINATION: This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l'innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

Evaluation of a national e-booking system for medical consultation in primary care in a universal health system.

PURPOSE: The Rendez-vous Santé Québec is a national online booking (e-booking) system of medical appointments in primary care rolled out in 2018 in Québec (Canada). The objectives of this study were to describe the adoption by targeted users, and analyze the facilitating and limiting factors at the technological, individual and organizational levels to inform policy makers. METHODS: A mixed methods evaluation was conducted involving interviews with key stakeholders (n = 40), audit logs of the system in 2019, and a population-based survey (n = 2 003). All data were combined to analyze facilitating and limiting factors, based on the DeLone and McLean framework. RESULTS: The RVSQ e-booking system had a low adoption across the province mainly because it was poorly aligned with the diversity of organizational and professional practices. The other commercial e-booking systems already used by clinics seemed better adapted to interdisciplinary care, patient prioritization and advanced access. e-Booking system was appreciated by patients, but has implications for the performance of primary care organization that goes beyond scheduling management issues, with potential detrimental consequences for care continuity and appropriateness. Further research is needed to define how e-booking systems could support a better alignment between primary care innovative practices and improve the fit between patients' needs and resources availability in primary care.

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.

OBJECTIVES: Computerised provider order entry (CPOE) systems have been implemented around the world as a solution to reduce ordering and transcription errors. However, previous literature documented many challenges to attain this goal, especially in paediatric settings. The objectives of this study were to (1) analyse the impact of a paediatric CPOE system on medication safety and (2) suggest potential error prevention strategies. METHODS: A pre-post observational study was conducted at the pilot ward (n=60 beds) of a paediatric academic health centre through mixed methods. The implementation project and medication management workflows were described through active participation to the project management team, observation, discussions and analysis of related documents. Furthermore, using incident reports, the nature of each error and error rate was compared between the preperiod and postperiod. RESULTS: The global error rate was lower, but non-statistically significant, in the post implementation phase, which was mostly driven by a significant reduction in errors during order acknowledgement, transmission and transcription. Few errors occurred at the prescription step, and most errors occurred during medication administration. Furthermore, some errors could have been prevented using a CPOE in the pre-implementation period, and the CPOE led to few technology-related errors. DISCUSSION AND CONCLUSION: This study identified both intended and unintended effects of CPOE adoption through the entire medication management workflow. This study revealed the importance of simplifying the acknowledgement, transmission and transcribing steps through the implementation of a CPOE to reduce medication errors. Improving the usability of the electronic medication administration record could help further improve medication safety.

Evaluating the implementation of a referral system for virtual pharmacy counselling in a province-wide nurse phone line.

Digital technology offers several opportunities to improve access to professional expertise in primary care, and the offer of various "virtual" services has exploded in the past few years. The aim of this study was to evaluate the implementation of a direct-to-consumer on-line pharmacy consultation service (Ask Your Pharmacist - AYP) to a universal phone consultation service led by the universal public health system in Quebec (811 Info-Santé), through a direct bridge. Semi-structured interviews were conducted with clinician users of the service, and stakeholders involved in this pilot project funded by the Ministry of Economy (n = 22); documents were also analyzed, and content of the question was asked through the AYP service. Adoption of the service was low, and it suggests a poor alignment between the need and the service as implemented. Further research should investigate the mechanisms for an appropriate integration of digital services for primary care universal consultation services.

Structuring and organizing interprofessional healthcare in partnership with patients with diabetes: the INterprofessional Management and Education in Diabetes care (INMED) pathway.

Type 2 diabetes is a complex chronic disease that requires ongoing monitoring by an interprofessional team to prevent complications. The INMED (INterprofessional Management and Education in Diabetes) care pathway was developed by our team to optimize primary care services for these patients and their families. The objective of this study is to describe the preliminary results of its adoption and implementation. The INMED care pathway is organized into four axes: (a) continuing professional education, (b) self-management support, (c) case management, and (d) ongoing evaluation of the quality of diabetes care and services. A multiple-case study is underway to document its effects on practice change using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Preliminary results on the adoption and implementation revealed some strengths: (a) regular patient follow-up by the case manager, (b) scheduling of physician appointments when required, and (c) regular screening for risk factors. Barriers were also identified: (a) lack of clear understanding of the case manager role, (b) lack of referrals to team members, and (c) lack of use of the motivational interview approach. The INMED care pathway is being adopted by primary care teams but challenges need to be overcome to improve its reach and effectiveness.

Nature and perceived benefits of patient-initiated consultations in community pharmacies: A population survey.

Background: The role of community pharmacists in enhancing patient care has received increased attention. However, there is a paucity of literature on the nature, frequency, and perceived impacts of patient-initiated consultations in community pharmacies. Objectives: We aim to describe the profile of patients seeking advice from community pharmacists as well as the nature and impact of those consultations. Methods: A survey was conducted with Quebec adults who had consulted a pharmacist in the previous four weeks. Data was collected in 2017 and 1104 agreed to participate (25.3%). Of those, 93 were withdrawn due to incomplete data and 98 failed to meet the inclusion criteria. Sample representativeness was ensured by quota sampling (gender, age) after stratification by region. Results: Among the 913 respondents, 46% had consulted a pharmacist more than once during the four weeks prior to the survey. Individuals with a university degree consulted less often than those without (1.97 vs. 2.17 times; t = 2.0; p < .05) and participants with one or several chronic diseases consulted more frequently than those having no chronic disease (2.18 vs. 1.94 times; t = 5.7; p < .05). Older adults (55+) consulted more often for themselves compared to younger (18-34) and middle-aged (35-54) adults (1.53 vs. 1.31 vs. 1.44 times; F = 4.0; p < .05). Concerning the consultations, 58% were related to medications and 33% to health problems. In terms of impacts, 81% of consultations were perceived to have prevented the use of other healthcare resources. Patient satisfaction with their consultations was high with an average score of 8.75 on a 10-point scale (SD = 1.63). Conclusions: Findings reveal that the reasons for consulting a community pharmacist are diverse, most being related to medications or health issues. Patients reported that pharmacists were able to manage most consultations without referring them to other health care resources or professionals, and their satisfaction with their consultation was high. MeSH terms: Community pharmacy; counselling; patient satisfaction; primary health care; surveys and questionnaires.

Assessing the Quality of Direct-to-Consumer Teleconsultation Services in Canada.

The objective of this study was to describe and assess the quality of the direct-to-consumer medical teleconsultation landscape in three Canadian provinces. An environmental scan of primary care teleconsultation platforms was conducted in January 2022 to identify medical teleconsultation platforms in Quebec (Qc), Ontario, and British Columbia (BC). The quality of each teleconsultation platform was assessed using a modified version of the HONcode principles. Nineteen different direct-to-consumer medical teleconsultation platforms were identified across the three provinces. The quality of these teleconsultation platforms was very heterogeneous. The landscape of virtual primary care is changing rapidly in the Canadian ecosystem, and the transparency of current teleconsultation platforms could be improved.

Association of Antidepressant Prescription Filling With Treatment Indication and Prior Prescription Filling Behaviors and Medication Experiences.

BACKGROUND: Given the wide range of uses for antidepressants, understanding indication-specific patterns of prescription filling for antidepressants provide valuable insights into how patients use these medications in real-world settings. OBJECTIVE: The objective of this study was to determine the association of antidepressant prescription filling with treatment indication, as well as prior prescription filling behaviors and medication experiences. DESIGN: This retrospective cohort study took place in Quebec, Canada. PARTICIPANTS: Adults with public drug insurance prescribed antidepressants using MOXXI (Medical Office of the XXIst Century)-an electronic prescribing system requiring primary care physicians to document treatment indications and reasons for prescription stops or changes. MEASURES: MOXXI provided information on treatment indications, past prescriptions, and prior medication experiences (treatment ineffectiveness and adverse drug reactions). Linked claims data provided information on dispensed medications and other patient-related factors. Multivariable logistic regression models estimated the independent association of not filling an antidepressant prescription (within 90 d) with treatment indication and patients' prior prescription filling behaviors and medication experiences. RESULTS: Among 38,751 prescriptions, the prevalence of unfilled prescriptions for new and ongoing antidepressant therapy was 34.2% and 4.1%, respectively. Compared with depression, odds of not filling an antidepressant prescription varied from 0.74 to 1.57 by indication and therapy status. The odds of not filling an antidepressant prescription was higher among adults filling < 50% of their medication prescriptions in the past year and adults with an antidepressant prescription stopped or changed in the past year due to treatment ineffectiveness. CONCLUSION: Antidepressant prescription filling behaviors differed by treatment indication and were lower among patients with a history of poor prescription filling or ineffective treatment with antidepressants.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic.

OBJECTIVE: This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth. METHOD: A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers. RESULTS: Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients. CONCLUSION: The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

Implementation of a Computerized Provider Order Entry System in a Pediatric Hospital in Canada.

The Centre Hospitalier Universitaire Sainte-Justine (Montreal, Canada) is a pediatric academic tertiary hospital that has begun the implementation of a commercial computerized provider order entry system (CPOE) in October 2019. The objectives of this paper are 1) to estimate the impact of the CPOE system on medication errors, and 2) to identify vulnerability issues related to the configuration of the CPOE system's design. Using a pre-post implementation methodology measuring medication errors captured by clinical pharmacists revealed that the implementation of a CPOE has eliminated all prescription conformity (e.g., missing fields) and legibility errors. Pharmacists have continued to detect medication errors, especially inappropriate dosing instructions, and to intervene in similar clinical situations (medication reconciliation, deprescribing, adjusting orders). Additionally, the vulnerability analysis, based on typical clinical order test cases in an inpatient pediatric setting, highlighted the need to configure a clinical decision support system that can identify inappropriate dosing instructions for pediatric patients.

Usage of Digital Tools to Access Primary Care in Quebec: An Environmental Scan.

Timely access to care is a persistent challenge for health care systems. Providing the right care to the right patient at the right time is important to reduce inappropriate use and improve the performance of healthcare services. The complexity of accessing primary care contributes to the high usage of emergency rooms for not-urgent conditions. Many digital tools try to offer a better access to care for patients and reduce ER overuse. This environmental scan of the digital tools available in Quebec identifies those digital tools and some of their limitations. The results reveal the complexity of mobilizing digital tools in the healthcare sector and highlight the need for all stakeholders to work together to enhance access to care.

OCRx: Canadian Drug Ontology.

This paper describes the development and evaluation of a Canadian drug ontology (OCRx), built to provide a normalized and standardized description of drugs that are authorized to be marketed in Canada. OCRx aims to improve the usability and interoperability of drugs terminologies for a non-ambiguous access to drugs information that is available in electronic health record systems. We present the first release of OCRx that is described in Web Ontology Language and aligned to the Identification of Medicinal Product (IDMP) standards. For comparison purposes, OCRx is mapped to RxNorm, its US variant.

Patient-initiated consultations in community pharmacies.

BACKGROUND: Mobilizing pharmacists practicing in community pharmacies as a new player in primary care has recently emerged as a cost-effective strategy for clinical consultations related to minor ailments. However, little is known about these consultations initiated by patients. The objectives of this study were to describe patient initiated consultations in community pharmacies, and to estimate the impact of these consultations on care-seeking behaviors of patients. METHODS: A cross sectional study was conducted in 11 retail pharmacies in Quebec, Canada, from October until December 2017, using two data sources: 1) an application and 2) structured interviews. Pharmacists had to compile all consultations in the app during a 4 week-period. Consenting patients were interviewed on the day of the consultation and one week after. Descriptive statistics on the number of consultations were calculated, as well as on the recommendation and the experience of the patient. RESULTS: A total number of 4994 consultations were entered in the app by 55 pharmacists, with an average of 18 consultations (SD = 7) per pharmacy per day. Of the 900 patients consented to participate to the study, 600 (67%) completed the two interviews. Pharmacists reported that they recommended another healthcare resource to patients (e.g. emergency department (ED), walk-in clinic) in only 15% of cases. In the week following the consultation, 105 (18%) patients reported that they avoided going to the ED as a result of the consultation. Patients in rural regions or consulting in a pharmacy far from a medical clinic were more likely to report avoiding an ED visit as a result of the consultation with the pharmacist. CONCLUSIONS: This study suggests that patients are seeking advice from pharmacists for a variety of health care concerns and that pharmacists are able to manage most of these consultations, with a high level of patient satisfaction.

Organizational readiness for artificial intelligence in health care: insights for decision-making and practice.

PURPOSE: Artificial intelligence (AI) raises many expectations regarding its ability to profoundly transform health care delivery. There is an abundant literature on the technical performance of AI applications in many clinical fields (e.g. radiology, ophthalmology). This article aims to bring forward the importance of studying organizational readiness to integrate AI into health care delivery. DESIGN/METHODOLOGY/APPROACH: The reflection is based on our experience in digital health technologies, diffusion of innovations and healthcare organizations and systems. It provides insights into why and how organizational readiness should be carefully considered. FINDINGS: As an important step to ensure successful integration of AI and avoid unnecessary investments and costly failures, better consideration should be given to: (1) Needs and added-value assessment; (2) Workplace readiness: stakeholder acceptance and engagement; (3) Technology-organization alignment assessment and (4) Business plan: financing and investments. In summary, decision-makers and technology promoters should better address the complexity of AI and understand the systemic challenges raised by its implementation in healthcare organizations and systems. ORIGINALITY/VALUE: Few studies have focused on the organizational issues raised by the integration of AI into clinical routine. The current context is marked by a perplexing gap between the willingness of decision-makers and technology promoters to capitalize on AI applications to improve health care delivery and the reality on the ground, where it is difficult to initiate the changes needed to realize their full benefits while avoiding their negative impacts.

Investigating the Barriers to Physician Adoption of an Artificial Intelligence- Based Decision Support System in Emergency Care: An Interpretative Qualitative Study.

The development of artificial intelligence (AI) systems to support diagnostic decision-making is rapidly expanding in health care. However, important challenges remain in executing algorithmic systems at the frontlines of clinical practice. Hence, most often, these systems have not been trained with local data nor do they fit with context-specific patterns of care. This research examines the implementation of an AI-based decision support system (DSS) in the emergency department of a large Academic Health Center (AHC) in Canada, focusing specifically on the question of end-user adoption. Based in an interpretative perspective, the study analyzes the perceptions of healthcare managers, AI developers, physicians and nurses on the DSS, so as to make sense of the main barriers to its adoption by emergency physicians. The study points to the importance of considering interconnections between technical, human and organizational factors to better grasp the unique challenges raised by AI systems in health care. It further emphasizes the need to investigate actors' perceptions of AI in order to develop strategies to adequately test and adapt AI systems, and ensure that they meet the needs of health professionals and patients. This research is particularly relevant at a time when considerable investments are being made to develop and deploy AI-based systems in health care. Empirically probing the conditions under which AI-based systems can effectively be integrated into processes and workflow is essential for maximizing the benefits these investments can bring to the organization and delivery of care.