Canada's Digital Health Workforce: The Role of Innovation, Research and Policy.

The rapid growth of digital health and use of technology has led to an increased demand for qualified professionals in the areas of health informatics (HI) and health information management (HIM). This is reflected by the growth in the number of educational programs and graduates in these areas. However, to develop a culture of digital health innovation in Canada, the role of research needs to be critically examined. In this paper we discuss some of these issues around the relation between research and innovation, and the development of an innovation culture in health informatics, health information management and digital health in Canada. Recommendations for facilitating this development in terms of funding, granting and policy are also explored.

Human factors in healthcare IT: Management considerations and trends.

A range of human factors issues are recognized as critical to the success of projects involving Health Information Technology (HIT). Problems related to the usability of HIT have come to the fore, with continued reports of systems that are non-intuitive and difficult to use and that may even pose safety risks. In this article, we consider a number of approaches from usability engineering and human factors that can be applied to improve the chances of system success and adoption. A range of methods focused around human factors can be employed throughout the system development cycle of HIT. The purpose of this article is to discuss human factors approaches that can be used to improve the likelihood of successful system adoption and also provide input into the selection and procurement process of HIT. The article concludes with recommendations regarding how understanding of human factors can be integrated into healthcare organizational decision making.

An Evaluation Guide and Decision Support Tool for Journey Maps in Healthcare and Beyond.

The journey map concept evolved out of the service design field and is still relatively new in the healthcare landscape [1]. Journey maps are visualizations that effectively highlight organizational issues and allow stakeholder groups to be depicted by interest or function for a comparative visual analysis [2]. There are five journey map approaches: 1) Mental (Cognitive) Model Map, 2) Customer Journey Map, 3) Experience Map, 4) Service Blueprint Map, 5) Spatial Map. The objective of this article is three-fold: 1) quantify and delineate the journey mapping visualization techniques utilized from the phase 1 scoping review [2], 2) create a Journey Map Evaluation Guide, 3) create a Journey Map Decision Support Tool to facilitate a standardized method for journey map selection. For those less familiar with journey mapping, this framework can serve as a decision-making tool to facilitate the most effective choice among the different journey mapping visualization approaches. The tools presented in this study can provide a mechanism to standardize the assessment, classification and utilization of journey maps in the healthcare sector and industries abound.

Contextualizing Online Laboratory (lab) Results and Mapping the Patient Journey.

The 21st century has brought forth unprecedented technological advances, such as the advent of portable digital devices [1]. This trend has also permeated the health care sector, with the introduction of digital health services, like providing citizens with access to their online laboratory (lab) results. This qualitative study will illustrate the patient journey, namely participant 16 (P16), to address the research question: what phases does a person go through when accessing their lab results online? The findings revealed that lab results were accessed from two types of devices a tablet (e.g., portable computer) when at home and a mobile phone when away from home. We also found that interpretation of results can be a challenge and it was unclear if P16 was able to understand her lab results. To illustrate the complexity of interpreting and accessing online lab results, the authors created a Customer Journey Map to contextualize the experiences of P16. The journey map depicts a combination of factors such as: eHealth literacy, limited access to providers, difficulty interpreting lab test results. Additionally, recommendations for online lab portal functionality enhancements were discovered through the mapping exercise. This study demonstrated that along with providing citizens with access to digital health technologies and services, considerations to eHealth literacy, the digital divide and health equity are paramount. As evidenced by the visualization, journey maps hold promise to serve as efficient tools to build empathy and identify the unique needs and perspectives of citizens.

Integrating Human Patterns of Qualitative Coding with Machine Learning: A Pilot Study Involving Technology-Induced Error Incident Reports.

The objective of this research was to develop a reproducible method of integrating human patterns of qualitative coding with machine learning. The application of qualitative codes from the technology-induced error and safety literatures to the analysis of incident reports was done successfully, helping to identify the factors that lead to an error as well as the errors themselves. The method described in this paper may provide additional insights into understanding technology-induced errors.

Complexity and Health Technology Safety.

In many ways health technology safety has improved significantly over the past few decades. Yet, we still have examples of incidents where safety of health technology systems of care have led to possible and actual safety incidents. In this paper we examine the complexity of errors in an increasingly complex and digitized system of care. Although safety incidents are decreasing over time due to improvements in the tools used to support care, they still occur. Simple safety incidents prevailed in the 2005. Today, incident reports suggest complexity has emerged as an important issue that needs to be addressed in order to make further healthcare industry safety gains.

Evaluating a post-implementation electronic medical record training intervention for diabetes management in primary care.

OBJECTIVE: This study evaluated the potential for electronic medical record (EMR) video tutorials to improve diabetes (type 1 and 2) care processes by primary care physicians (PCP) using OSCAR EMR. DESIGN: A QUAN(qual) mixed methods approach with an embedded design was used for the overall research study. EMR video tutorials were developed based on the chronic care model (CCM), value-adding EMR use, best practice guidelines for designing software video tutorials and clinician-led EMR training. RESULTS: In total, 18 PCPs from British Columbia, Canada, participated in the study. The video EMR intervention elicited a statistically significant increase in EMR advanced feature use for diabetes care, with a large effect size (ie, F(1,51)=6.808, p<0.001, partial η2=0.286). CONCLUSION: This small-scale efficacy study demonstrates the potential of CCM-based EMR video tutorials to improve EMR use for chronic diseases, such as diabetes. A larger-scale effectiveness study with a control group is needed to further validate the study findings and determine their generalisability. The demonstrated efficacy of the intervention suggests that EMR video tutorials may be a cost-effective, sustainable and scalable strategy for supporting EMR optimisation and the continuous learning and development of PCPs. Health informatics practitioners may develop video tutorials for their respective EMR/electronic health record software based on theory and best practices for video tutorial design. For patients, EMR video tutorials may lead to improved tracking of processes of care for diabetes, and potentially other chronic conditions.

Effects of Telenursing Triage and Advice on Healthcare Costs and Resource Use.

Telenursing triage and advice services are continuing to expand both nationally and internationally. A primary role of telehealth nursing triage is to channel patients or clients towards appropriate levels of care, thereby reducing healthcare costs and freeing up resources. PURPOSE: The objective of this research is to: (a) present an overview of the current research, (b) describe the extent to which telenursing services are fulfilling this role, (c) identify gaps in the literature and (d) propose future research directions. METHODS: The report consists of a scoping review of current literature based on the framework suggested by Arkseyand O'Malley (2005). RESULTS: Although the available research spans a variety of jurisdictions, which makes comparison difficult, there is some evidence that suggests telenursing services empower clients to access levels of care in keeping with the severity of their symptoms, as well as enabling clients to engage in self-care when appropriate. This in turn leads to cost savings for the broader health care system. CONCLUSION: More evaluation of telenursing programs is needed to identify consistent savings. Health outcomes should be a part of the research.

Bridging the Gap Between Academic Research and Pragmatic Needs in Usability: A Hybrid Approach to Usability Evaluation of Health Care Information Systems.

BACKGROUND: Technology is increasingly embedded into the full spectrum of health care. This movement has benefited from the application of software development practices such as usability testing and agile development processes. These practices are frequently applied in both commercial or operational and academic settings. However, the relative importance placed on rapid iteration, validity, reproducibility, generalizability, and efficiency differs between the 2 settings and the needs and objectives of academic versus pragmatic usability evaluations. OBJECTIVE: This paper explores how usability evaluation typically varies on key dimensions in pragmatic versus academic settings that impact the rapidity, validity, and reproducibility of findings and proposes a hybrid approach aimed at satisfying both pragmatic and academic objectives. METHODS: We outline the characteristics of pragmatic versus academically oriented usability testing in health care, describe the tensions and gaps resulting from differing contexts and goals, and present a model of this hybrid process along with 2 case studies of digital development projects in which we demonstrate this integrated approach to usability evaluation. RESULTS: The case studies presented illustrate design choices characteristic of our hybrid approach to usability evaluation. CONCLUSIONS: Designed to leverage the strengths of both pragmatically and academically focused usability studies, a hybrid approach allows new development projects to efficiently iterate and optimize from usability data as well as preserves the ability of these projects to produce deeper insights via thorough qualitative analysis to inform further tool development and usability research by way of academically focused dissemination.

Towards a Framework for Managing Risk Associated with Technology-Induced Error.

Health information technologies (HIT) promised to streamline and modernize healthcare processes. However, a growing body of research has indicated that if such technologies are not designed, implemented or maintained properly this may lead to an increased incidence of new types of errors which the authors have referred to as "technology-induced errors". In this paper, framework is presented that can be used to manage HIT risk. The framework considers the reduction of technology-induced errors at different stages by managing risks associated with the implementation of HIT. Frameworks that allow health information technology managers to employ proactive and preventative approaches that can be used to manage the risks associated with technology-induced errors are critical to improving HIT safety and managing risk associated with implementing new technologies.

Deriving a Set of Privacy Specific Heuristics for the Assessment of PHRs (Personal Health Records).

With the emergence of personal health record (PHR) platforms becoming more widely available, this research focused on the development of privacy heuristics to assess PHRs regarding privacy. Existing sets of heuristics are typically not application specific and do not address patient-centric privacy as a main concern prior to undergoing PHR procurement. A set of privacy specific heuristics were developed based on a scoping review of the literature. An internet-based commercially available, vendor specific PHR application was evaluated using the derived set of privacy specific heuristics. The proposed set of privacy specific derived heuristics is explored in detail in relation to ISO 29100. The assessment of the internet-based commercially available, vendor specific PHR application indicated numerous violations. These violations were noted within the study. It is argued that the new derived privacy heuristics should be used in addition to Nielsen's well-established set of heuristics. Privacy specific heuristics could be used to assess PHR portal system-level privacy mechanisms in the procurement process of a PHR application and may prove to be a beneficial form of assessment to prevent the selection of a PHR platform with a poor privacy specific interface design.

Low-Cost Rapid Usability Testing: Its Application in Both Product Development and System Implementation.

In recent years there has been considerable discussion around the need for certification and regulation of healthcare information technology (IT). In particular, the usability of the products being developed needs to be evaluated. This has included the application of standards designed to ensure the process of system development is user-centered and takes usability into consideration while a product is being developed. In addition to this, in healthcare, organizations in the United States and Europe have also addressed the need and requirement for product certification. However, despite these efforts there are continued reports of unusable and unsafe implementations. In this paper we discuss the need to not only include (and require) usability testing in the one-time development process of health IT products (such as EHRs), but we also argue for the need to additionally develop specific usability standards and requirements for usability testing during the implementation of vendor products (i.e. post product development) in healthcare settings. It is further argued that health IT products that may have been certified regarding their development process will still require application of usability testing in the process of implementing them in real hospital settings in order to ensure usability and safety. This is needed in order to ensure that the final result of both product development and implementation processes take into account and apply the latest usability principles and methods.

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.

A Comparison of Two Principal Systems for Monitoring of Technology-Induced Errors in Electronic Health Records.

Current methods for monitoring harm caused by health information technology (HIT) are minimal, even if there are known risks associated with the use of HIT. Monitoring is predominantly based on voluntary reporting using generic patient safety adverse events reporting systems. Another important means for monitoring technology-induced errors is a health authority reporting system. International oversight systems have medical devices' related software's adverse event and failure reporting models, but these systems differ due to differencies in the legislation. The protocol for this study included an electronic database literature search and the eliciting of information for study purposes from the literature. The purpose is to provide a scoping review focused on two types of systems and provide implications for monitoring technology-induced errors in the future. The analysis revealed not only differences, but also similarities between these systems which raises the question of these systems' effectiveness due to overlapping goals in collecting data.

Evidence-based Heuristics for Evaluating Demands on eHealth Literacy and Usability in a Mobile Consumer Health Application.

Heuristic evaluations have proven to be valuable for identifying usability issues in systems. Commonly used sets of heuritics exist; however, they may not always be the most suitable, given the specific goal of the analysis. One such example is seeking to evaluate the demands on eHealth literacy and usability of consumer health information systems. In this study, eight essential heuristics and three optional heuristics subsumed from the evidence on eHealth/health literacy and usability were tested for their utility in assessing a mobile blood pressure tracking application (app). This evaluation revealed a variety of ways the design of the app could both benefit and impede users with limited eHealth literacy. This study demonstrated the utility of a low-cost, single evaluation approach for identifying both eHealth literacy and usability issues based on existing evidence in the literature.

Use of Techno-Anthropologic Approaches in Studying Technology--induced Errors.

In this book chapter the authors review several Techno-Anthropologic approaches that can be used to improve the quality and safety of health information technology (HIT) by eliminating or reducing the incidence and occurrence of technology-induced errors. Technology-induced errors arise from interactions between health professionals, patients and/or HIT (i.e., software and hardware) and lead to a medical error. Techno-Anthropologic methods can be used to address these types of medical errors before they occur. In this book chapter they are discussed in the context of: (a) how they can be applied to identifying technology-induced errors and (b) how this information can be used to design and implement safer HIT. Important in this chapter is a review of several methods: traditional ethnography, rapid assessment of clinical information systems, video ethnography and photovoice as they are applied to the discovery of potential (i.e., near misses) and actual (i.e., mistakes) technology-induced errors.

Insights and limits of usability evaluation methods along the health information technology lifecycle.

A great variety of usability evaluation methods exist but they do not provide the same kind of results and do not address the same stage of the Health Information Technology (HIT) lifecycle. This paper takes stock of the application of expert evaluation, usability testing, clinical simulation, clinical trials and post-implementation surveillance to provide an overview of their main similarities and differences. Results from this comparison will help in choosing methods that are best able to evaluate a HIT and improve its usability and ultimately its safety of use.

Integrating Low-Cost Rapid Usability Testing into Agile System Development of Healthcare IT: A Methodological Perspective.

The development of more usable and effective healthcare information systems has become a critical issue. In the software industry methodologies such as agile and iterative development processes have emerged to lead to more effective and usable systems. These approaches highlight focusing on user needs and promoting iterative and flexible development practices. Evaluation and testing of iterative agile development cycles is considered an important part of the agile methodology and iterative processes for system design and re-design. However, the issue of how to effectively integrate usability testing methods into rapid and flexible agile design cycles has remained to be fully explored. In this paper we describe our application of an approach known as low-cost rapid usability testing as it has been applied within agile system development in healthcare. The advantages of the integrative approach are described, along with current methodological considerations.

Integrating heuristic evaluation with cognitive walkthrough: development of a hybrid usability inspection method.

Developing more usable healthcare information systems has become an important goal in health informatics. Although methods from usability engineering have appeared and been effectively applied in the design and evaluation of healthcare systems, there continues to be reports of deployment of unusable systems and issues with adoption of healthcare IT worldwide. In this paper we propose a new cost-effective usability engineering approach for healthcare IT that integrates two of the major usability inspection approaches (heuristic evaluation and cognitive walkthrough) into one combined approach that leverages the advantages of both heuristic evaluation and cognitive walkthrough. The approach will be described as will a pilot application of the method in evaluating the usability of a well-known electronic health record system. Implications and future work will also be described.

An evaluation of health information technology outsourcing success.

Outsourcing involves contracting out functions performed by an organization to another organization. Many healthcare organizations are exploring outsourcing as a way to address demands for health information technology (HIT). This study researches the success of outsourcing in the health informatics industry in Canada. The study is designed to help understand whether outsourcing four functions of HIT (i.e. development, implementation, operations, and maintenance) can prove successful for an organization. Findings demonstrate that outsourcing these four functions occurs in Canada; however, the research from the semi-structured interviews finds that operations and maintenance may be more commonly outsourced in Canada, over development and implementation functions. Despite this, findings from this research suggest that outsourcing development and implementation may offer more benefits and fewer challenges than outsourcing operations and maintenance. The research also finds that there can be benefits of outsourcing, such as gaining access to expertise and improving service levels. A weakness of outsourcing may be that internal knowledge is lost and having to manage the change required from outsourcing. The study proposes that there are many factors that need to be considered when outsourcing to ensure it is successful.