Cashing in: cost-benefit analysis framework for digital hospitals.

BACKGROUND: For many countries, especially those outside the USA without incentive payments, implementing and maintaining electronic medical records (EMR) is expensive and can be controversial given the large amounts of investment. Evaluating the value of EMR implementation is necessary to understand whether or not, such investment, especially when it comes from the public source, is an efficient allocation of healthcare resources. Nonetheless, most countries have struggled to measure the return on EMR investment due to the lack of appropriate evaluation frameworks. METHODS: This paper outlines the development of an evidence-based digital health cost-benefit analysis (eHealth-CBA) framework to calculate the total economic value of the EMR implementation over time. A net positive benefit indicates such investment represents improved efficiency, and a net negative is considered a wasteful use of public resources. RESULTS: We developed a three-stage process that takes into account the complexity of the healthcare system and its stakeholders, the investment appraisal and evaluation practice, and the existing knowledge of EMR implementation. The three stages include (1) literature review, (2) stakeholder consultation, and (3) CBA framework development. The framework maps the impacts of the EMR to the quadruple aim of healthcare and clearly creates a method for value assessment. CONCLUSIONS: The proposed framework is the first step toward developing a comprehensive evaluation framework for EMRs to inform health decision-makers about the economic value of digital investments rather than just the financial value.

Perceived Impact of Digital Health Maturity on Patient Experience, Population Health, Health Care Costs, and Provider Experience: Mixed Methods Case Study.

BACKGROUND: Health care organizations understand the importance of new technology implementations; however, the best strategy for implementing successful digital transformations is often unclear. Digital health maturity assessments allow providers to understand the progress made toward technology-enhanced health service delivery. Existing models have been criticized for their lack of depth and breadth because of their technology focus and neglect of meaningful outcomes. OBJECTIVE: We aimed to examine the perceived impacts of digital health reported by health care staff employed in health care organizations across a spectrum of digital health maturity. METHODS: A mixed methods case study was conducted. The digital health maturity of public health care systems (n=16) in Queensland, Australia, was examined using the quantitative Digital Health Indicator (DHI) self-assessment survey. The lower and upper quartiles of DHI scores were calculated and used to stratify sites into 3 groups. Using qualitative methods, health care staff (n=154) participated in interviews and focus groups. Transcripts were analyzed assisted by automated text-mining software. Impacts were grouped according to the digital maturity of the health care worker's facility and mapped to the quadruple aims of health care: improved patient experience, improved population health, reduced health care cost, and enhanced provider experience. RESULTS: DHI scores ranged between 78 and 193 for the 16 health care systems. Health care systems in the high-maturity category (n=4, 25%) had a DHI score of ≥166.75 (the upper quartile); low-maturity sites (n=4, 25%) had a DHI score of ≤116.75 (the lower quartile); and intermediate-maturity sites (n=8, 50%) had a DHI score ranging from 116.75 to 166.75 (IQR). Overall, 18 perceived impacts were identified. Generally, a greater number of positive impacts were reported in health care systems of higher digital health maturity. For patient experiences, higher maturity was associated with maintaining a patient health record and tracking patient experience data, while telehealth enabled access and flexibility across all digital health maturity categories. For population health, patient journey tracking and clinical risk mitigation were reported as positive impacts at higher-maturity sites, and telehealth enabled health care access and efficiencies across all maturity categories. Limited interoperability and organizational factors (eg, strategy, policy, and vision) were universally negative impacts affecting health service delivery. For health care costs, the resource burden of ongoing investments in digital health and a sustainable skilled workforce was reported. For provider experiences, the negative impacts of poor usability and change fatigue were universal, while network and infrastructure issues were negative impacts at low-maturity sites. CONCLUSIONS: This is one of the first studies to show differences in the perceived impacts of digital maturity of health care systems at scale. Higher digital health maturity was associated with more positive reported impacts, most notably in achieving outcomes for the population health aim.

Impact of digital health on the quadruple aims of healthcare: A correlational and longitudinal study (Digimat Study).

BACKGROUND: Digital healthcare aims to deliver on the quadruple aim: enhance patient experiences, improve population health, reduce costs and improve provider experiences. Despite large investments, it is unclear how advancing digital health enables these healthcare aims. OBJECTIVE: Our objectives were to: 1) measure the correlation between digital capability and health system outcomes mapped to the quadruple aim, and 2) measure the longitudinal impact of electronic medical record implementations upon health system outcomes. MATERIALS AND METHODS: We undertook two studies: 1) Digital health correlational study investigating the association among healthcare system capability and healthcare aims, and 2) Digital hospital longitudinal study investigating outcomes pre and post electronic medical record implementation. RESULTS: Digital health capability was associated with lower staff turnover. Digitising healthcare services was associated with decreased medication errors, decreased nosocomial infections, increased hospital activity, and a transient increase in staff leave. DISCUSSION: These results suggest positive impacts on the population health and healthcare costs aim, minimal impacts on the provider experience aim and no observed impacts to the patient experience aim. CONCLUSION: These findings should provide confidence to healthcare decision-makers investing in digital health.

Translational artificial intelligence-led optimization and realization of estimated discharge with a supportive weekend interprofessional flow team (TAILORED-SWIFT).

Weekend discharges occur less frequently than discharges on weekdays, contributing to hospital congestion. Artificial intelligence algorithms have previously been derived to predict which patients are nearing discharge based upon ward round notes. In this implementation study, such an artificial intelligence algorithm was coupled with a multidisciplinary discharge facilitation team on weekend shifts. This approach was implemented in a tertiary hospital, and then compared to a historical cohort from the same time the previous year. There were 3990 patients included in the study. There was a significant increase in the proportion of inpatients who received weekend discharges in the intervention group compared to the control group (median 18%, IQR 18-20%, vs median 14%, IQR 12% to 17%, P = 0.031). There was a corresponding higher absolute number of weekend discharges during the intervention period compared to the control period (P = 0.025). The studied intervention was associated with an increase in weekend discharges and economic analyses support this approach as being cost-effective. Further studies are required to examine the generalizability of this approach to other centers.

Adverse childhood experiences, the risk of pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis.

BACKGROUND: Adverse childhood experiences (ACEs) have a profound negative impact on health. However, the strength of the association between ACEs and pregnancy complications and adverse pregnancy outcomes is not well quantified or understood. OBJECTIVE: To conduct a systematic review and meta-analysis of the association between ACEs and risk of pregnancy complications and adverse pregnancy outcomes. SEARCH STRATEGY: A comprehensive search was conducted using PubMed, Embase, CINAHL, PsycINFO, ClinicalTrials.gov and Google scholar up to July 2022. DATA COLLECTION AND ANALYSIS: Two reviewers independently conducted the screening and quality appraisal using a validated tool. Meta-analysis using the quality-effects model on the reported odds ratio (OR) was conducted. Heterogeneity and inconsistency were examined using the I2 statistics. RESULTS: 32 studies from 1508 met a priori inclusion criteria for systematic review, with 21 included in the meta-analysis. Pooled analyses showed that exposure to ACEs increased the risk of pregnancy complications (OR 1.37, 95% CI 1.20 to 1.57) and adverse pregnancy outcomes (OR 1.31, 95% CI 1.17 to 1.47). In sub-group analysis, maternal ACEs were associated with gestational diabetes mellitus (OR 1.39, 95% CI 1.11 to 1.74), antenatal depression (OR 1.59, 95% CI 1.15 to 2.20), low offspring birth weight (OR 1.27, 95% CI 1.02 to 1.47), and preterm delivery (OR 1.41, 95% CI 1.16 to 1.71). CONCLUSION: The results suggest that exposure to ACEs increases the risk of pregnancy complications and adverse pregnancy outcomes. Preventive strategies, screening and trauma-informed care need to be examined to improve maternal and child health.

Evaluating Digital Health Capability at Scale Using the Digital Health Indicator.

BACKGROUND: Health service providers must understand their digital health capability if they are to drive digital transformation in a strategic and informed manner. Little is known about the assessment and benchmarking of digital maturity or capability at scale across an entire jurisdiction. The public health care system across the state of Queensland, Australia has an ambitious 10-year digital transformation strategy. OBJECTIVE: The aim of this research was to evaluate the digital health capability in Queensland to inform digital health strategy and investment. METHODS: The Healthcare Information and Management Systems Society Digital Health Indicator (DHI) was used via a cross-sectional survey design to assess four core dimensions of digital health transformation: governance and workforce; interoperability; person-enabled health; and predictive analytics across an entire jurisdiction simultaneously. The DHI questionnaire was completed by each health care system (n = 16) within Queensland in February to July 2021. DHI is scored 0 to 400 and dimension score is 0 to 100. RESULTS: The results reveal a variation in DHI scores reflecting the diverse stages of health care digitization across the state. The average DHI score across sites was 143 (range 78-193; SD35.3) which is similar to other systems in the Oceania region and global public systems but below the global private average. Governance and workforce was on average the highest scoring dimension (x̅= 54), followed by interoperability (x̅ = 46), person-enabled health (x̅ = 36), and predictive analytics (x̅ = 30). CONCLUSION: The findings were incorporated into the new digital health strategy for the jurisdiction. As one of the largest single simultaneous assessments of digital health capability globally, the findings and lessons learnt offer insights for policy makers and organizational managers.

Understanding consumer preference for vascular access safety and quality measurement: an international survey.

Objectives The aim of this study was to examine patient perceptions regarding vascular access quality measurement. Methods A web-based, cross-sectional survey was performed using a convenience sample of healthcare consumers with vascular access experience, recruited from September 2019 to June 2020. Survey respondents were asked to rate the perceived importance of 50 vascular access data items, including patient demographics, clinical and device characteristics, and insertion, management and complication data. Data were ranked using a five-point Likert scale (1, least important; 5, most important), and are reported as median values. Respondents proposed additional items and explored broader perspectives using free-text responses, which were analysed using inductive thematic analysis. Results In all, 68 consumers completed the survey. Participants were primarily female (82%), aged 40-49 years (29%) and living in Australia or New Zealand (84%). All respondents indicated that measuring the quality of vascular access care was important. Of the 50 items, 37 (74%) were perceived as 'most important' (median score 5), with measures of quality (i.e. outcomes and complications) rated highly (e.g. thrombosis and primary blood stream infection). Participants proposed 16 additional items. 'Gender' received the lowest perceived importance score (median score 3). Two themes emerged from the qualitative analysis of broader perspectives: (1) measurement of vascular access device complication severity and associated factors; and (2) patient experience. Conclusion Measuring vascular access quality and safety is important to consumers. Outcome and complication measures were rated 'most important', with respondents identifying a need for increased monitoring of their overall vascular access journey through the health system. What is known about the topic? The use of vascular access devices is common among hospitalised patients. Quality surveillance is not standardised, with no incorporation of patient preference. What does this paper add? We identify the data items consumers perceive as valuable to measure related to their vascular access journey; most importantly, consumers perceived the collecting of vascular access data as important. What are the implications for practitioners? Health services can use these data to develop platforms to monitor the quality and safety of vascular access care.

Moving Faster than the COVID-19 Pandemic: The Rapid, Digital Transformation of a Public Health System.

BACKGROUND: Queensland, Australia has been successful in containing the COVID-19 pandemic. Underpinning that response has been a highly effective virus containment strategy which relies on identification, isolation, and contact tracing of cases. The dramatic emergence of the COVID-19 pandemic rendered traditional paper-based systems for managing contact tracing no longer fit for purpose. A rapid digital transformation of the public health contact tracing system occurred to support this effort. OBJECTIVES: The objectives of the digital transformation were to shift legacy systems (paper or standalone electronic systems) to a digitally enabled public health system, where data are centered around the consumer rather than isolated databases. The objective of this paper is to outline this case study and detail the lessons learnt to inform and give confidence to others contemplating digitization of public health systems in response to the COVID-19 pandemic. METHODS: This case study is set in Queensland, Australia. Universal health care is available. A multidisciplinary team was established consisting of clinical informaticians, developers, data strategists, and health information managers. An agile "pair-programming" approach was undertaken to application development and extensive change efforts were made to maximize adoption of the new digital workflows. Data governance and flows were changed to support rapid management of the pandemic. RESULTS: The digital coronavirus application (DCOVA) is a web-based application that securely captures information about people required to quarantine and creates a multiagency secure database to support a successful containment strategy. CONCLUSION: Most of the literature surrounding digital transformation allows time for significant consultation, which was simply not possible under crisis conditions. Our observation is that staff was willing to adopt new digital systems because the reason for change (the COVID-19 pandemic) was clearly pressing. This case study highlights just how critical a unified purpose, is to successful, rapid digital transformation.

Managing the Digital Disruption Associated with COVID-19-Driven Rapid Digital Transformation in Brisbane, Australia.

BACKGROUND: The COVID-19 pandemic has forced rapid digital transformation of many health systems. These innovations are now entering the literature, but there is little focus on the resulting disruption. OBJECTIVE: We describe the implementation of digital innovations during the COVID-19 response of Australia's largest health service, Metro North (in Brisbane, Queensland), the challenges of the subsequent digital disruption, how these were managed, and lessons learned. METHODS: Prior to the COVID-19 pandemic, the Australian state of Queensland created the Queensland Digital Clinical Charter, which provides guidance for the development of digital health programs. The guidelines utilize three horizons: digitizing workflows, leveraging digital data to transform clinical care, and reimagining new and innovative models of care. The technical response to COVID-19 in Metro North is described across these horizons. The rapid digital response caused significant disruption to health care delivery; management of the disruption and the outcomes are detailed. This is a participatory action research project, with members of the research team assisting with leading the implementation project informing the case report content. RESULTS: Several digital innovations were introduced across Metro North during the COVID-19 response. This resulted in significant disruption creating digital hypervigilance, digital deceleration, data discordance, and postdigital "depression." Successful management of the digital disruption minimized the negative effects of rapid digital transformation, and contributed to the effective management of the pandemic in Queensland. CONCLUSION: The rapid digital transformation in Metro North during COVID-19 was successful in several aspects; however, ongoing challenges remain. These include the need to improve data sharing and increase interoperability. Importantly, the innovations need to be evaluated to ensure that Metro North can capitalize on these changes and incorporate them into long-term routine practice. Moving forward, it will be essential to manage not only the pandemic, but increasingly, the resultant digital disruption.

Queensland Genomics: an adaptive approach for integrating genomics into a public healthcare system.

The establishment of genomics in health care systems has been occurring for the past decade. It is recognised that implementing genomics within a health service is challenging without a system-wide approach. Globally, as clinical genomics implementation programs have matured there is a growing body of information around program design and outcomes. Program structures vary depending on local ecosystems including the health system, politics and funding availability, however, lessons from other programs are important to the design of programs in different jurisdictions. Here we describe an adaptive approach to the implementation of genomics into a publicly funded health care system servicing a population of 5.1 million people. The adaptive approach enabled flexibility to facilitate substantial changes during the program in response to learnings and external factors. We report the benefits and challenges experienced by the program, particularly in relation to the engagement of people and services, and the design of both individual projects and the program as a whole.

Narrowing of T-cell receptor beta variable repertoire during symptomatic herpesvirus infection in transplant patients.

Primary infection or recrudescence of latent virus infection in transplant recipients can be manifested either as asymptomatic or symptomatic disease. Here we show that symptomatic human cytomegalovirus (HCMV) or Epstein-Barr virus (EBV) infection or recrudescence following solid organ transplantation (SOT) was coincident with a dramatic skewing of T-cell receptor beta variable (TRBV) repertoire, with expansions of monoclonal/oligoclonal clonotypes. As the clinical symptoms resolved, the peripheral blood repertoire reverted to a more diverse distribution. In contrast, SOT recipients with asymptomatic or no viral infection or recrudescence showed minimal or no skewing of the T-cell receptor repertoire to maintain peripheral blood repertoire diversity. More importantly, we show that large monoclonal/oligoclonal repertoire expansions are associated with the loss of HCMV-specific T-cell function observed in SOT patients undergoing symptomatic viral infection or recrudescence, whereas SOT recipients who maintain peripheral blood TRBV repertoire diversity and functional antigen-specific T-cell responses can resist clinical symptomatic disease in spite of high levels of viral load.

Atrial versus ventricular cannulation for a rotary ventricular assist device.

The ventricular assist device inflow cannulation site is the primary interface between the device and the patient. Connecting these cannulae to either atria or ventricles induces major changes in flow dynamics; however, there are little data available on precise quantification of these changes. The objective of this investigation was to quantify the difference in ventricular/vascular hemodynamics during a range of left heart failure conditions with either atrial (AC) or ventricular (VC) inflow cannulation in a mock circulation loop with a rotary left VAD. Ventricular ejection fraction (EF), stroke work, and pump flow rates were found to be consistently lower with AC compared with VC over all simulated heart failure conditions. Adequate ventricular ejection remained with AC under low levels of mechanical support; however, the reduced EF in cases of severe heart failure may increase the risk of thromboembolic events. AC is therefore more suitable for class III, bridge to recovery patients, while VC is appropriate for class IV, bridge to transplant/destination patients.

Queensland Digital Health Clinical Charter: a clinical consensus statement on priorities for digital health in hospitals.

Digital transformation of Australian hospitals is occurring rapidly. Although the clinical community has had limited ability to influence high-level decision making and investments into digital health technologies, as these technologies increasingly transform the way patients are cared for, the clinical community must influence the digital health agenda and be an integral part of the decision-making process. This case study details the process and lessons learnt during the development of the state-wide consensus statement detailing the clinical requirements for digital health initiatives to form the Queensland Digital Health Clinical Charter. To the best of our knowledge, Queensland is the first Australian jurisdiction to create a Digital Clinical Charter to be specifically referenced in the investment in and governance of digital health in hospitals. By developing this clinical charter for digital health, and in articulating the needs of clinicians, a clinical framework will be added to both the decision-making process around the investments in digital health and the definition and realisation of the expected benefits from these sizable investments.

Human metapneumovirus in lung transplant recipients and comparison to respiratory syncytial virus.

RATIONALE: Human metapneumovirus is a newly described virus isolated in 2001 from children with acute respiratory viral infection. It has subsequently been reported globally, although there are limited data in lung transplant recipients. OBJECTIVES: To prospectively analyze whether human metapneumovirus was circulating in our adult lung transplant community and assess the morbidity of this infection and to compare the clinical presentation and outcome after intravenous ribavirin of human metapneumovirus with that of respiratory syncytial virus (RSV). METHODS: Lung transplant patients with clinical features of respiratory viral infection underwent nasopharyngeal aspirates. Patients with a positive specimen for RSV or human metapneumovirus by reverse transcriptase-polymerase chain reaction analysis and graft dysfunction received intravenous ribavirin and pulse steroid therapy. MEASUREMENTS AND MAIN RESULTS: Eighty-nine patients had 199 visits for aspirate studies. A viral cause was determined for 62 visits in 47 patients (19 human metapneumovirus, 18 RSV, 13 parainfluenza, 9 influenza A, 2 adenovirus, and 1 influenza B). A significant percentage of patients with metapneumovirus (63%) and RSV (72%) developed graft dysfunction, with average declines in FEV(1) of 30 +/- 12.4% and 25.9 +/- 11.2%, respectively. In these patients, bronchiolitis obliterans syndrome onset or progression occurred in no patients with human metapneumovirus compared with 5 of 13 (38%) patients with RSV at 6 months. CONCLUSIONS: Human metapneumovirus is a leading cause of acute respiratory tract illness in lung transplant recipients. The incidence and clinical spectrum at presentation are similar to RSV, although the latter seems to be associated with a higher risk of chronic rejection. We recommend testing of nasopharyngeal aspirates for human metapneumovirus with polymerase chain reaction to assess local epidemiologic patterns.

Bosentan therapy in patients with pulmonary arterial hypertension: the relationship between improvements in 6 minute walk distance and quality of life.

BACKGROUND AND OBJECTIVE: Bosentan, an oral, dual endothelin receptor antagonist, significantly improves functional status, haemodynamic measures and survival in patients with pulmonary arterial hypertension (PAH). However, there are limited data on the effect of bosentan on quality of life (QOL) and its relationship to changes in functional status, as measured by the 6 minute walk distance (6MWD). METHODS: A retrospective analysis was performed of a large, open-label, multicentre trial (VITAL) of bosentan in patients with PAH. Data for 6MWD were collected at baseline, 3 or 6 months and these results were correlated with QOL measurements collected as part of the assessment of patients enrolled in the trial. RESULTS: Sixty-nine patients with PAH (mean age 52 years) who were enrolled in the trial had valid QOL (SF-36) measurements and 6MWD data that could be retrieved from clinical notes. At 3 and 6 months, bosentan therapy improved 6MWD compared with baseline (49.5 m and 47.2 m, respectively, P < 0.001) as well as QOL domains, with a significant correlation between these two markers on cross-sectional analysis. However, there was a poor relationship when comparing changes in 6MWD with changes in QOL, in response to therapy. CONCLUSION: Bosentan therapy was associated with improvements in QOL and 6MWD for at least 6 months. At all measured time points, there was a close correlation between 6MWD and most QOL domains. QOL is an important parameter and should be considered as part of the standard assessment for any trial investigating therapy in PAH.

The BiVACOR rotary biventricular assist device: concept and in vitro investigation.

The BiVACOR is a novel rotary Biventricular Assist Device (BiVAD) undergoing development to treat global end-stage heart failure. The design includes left and right vanes positioned on a shared rotating hub to form a double-sided magnetically and hydrodynamically suspended centrifugal impeller. The performance of the device was assessed in a pulsatile mock circulation loop replicating end-stage biventricular heart failure, and was shown to restore flow from pathological (2 L/min) to normal levels (5 L/min). A novel technique to balance the left/right outflow of the BiVAD was also investigated, for which a maximum relative left to right outflow differential of 1.8 L/min was achieved at normal physiologic afterloads. The in vitro results encourage device progression to in vivo animal studies. Successful development of this BiVAD will provide a suitably miniature device for patients who require biventricular assistance.

Fast track recovery following en bloc heart-lung-liver transplantation in a patient with cystic fibrosis complicated by severe portal hypertension.

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Evidence for immunosuppression in lung transplantation.

PURPOSE OF REVIEW: Historically, most lung transplant recipients have received triple-drug maintenance immunosuppression consisting of a calcineurin inhibitor, azathioprine, and prednisolone. The introduction of mycophenolate mofetil, mammalian target of rapamycin (mTOR) inhibitors, and antibody-based induction therapy has broadened immunosuppressive options. The purpose of this review is to summarize the evidence for immunosuppressive regimens in the prevention and treatment of lung allograft rejection. RECENT FINDINGS: In clinical practice there has been a shift towards the de-novo use of more potent immunosuppressive regimens incorporating tacrolimus and mycophenolate post-transplant. The available evidence, however, suggests that such protocols do not lessen the risk of development of chronic allograft rejection [bronchiolitis obliterans syndrome (BOS)] compared with more traditional therapy. The role of antibody-based induction therapy remains controversial, with no survival benefit demonstrated in trials to date. The mTOR inhibitors have marked antifibroproliferative activity and are being rigorously evaluated in large, multicenter, randomized trials focused on the prevention of both acute and chronic lung rejection. SUMMARY: Combination therapy with a calcineurin inhibitor, antimetabolite, and a corticosteroid derivative remains the backbone of lung transplant immunosuppression. Induction therapy (in whatever form) may reduce acute rejection, but does not lower the incidence of chronic rejection or improve survival. New strategies utilizing mTOR inhibitors may herald a more promising era.