Shifting Mindsets: The Impact of a Patient Portal on Functioning and Recovery in a Mental Health Setting.

OBJECTIVE: This study aims to understand whether higher use of a patient portal can have an impact on mental health functioning and recovery. METHOD: A mixed methods approach was used for this study. In 2019-2021, patients with mental health diagnoses at outpatient clinics in an academic centre were invited to complete World Health Organization Disability Assessment Scale 12 (WHODAS-12) and Mental Health Recovery Measure surveys at baseline, 3 months, and 6 months after signing up for the portal. At the 3-month time point, patients were invited to a semistructured interview with a member of the team to contextualize the findings obtained from the surveys. Analytics data was also collected from the platform to understand usage patterns on the portal. RESULTS: Overall, 113 participants were included in the analysis. There was no significant change in mental health functioning and recovery scores over the 6-month period. However, suboptimal usage was observed as 46% of participants did not complete any tasks within the portal. Thirty-five participants had low use of the portal (1-9 interactions) and 18 participants had high usage (10+ interactions). There were also no differences in mental health functioning and recovery scores between low and high users of the portal. Qualitative interviews highlighted many opportunities where the portal can support overall functioning and mental health recovery. CONCLUSIONS: Collectively, this study suggests that higher use of a portal had no impact, either positive or negative, on mental health outcomes. While it may offer convenience and improved patient satisfaction, adequate support is needed to fully enable these opportunities for patient care. As the type of interaction with the portal was not specifically addressed, future work should focus on looking at ways to support patient engagement and portal usage throughout their care journey.

AI Quality Standards in Health Care: Rapid Umbrella Review.

BACKGROUND: In recent years, there has been an upwelling of artificial intelligence (AI) studies in the health care literature. During this period, there has been an increasing number of proposed standards to evaluate the quality of health care AI studies. OBJECTIVE: This rapid umbrella review examines the use of AI quality standards in a sample of health care AI systematic review articles published over a 36-month period. METHODS: We used a modified version of the Joanna Briggs Institute umbrella review method. Our rapid approach was informed by the practical guide by Tricco and colleagues for conducting rapid reviews. Our search was focused on the MEDLINE database supplemented with Google Scholar. The inclusion criteria were English-language systematic reviews regardless of review type, with mention of AI and health in the abstract, published during a 36-month period. For the synthesis, we summarized the AI quality standards used and issues noted in these reviews drawing on a set of published health care AI standards, harmonized the terms used, and offered guidance to improve the quality of future health care AI studies. RESULTS: We selected 33 review articles published between 2020 and 2022 in our synthesis. The reviews covered a wide range of objectives, topics, settings, designs, and results. Over 60 AI approaches across different domains were identified with varying levels of detail spanning different AI life cycle stages, making comparisons difficult. Health care AI quality standards were applied in only 39% (13/33) of the reviews and in 14% (25/178) of the original studies from the reviews examined, mostly to appraise their methodological or reporting quality. Only a handful mentioned the transparency, explainability, trustworthiness, ethics, and privacy aspects. A total of 23 AI quality standard-related issues were identified in the reviews. There was a recognized need to standardize the planning, conduct, and reporting of health care AI studies and address their broader societal, ethical, and regulatory implications. CONCLUSIONS: Despite the growing number of AI standards to assess the quality of health care AI studies, they are seldom applied in practice. With increasing desire to adopt AI in different health topics, domains, and settings, practitioners and researchers must stay abreast of and adapt to the evolving landscape of health care AI quality standards and apply these standards to improve the quality of their AI studies.

Exploring the Impact of In Basket Metrics on the Adoption of a New Electronic Health Record System Among Specialists in a Tertiary Hospital in Alberta: Descriptive Study.

BACKGROUND: Health care organizations implement electronic health record (EHR) systems with the expectation of improved patient care and enhanced provider performance. However, while these technologies hold the potential to create improved care and system efficiencies, they can also lead to unintended negative consequences, such as patient safety issues, communication problems, and provider burnout. OBJECTIVE: This study aims to document metrics related to the In Basket communication hub (time in In Basket per day, time in In Basket per appointment, In Basket messages received per day, and turnaround time) of the EHR system implemented by Alberta Health Services, the province-wide health delivery system called Connect Care (Epic Systems). The objective was to identify how a newly implemented EHR system was used, the timing of its use, and the duration of use specifically related to In Basket activities. METHODS: A descriptive study was conducted. Due to the diversity of specialties, the providers were grouped into medical and surgical based on previous similar studies. The participants were further subgrouped based on their self-reported clinical full-time equivalent (FTE ) measure. This resulted in 3 subgroups for analysis: medical FTE <0.5, medical FTE >0.5, and surgical (all of whom reported FTE >0.5). The analysis was limited to outpatient clinical interactions and explicitly excluded inpatient activities. RESULTS: A total of 72 participants from 19 different specialties enrolled in this study. The providers had, on average, 8.31 appointments per day during the reporting periods. The providers received, on average, 21.93 messages per day, and they spent 7.61 minutes on average in the time in In Basket per day metric and 1.84 minutes on average in the time in In Basket per appointment metric. The time for the providers to mark messages as done (turnaround time) was on average 11.45 days during the reporting period. Although the surgical group had, on average, approximately twice as many appointments per scheduled day, they spent considerably less connected time (based on almost all time metrics) than the medical group. However, the surgical group took much longer than the medical group to mark messages as done (turnaround time). CONCLUSIONS: We observed a range of patterns with no consistent direction. There does not seem to be evidence of a "learning curve," which would have shown a consistent reduction in time spent on the system over time due to familiarity and experience. While this study does not show how the included metrics could be used as predictors of providers' satisfaction or feelings of burnout, the use trends could be used to start discussions about future Canadian studies needed in this area.

Framework for policymaking on self-management of health by older adults using technologies.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, the use of information and communication technologies (ICTs) to support care management exponentially increased. Governments around the world adapted existing programs to meet the needs of patients. The reactivity of governments, however, led to changes that were inequitable, undermining groups such as older adults living with chronic diseases and disability. Policies that align with recent developments in ICTs can promote better health outcomes and innovation in care management. A framework for policymaking presents potential for overcoming barriers and gaps that exist in current policies. OBJECTIVE: The goal of this study was to examine how well a provisional framework for policymaking represented the interactions between various components of government policymaking on older adults' self-management of chronic disease and disability using ICTs. METHODS: Through an online survey, the study engaged policymakers from various ministries of the government of Ontario in the evaluation and revision of the framework. The data were analyzed using simple statistics and by interpreting written comments. RESULTS: Nine participants from three ministries in the government of Ontario responded to the questionnaire. Overall, participants described the framework as useful and identified areas for improvement and further clarification. A revised version of the framework is presented. CONCLUSIONS: Through the revision exercise, our study confirmed the relevance and usefulness for a policymaking framework on the self-management of disease and disability of older adults' using ICTs. Further inquiries should examine the application of the framework to jurisdictions other than Ontario considering the dissociated nature of Canadian provincial healthcare systems.

When rules turn into tools: An activity theory-based perspective on implementation processes and unintended consequences.

The idea that actions of people, organizations or governments may lead to Unintended Consequences (UICs) is not new. In health, UICs have been reported as a result of various interventions including quality improvement initiatives, health information technology implementation, and knowledge translation, especially those involving translation of broad policies (evidence-based medicine and patient-centred care) or system level improvement into actionable items or tools. While some unintended consequences cannot be anticipated, others may be predictable. In this article, we present a model based on cultural historical activity theory, which may help policy-makers, health leaders, and researchers better anticipate UICs resulting from implementation of new programs or technologies and take action to address them or mitigate their risk of occurrence. We support this model using examples of UICs of implementing family centred care principles, electronic health records, and computerized templates for quality improvement in chronic disease management.

Evolution of public health policy on healthcare self-management: the case of Ontario, Canada.

BACKGROUND: As people live longer, they are at increased risk for chronic diseases and disability. Self-management is a strategy to improve health outcomes and quality of life of those who engage in it. This study sought to gain a better understanding of the factors, including digital technology, that affect public health policy on self-management through an analysis of government policy in the most populous and multicultural province in Canada: Ontario. The overarching question guiding the study was: What factors have influenced the development of healthcare self-management policies over time? METHODS: Archival research methods, combining document review and evaluation, were used to collect data from policy documents published in Ontario. The documents were analyzed using the READ approach, evaluated using a data extraction table, and synthesized into themes using the model for health policy analysis. RESULTS: Between January 1, 1985, and May 5, 2022, 72 policy documents on self-management of health were retrieved from databases, archives, and grey literature. Their contents largely focussed on self-management of general chronic conditions, while 47% (n = 18/72) mention diabetes, and 3% (n = 2/72) focussed solely on older adults. Digital technologies were mentioned and were viewed as tools to support self-management in the context of healthcare delivery and enhancing healthcare infrastructure (i.e., telehealth or software in healthcare settings). The actors involved in the policy document creation included mostly Ontario government agencies and departments, and sometimes expert organizations, community groups and engaged stakeholders. The results suggest that several factors including pressures on the healthcare system, hybrid top-down and bottom-up policymaking, and political context have influenced the nature and implementation timing of self-management policy in Ontario. CONCLUSIONS: The policy documents on self-management of health reveal a positive evolution of the content discussed over time. The changes were shaped by an evolving context, both from a health and political perspective, within a dynamic system of interactions between actors. This research helps understand the factors that have shaped changes and suggests that a critical evidence-based approach on public health policy is needed in understanding processes involved in the development of healthcare self-management policies from the perspective of a democratic governing system.

Policymaker perspectives on self-management of disease and disabilities using information and communication technologies.

BACKGROUND: Policies that support health self-management are malleable and highly dependent on various factors that influence governments. Within a world that is shifting toward digitalization due to pressures such as the COVID-19 pandemic and labor shortages, policymaking on older adults' self-management of chronic diseases and disability using information and communication technologies (ICTs) needs to be better understood. Using the province of Ontario, in Canada, as a case study, the research question was What is the environment that policymakers must navigate through in development and implementation of policies related to older adults' self-management of disease and disability using information and communication technologies (ICTs)? METHODS: This study used a qualitative approach where public servants from 4 ministries within the government of Ontario were invited to participate in a 1-h, one-on-one, semi-structured interview. The audio-recorded interviews were based on an adapted model of the policy triangle, where the researcher asked questions about the influences from the different sources identified in the model. The interviews were later transcribed and analyzed using a deductive-inductive coding approach. RESULTS: Ten participants across 4 different Ministries participated in the interviews. Participants shared insights on various aspects of context, process and actors that help shape the current content of policies. The analysis revealed that policies, in the form of programs, services, legislation and regulations, are the result of collaborations and dialogue between different actors and get developed and implemented via a set of complex government processes. In addition, policy actions come from a plethora of sectors which all get influenced by several predictable and unpredictable external pressures. CONCLUSIONS: The environment for policymaking in the government of Ontario regarding older adults' self-management of disease and disability using ICTs is one that is mostly reactive to external pressures, while organized within a set of complex processes and multi-sectoral collaborations. The present research helped us to understand the complexity of policymaking on the topic and highlights the need for increased foresight and proactive policymaking, regardless of which governments are in-place.

A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus.

BACKGROUND: Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery. METHODS: Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus. RESULTS: The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service. CONCLUSION: Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

Quality of telephone-based cancer symptom management by nurses: a quality improvement project.

PURPOSE: To determine the quality of cancer symptom management when evidence from clinical practice guidelines are used in telephone-based oncology nursing services. METHODS: Guided by the Knowledge to Action Framework, we conducted a quality improvement (QI) project focused on "monitoring knowledge use" (e.g., use of practice guides) and "measuring outcomes." In 2016, 15 Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides that synthesize evidence from guidelines were implemented with training for all oncology nurses at a regional ambulatory oncology program. Eighteen months post-implementation, Symptom Management Analysis Tool (SMAT) was used to analyze audio-recorded calls and related documentation of cancer symptom management. RESULTS: Of 113 audio-recorded calls, 66 were COSTaRS symptoms (58%), 43 other symptoms (38%), and 4 medically complex situations (4%). Of 66 recorded calls, 63 (95%) were documented. Average SMAT quality score was 71% (range 21-100%) for audio-recordings and 63% (range 19-100%) for documentation of calls. COSTaRS practice guide use was documented in 33% calls. For these calls, average SMAT quality scores were 74% with COSTaRS versus 69% without COSTaRS for audio-recording and 73% (range 33-100%) with COSTaRS versus 58% without COSTaRS for documentation. Patient outcomes indicated symptom was resolved (38%), worse (25%), unchanged (3%), or unknown (33%). Eight patients (13%) had an ED visit within 14 days post that was related to the symptom discussed. CONCLUSIONS: Only a third of nurses indicated use of COSTaRS practice guides. There were higher quality symptom management scores when COSTaRS use was reported. Nurses documented less than what they discussed.

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review.

BACKGROUND: Despite a substantial increase in the adoption of electronic medical records (EMRs) in primary health care settings, the use of advanced EMR features is limited. Several studies have identified both barriers and facilitating factors that influence primary care physicians' (PCPs) use of advanced EMR features and the maturation of their EMR use. The purpose of this study is to explore and identify the factors that impact PCPs' mature use of EMRs. METHODS: A systematic review was conducted in accordance with the Cochrane Handbook. The MEDLINE, Embase, and PsycINFO electronic databases were searched from 1946 to June 13, 2019. Two independent reviewers screened the studies for eligibility; to be included, studies had to address factors influencing PCPs' mature use of EMRs. A narrative synthesis was conducted to collate study findings and to report on patterns identified across studies. The quality of the studies was also appraised. RESULTS: Of the 1893 studies identified, 14 were included in this study. Reported factors that influenced PCPs' mature use of EMRs fell into one of the following 5 categories: technology, people, organization, resources, and policy. Concerns about the EMR system's functionality, lack of physician awareness of EMR functionality, limited physician availability to learn more about EMRs, the habitual use of successfully completing clinical tasks using only basic EMR features, business-oriented organizational objectives, lack of vendor training, limited resource availability, and lack of physician readiness were reported as barriers to PCPs' mature use of EMRs. The motivation of physicians, user satisfaction, coaching and peer mentoring, EMR experience, gender, physician perception, transition planning for changes in roles and work processes, team-based care, adequate technical support and training, sharing resources, practices affiliated with an integrated delivery system, financial incentives, and policies to increase EMR use all had a favorable impact on PCPs' use of advanced EMR features. CONCLUSIONS: By using a narrative synthesis to synthesize the evidence, we identified interrelated factors influencing the mature use of EMRs by PCPs. The findings underline the need to provide adequate training and policies that facilitate the mature use of EMRs by PCPs. TRIAL REGISTRATION: PROSPERO CRD42019137526.

Shared care in surgery: Practical considerations for surgical leaders.

The recent COVID-19 pandemic has highlighted limitations in current healthcare systems and needed strategies to increase surgical access. This article presents a team-based integration model that embraces intra-disciplinary collaboration in shared clinical care, professional development, and administrative processes to address this surge in demand for surgical care. Implementing this model will require communicating the rationale for and benefits of shared care, while shifting patient trust to a team of providers. For the individual surgeon, advantages of clinical integration through shared care include decreased burnout and professional isolation, and more efficient transitions into and out of practice. Advantages to the system include greater surgeon availability, streamlined disease site wait lists, and promotion of system efficiency through a centralized distribution of clinical resources. We present a framework to stimulate national dialogue around shared care that will ultimately help overcome system bottlenecks for surgical patients and provide support for health professionals.

Key factors for national spread and scale-up of an eConsult innovation.

BACKGROUND: Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada. METHODS: We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research. RESULTS: This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes. CONCLUSIONS: Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

Quality of telephone nursing services for adults with cancer and related non-emergent visits to the emergency department.

A quality improvement project was conducted to determine the quality of telephone nursing for patients with cancer symptoms. Eligible patients were ones who telephoned the nurse about cancer symptom(s) within four weeks prior to an emergency department (ED) visit not requiring hospital admission. Experienced oncology nurses extracting data indicated appropriateness of ED visits and opportunities for improvement. The Symptom Management Analysis Tool was used to analyze nurse documentation. For 77 patients, 87% ED visits occurred within four days of calls about symptoms (e.g., pain, breathlessness, constipation, diarrhea, nausea/vomiting) and 91% could have been managed by more complete telephone assessment and/or an urgent clinic visit. Quality of nurse documentation revealed few patients were assessed adequately (38%), received any symptom-specific medication review (49%), or were guided in self-care strategies (17%). There was low-quality telephone symptom management by nurses and a need for alternative options for patients requiring urgent face-to-face assessments. Our findings highlight a gap in use of guidelines for informing telephone symptom management.

Beyond TAM and UTAUT: Future directions for HIT implementation research.

The Technology Acceptance Model (TAM) and Unified Theory of Acceptance and Use of Technology (UTAUT) have been used widely in studies of health information technology (HIT) implementation. However, TAM and UTAUT have also been criticized for being overly simplistic (TAM) and for taking a narrow perspective, which focuses only on individual adopters' beliefs, perceptions and usage intention. Furthermore, with thousands of studies using these theories, their contribution to knowledge has reached a plateau. In this commentary, we discuss some of the criticism of TAM and UTAUT, and argue that biomedical informatics research would benefit from shifting attention from these theories to multi-dimensional approaches that can better capture the complexity of issues surrounding implementation and use of HIT. We propose a number of future undertakings which, in our opinion, are more likely to move the field forward.

Using Patient and Family Engagement Strategies to Improve Outcomes of Health Information Technology Initiatives: Scoping Review.

BACKGROUND: Many health care organizations around the world have implemented health information technologies (ITs) to enhance health service efficiency, effectiveness, and safety. Studies have demonstrated that promising outcomes of health IT initiatives can be obtained when patients and family members participate and engage in the adoption, use, and evaluation of these technologies. Despite knowing this, there is a lack of health care organizations using patient and family engagement strategies to enhance the use and adoption of health ITs, specifically. OBJECTIVE: This study aimed to answer the following three research questions (RQs): (1) what current frameworks or theories have been used to guide patient and family engagement in health IT adoption, use, implementation, selection, and evaluation?, (2) what studies have been done on patient and family engagement strategies in health IT adoption, use, implementation, selection, and evaluation?, and (3) what patient and family engagement frameworks, studies, or resources identified in the literature can be applied to health IT adoption, use, implementation, selection, and evaluation? METHODS: This scoping review used a five-step framework developed by Arksey and O'Malley and adapted by Levac et al. These steps include the following: (1) identifying the RQ, (2) identifying relevant studies, (3) selecting studies, (4) charting relevant data, and (5) summarizing and reporting the result. Retrieved academic and grey literature records were evaluated using a literature review software based on inclusion and exclusion criteria by two independent reviewers. If consensus was not achieved, two reviewers would resolve conflicts by discussion. Research findings and strategies were extracted from the studies and summarized in data tables. RESULTS: A total of 35 academic articles and 23 gray literature documents met the inclusion criteria. In total, 20 of the 35 included studies have been published since 2017. Frameworks found include the patient engagement framework developed by Healthcare Information and Management Systems Society and the patient and family engagement framework proposed by Carman et al. Effective strategies include providing patients with clear expectations and responsibilities and providing reimbursement for time and travel. The gray literature sources outlined key considerations for planning and supporting engagement initiatives such as providing patients with professional development opportunities, and embedding patients in existing governance structures. CONCLUSIONS: Several studies have reported their findings regarding successful strategies to engage patients and family members in health IT initiatives and the positive impact that can emerge when patients and family members are engaged in such initiatives in an effective manner. Currently, no framework has consolidated all of the key strategies and considerations that were found in this review to guide health care organizations when engaging patients and family members in a health IT-specific project or initiative. Further research to evaluate and validate the existing strategies would be of value.

A tactical framework for EMR adoption.

Hospitals and other health settings across Canada are transitioning from paper or legacy information systems to Electronic Medical Records (EMR) systems to improve patient care and service delivery. The literature speaks to benefits of EMR systems, but also challenges, such as adverse patient events and provider workflow interruptions. Theoretical models have been proposed to help understand the complex interaction between health information technologies and the healthcare environment, but a shortcoming is the transition from conceptual models to actual clinical settings. The health ecosystem is filled with human diversity and organizational culture considerations that cannot be separated from technical implementation strategies. This paper analyzes literature on EMR implementation and adoption to develop a tactical framework for EMR adoption. The framework consists of six categories, each with a set of seed questions to consider when leading technology adoption projects.

Physician extenders on surgical services: the need for a systems perspective.

SUMMARY: Adding physician extenders (PEs) to surgical teams has the potential to affect care delivery in multiple ways. To develop evidence-based recommendations on integrating PEs into surgical teams, we must recognize that patient care is a complex, adaptive system and requires a health systems perspective to understand how changes will affect outcomes. It is the best method of assessing the system adaptations and trade-offs of adding PEs prior to implementation. Such work would help to optimize research and management of limited health care resources.

Collaborative writing applications in healthcare: effects on professional practice and healthcare outcomes.

BACKGROUND: Collaborative writing applications (CWAs), such as wikis and Google Documents, hold the potential to improve the use of evidence in both public health and healthcare. Although a growing body of literature indicates that CWAs could have positive effects on healthcare, such as improved collaboration, behavioural change, learning, knowledge management, and adaptation of knowledge to local context, this has never been assessed systematically. Moreover, several questions regarding safety, reliability, and legal aspects exist. OBJECTIVES: The objectives of this review were to (1) assess the effects of the use of CWAs on process (including the behaviour of healthcare professionals) and patient outcomes, (2) critically appraise and summarise current evidence on the use of resources, costs, and cost-effectiveness associated with CWAs to improve professional practices and patient outcomes, and (3) explore the effects of different CWA features (e.g. open versus closed) and different implementation factors (e.g. the presence of a moderator) on process and patient outcomes. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and 11 other electronic databases. We searched the grey literature, two trial registries, CWA websites, individual journals, and conference proceedings. We also contacted authors and experts in the field. We did not apply date or language limits. We searched for published literature to August 2016, and grey literature to September 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after (CBA) studies, interrupted time series (ITS) studies, and repeated measures studies (RMS), in which CWAs were used as an intervention to improve the process of care, patient outcomes, or healthcare costs. DATA COLLECTION AND ANALYSIS: Teams of two review authors independently assessed the eligibility of studies. Disagreements were resolved by discussion, and when consensus was not reached, a third review author was consulted. MAIN RESULTS: We screened 11,993 studies identified from the electronic database searches and 346 studies from grey literature sources. We analysed the full text of 99 studies. None of the studies met the eligibility criteria; two potentially relevant studies are ongoing. AUTHORS' CONCLUSIONS: While there is a high number of published studies about CWAs, indicating that this is an active field of research, additional studies using rigorous experimental designs are needed to assess their impact and cost-effectiveness on process and patient outcomes.

Using a complex adaptive system lens to understand family caregiving experiences navigating the stroke rehabilitation system.

BACKGROUND: Family caregivers provide the stroke survivor with social support and continuity during the transition home from a rehabilitation facility. In this exploratory study we examined family caregivers' perceptions and experiences navigating the stroke rehabilitation system. The theories of continuity of care and complex adaptive systems were integrated to examine the transition from a stroke rehabilitation facility to the patient's home. This study provides an understanding of the interacting complexities at the macro and micro levels. METHODS: A convenient sample of family caregivers (n = 14) who provide care for a stroke survivor were recruited 4-12 weeks following the patient's discharge from a stroke rehabilitation facility in Ontario, Canada. Interviews were conducted with family caregivers to examine their perceptions and experiences navigating the stroke rehabilitation system. Directed and inductive content analysis and the theory of Complex Adaptive Systems were used to interpret the perceptions of family caregivers. RESULTS: Health system policies and procedures at the macro-level determined the types and timing of information being provided to caregivers, and impacted continuity of care and access to supports and services at the micro-level. Supports and services in the community, such as outpatient physiotherapy services, were limited or did not meet the specific needs of the stroke survivors or family caregivers. CONCLUSION: Relationships with health providers, informational support, and continuity in case management all influence the family caregiving experience and ultimately the quality of care for the stroke survivor, during the transition home from a rehabilitation facility.

Using Semantic Components to Represent Dynamics of an Interdisciplinary Healthcare Team in a Multi-Agent Decision Support System.

In healthcare organizations, clinical workflows are executed by interdisciplinary healthcare teams (IHTs) that operate in ways that are difficult to manage. Responding to a need to support such teams, we designed and developed the MET4 multi-agent system that allows IHTs to manage patients according to presentation-specific clinical workflows. In this paper, we describe a significant extension of the MET4 system that allows for supporting rich team dynamics (understood as team formation, management and task-practitioner allocation), including selection and maintenance of the most responsible physician and more complex rules of selecting practitioners for the workflow tasks. In order to develop this extension, we introduced three semantic components: (1) a revised ontology describing concepts and relations pertinent to IHTs, workflows, and managed patients, (2) a set of behavioral rules describing the team dynamics, and (3) an instance base that stores facts corresponding to instances of concepts from the ontology and to relations between these instances. The semantic components are represented in first-order logic and they can be automatically processed using theorem proving and model finding techniques. We employ these techniques to find models that correspond to specific decisions controlling the dynamics of IHT. In the paper, we present the design of extended MET4 with a special focus on the new semantic components. We then describe its proof-of-concept implementation using the WADE multi-agent platform and the Z3 solver (theorem prover/model finder). We illustrate the main ideas discussed in the paper with a clinical scenario of an IHT managing a patient with chronic kidney disease.