Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study.

BACKGROUND: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial. OBJECTIVE: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits. METHODS: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits. RESULTS: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services. CONCLUSIONS: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.

Artificial Intelligence in Clinical Decision Support: Challenges for Evaluating AI and Practical Implications.

OBJECTIVES: This paper draws attention to: i) key considerations for evaluating artificial intelligence (AI) enabled clinical decision support; and ii) challenges and practical implications of AI design, development, selection, use, and ongoing surveillance. METHOD: A narrative review of existing research and evaluation approaches along with expert perspectives drawn from the International Medical Informatics Association (IMIA) Working Group on Technology Assessment and Quality Development in Health Informatics and the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems. RESULTS: There is a rich history and tradition of evaluating AI in healthcare. While evaluators can learn from past efforts, and build on best practice evaluation frameworks and methodologies, questions remain about how to evaluate the safety and effectiveness of AI that dynamically harness vast amounts of genomic, biomarker, phenotype, electronic record, and care delivery data from across health systems. This paper first provides a historical perspective about the evaluation of AI in healthcare. It then examines key challenges of evaluating AI-enabled clinical decision support during design, development, selection, use, and ongoing surveillance. Practical aspects of evaluating AI in healthcare, including approaches to evaluation and indicators to monitor AI are also discussed. CONCLUSION: Commitment to rigorous initial and ongoing evaluation will be critical to ensuring the safe and effective integration of AI in complex sociotechnical settings. Specific enhancements that are required for the new generation of AI-enabled clinical decision support will emerge through practical application.

The Safe and Effective Use of Shared Data Underpinned by Stakeholder Engagement and Evaluation Practice.

OBJECTIVES: The paper draws attention to: i) key considerations involving the confidentiality, privacy, and security of shared data; and ii) the requirements needed to build collaborative arrangements encompassing all stakeholders with the goal of ensuring safe, secure, and quality use of shared data. METHOD: A narrative review of existing research and policy approaches along with expert perspectives drawn from the International Medical Informatics Association (IMIA) Working Group on Technology Assessment and Quality Development in Health Care and the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems. RESULTS: The technological ability to merge, link, re-use, and exchange data has outpaced the establishment of policies, procedures, and processes to monitor the ethics and legality of shared use of data. Questions remain about how to guarantee the security of shared data, and how to establish and maintain public trust across large-scale shared data enterprises. This paper identifies the importance of data governance frameworks (incorporating engagement with all stakeholders) to underpin the management of the ethics and legality of shared data use. The paper also provides some key considerations for the establishment of national approaches and measures to monitor compliance with best practice. CONCLUSION: Data sharing endeavours can help to underpin new collaborative models of health care which provide shared information, engagement, and accountability amongst all stakeholders. We believe that commitment to rigorous evaluation and stakeholder engagement will be critical to delivering health data benefits and the establishment of collaborative models of health care into the future.

Usability problems do not heal by themselves: National survey on physicians' experiences with EHRs in Finland.

PURPOSE: Survey studies of health information systems use tend to focus on availability of functionalities, adoption and intensity of use. Usability surveys have not been systematically conducted by any healthcare professional groups on a national scale on a repeated basis. This paper presents results from two cross-sectional surveys of physicians' experiences with the usability of currently used EHR systems in Finland. The research questions were: To what extent has the overall situation improved between 2010 and 2014? What differences are there between healthcare sectors? METHODS: In the spring of 2014, a survey was conducted in Finland using a questionnaire that measures usability and respondents' user experiences with electronic health record (EHR) systems. The survey was targeted to physicians who were actively doing clinical work. Twenty-four usability-related statements, that were identical in 2010 and 2014, were analysed from the survey. The respondents were also asked to give an overall rating of the EHR system they used. The study data comprised responses from 3081 physicians from the year 2014 and from 3223 physicians in the year 2010, who were using the nine most commonly used EHR system brands in Finland. RESULTS: Physicians' assessments of the usability of their EHR system remain as critical as they were in 2010. On a scale from 1 ('fail') to 7 ('excellent') the average of overall ratings of their principally used EHR systems varied from 3.2 to 4.4 in 2014 (and in 2010 from 2.5 to 4.3). The results show some improvements in the following EHR functionalities and characteristics: summary view of patient's health status, prevention of errors associated with medication ordering, patient's medication list as well as support for collaboration and information exchange between the physician and the nurses. Even so, support for cross-organizational collaboration between physicians and for physician-patient collaboration were still considered inadequate. Satisfaction with technical features had not improved in four years. The results show marked differences between the EHR system brands as well as between healthcare sectors (private sector, public hospitals, primary healthcare). Compared to responses from the public sector, physicians working in the private sector were more satisfied with their EHR systems with regards to statements about user interface characteristics and support for routine tasks. Overall, the study findings are similar to our previous study conducted in 2010. CONCLUSIONS: Surveys about the usability of EHR systems are needed to monitor their development at regional and national levels. To our knowledge, this study is the first national eHealth observatory questionnaire that focuses on usability and is used to monitor the long-term development of EHRs. The results do not show notable improvements in physician's ratings for their EHRs between the years 2010 and 2014 in Finland. Instead, the results indicate the existence of serious problems and deficiencies which considerably hinder the efficiency of EHR use and physician's routine work. The survey results call for considerable amount of development work in order to achieve the expected benefits of EHR systems and to avoid technology-induced errors which may endanger patient safety. The findings of repeated surveys can be used to inform healthcare providers, decision makers and politicians about the current state of EHR usability and differences between brands as well as for improvements of EHR usability. This survey will be repeated in 2017 and there is a plan to include other healthcare professional groups in future surveys.

Steps in Moving Evidence-Based Health Informatics from Theory to Practice.

OBJECTIVES: To demonstrate and promote the importance of applying a scientific process to health IT design and implementation, and of basing this on research principles and techniques. METHODS: A review by international experts linked to the IMIA Working Group on Technology Assessment and Quality Development. RESULTS: Four approaches are presented, linking to the creation of national professional expectations, adherence to research-based standards, quality assurance approaches to ensure safety, and scientific measurement of impact. CONCLUSIONS: Solely marketing- and aspiration-based approaches to health informatics applications are no longer ethical or acceptable when scientifically grounded evidence-based approaches are available and in use.

Theoretical Foundations for Evidence-Based Health Informatics: Why? How?

A scientific approach to health informatics requires sound theoretical foundations. Health informatics implementation would be more effective if evidence-based and guided by theories about what is likely to work in what circumstances. We report on a Medinfo 2015 workshop on this topic jointly organized by the EFMI Working Group on Assessment of Health Information Systems and the IMIA Working Group on Technology Assessment and Quality Development. We discuss the findings of the workshop and propose an approach to consolidate empirical knowledge into testable middle-range theories.

Multinational surveys for monitoring eHealth policy implementations--usefulness and pitfalls.

Development of multinational variables for monitoring eHealth policy implementations is a complex task and requires multidisciplinary, knowledge-based international collaboration. Experts in an interdisciplinary workshop identified useful data and pitfalls for comparative variable development. The results are presented and discussed in this paper.

User experiences with different regional health information exchange systems in Finland.

PURPOSE: The interest in cross-organizational Health Information Exchange (HIE) is increasing at regional, national and cross-European levels. The purpose of our study was to compare user experiences (usability) of different regional health information exchange system (RHIE) types as well as the factors related to the experienced level of success of different RHIE system types. METHODS: A web-based questionnaire was sent to 95% of Finnish physicians aged between 25 and 65 years of age. RHIE systems were mainly available in the public sector and only in certain regions. Those 1693 physicians were selected from the 3929 respondents of the original study, who met these criteria. The preferred means (paper/fax vs. electronic) of cross-organizational HIE, and replies to the 11 questions measuring RHIE success were used as the main dependent variables. RESULTS: Two thirds (73%) of the primary care physicians and one third (33%) of the specialized care physicians replied using an electronic RHIE system rather than paper or fax as a primary means of cross-organizational HIE. Respondents from regions where a regional virtual EHR (type 3) RHIE system was employed had used electronic means rather than paper HIE to a larger extend compared to their colleagues in regions where a master patient index-type (type 1) or web distribution model (type 2) RHIE system was used. Users of three local EHR systems preferred electronic HIE to paper to a larger extend than users of other EHR systems. Experiences with an integrated RHIE system (type 3) were more positive than those with other types or RHIE systems. CONCLUSIONS: The study revealed User preferences for the integrated virtual RHIE-system (type 3) over the master index model (type 1) or web distribution model (type 2). Success of individual HIE tasks of writing, sending and reading were impacted by the way these functionalities were realized in the EHR systems. To meet the expectations of increased efficiency, continuity, safety and quality of care, designers of HIE systems also need to take into account the different HIE needs of primary care clinicians and their secondary care colleagues in hospitals. Both national legislation and local interpretations of data protection possibly hinder the full use of any RHIE systems. These findings should be taken into account when designing usable HIE systems. More qualitative research is needed on specific features of those local systems that are associated with positive or negative user experience.

Nordic eHealth indicators: organisation of research, first results and plan for the future.

eHealth indicator and benchmarking activities are rapidly increasing nationally and internationally. The work is rarely based on a transparent methodology for indicator definition. This article describes first results of testing an indicator methodology for defining eHealth indicators, which was reported at the Medical Informatics Europe conference in 2012. The core elements of the methodology are illustrated, demonstrating validation of each of them in the context of Nordic eHealth Indicator work. Validation proved the importance of conducting each of the steps of the methodology, with several scientific as well as practical outcomes. The article is based on a report to be published by the Nordic Council of Ministers [4].

eHealth indicators: results of an expert workshop.

eHealth indicators are needed to measure defined aspects of national eHealth implementations. However, until now, eHealth indicators are ambiguous or unclear. Therefore, an expert workshop "Towards an International Minimum Dataset for Monitoring National Health Information System Implementations" was organized. The objective was to develop ideas for a minimum eHealth indicator set. The proposed ideas for indicators were classified based on EUnetHTA and De-Lone & McClean, and classification was compared with health IT evaluation criteria classification by Ammenwerth & Keizer. Analysis of the workshop results emphasized the need for a common methodological framework for defining and classifying eHealth indicators. It also showed the importance of setting the indicators into context. The results will benefit policy makers, developers and researchers in pursuit of provision and use of evidence in management of eHealth systems.

Next steps in evaluation and evidence - from generic to context-related.

INTRODUCTION: E-health systems are increasingly important and widespread, but their selection and implementation are still frequently based on belief, rather than scientific evidence, and adverse effects are not systematically addressed. Progress is being made in promoting generic evaluation methodologies as a source of scientific evidence, but effort is now needed to consider methods for special situations. METHOD: Review of five evaluation contexts - national e-health plans, telemedicine, Health Informatics 3.0, usability and economics. CONCLUSION: Identification of requirements for approaches to be developed in these five settings.