A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre-post implementation.

The purpose was to study users' attitudes towards an electronic medical record (EMR) closely integrated into the clinicians' cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real-time support to the coordination of shared care processes involving all the care personnel. Mixed method pre-post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users' attitudes towards the EMR (response rate of 71%) measured after the go-live were positive ranging from 3.42 to 3.95 on a 5-point scale. Besides, the content analysis of 33 pre-post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users' expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Replacing an inpatient electronic medical record. Lessons learned from user satisfaction with the former system.

OBJECTIVE: Since it is important to develop strategies for the successful implementation of electronic clinical information systems, the aim of this study is to explore where, and to what extent, users' attitudes toward the former system that is being replaced may vary. METHODS: A cross-sectional survey of 346 nurses and physicians practicing in two Canadian teaching hospitals resulted in a total response rate of 63%. User attitudes were measured in three dimensions: a) user satisfaction with the system's quality attributes, b) perceived system usefulness, and c) perceived impact on quality of care and patient safety. The current system (the one being replaced) was analyzed as a dual system composed of both paper-based and electronic records. RESULTS: The results on user satisfaction demonstrate a wide variation in opinions, with satisfaction ranging from 4.2 to 7.7 on a 10-point disagree-agree, Likert scale. The quality attributes varied by record type, with differences that were systematically in favor of the electronic record component, which received higher scores. The results also highlighted large differences by user group. Physicians and nurses systematically rated the two record formats differently. The nurses were more satisfied with the attributes of the paper-based record. Multivariate regression analyses results also revealed strong interdependencies among the three dimensions of user attitudes, to the extent that perceived system usefulness was strongly correlated with system quality attributes and the system outcomes were also correlated, although less strongly, with the two former system dimensions. CONCLUSION: Understanding users' attitudes toward a clinical information system in use, both in its paper and electronic aspects, is crucial for developing more successful implementation strategies for electronic record systems.

Prioritizing the risk factors influencing the success of clinical information system projects. A Delphi study in Canada.

OBJECTIVE: The aim of this study is to gain a better understanding of the risk factors influencing the success of clinical information system projects. METHODS: This study addresses this issue by first reviewing the extant literature on information technology project risks, and second conducting a Delphi survey among 21 experts highly involved in clinical information system projects in Québec, Canada, a region where government have invested heavily in health information technologies in recent years. RESULTS: Twenty-three risk factors were identified. The absence of a project champion was the factor that experts felt most deserves their attention. Lack of commitment from upper management was ranked second. Our panel of experts also confirmed the importance of a variable that has been extensively studied in information systems, namely, perceived usefulness that ranked third. Respondents ranked project ambiguity fourth. The fifth-ranked risk was associated with poor alignment between the clinical information systems' characteristics and the organization of clinical work. The large majority of risk factors associated with the technology itself were considered less important. This finding supports the idea that technology-associated factors rarely figure among the main reasons for a project failure. CONCLUSIONS: In addition to providing a comprehensive list of risk factors and their relative importance, the study presents a major contribution by unifying the literature on information systems and medical informatics. Our checklist provides a basis for further research that may help practitioners identify the effective countermeasures for mitigating risks associated with the implementation of clinical information systems.

Medical team interdependence as a determinant of use of clinical resources.

OBJECTIVE: Our objective, based on organization theory, is to examine whether interdependence among physicians leads to coordination problems that in turn may explain variations observed in the use of clinical resources. DATA SOURCES/STUDY SETTING: Secondary data about episodes of in-hospital care were collected over a 14-month period in two midsize acute care hospitals located in two suburbs of Montreal, Quebec. STUDY DESIGN: Hierarchical regression analysis was used to assess the marginal effect of medical team interdependence on clinical resource utilization after taking into account the effect attributable to the nature of several morbidities taken as specific and distinct tasks. PRINCIPAL FINDINGS: Medical team interdependence is found within medical specialties as well as between specialties. The largest portion of resource utilization was explained by morbidity characteristics, whereas team interdependence had a weaker, but systematic effect for all morbidities studied (15 regression models out of 18 performed). Task coordination was found to become more difficult as the number of physicians coming from different specialties increased in the context of teamwork. CONCLUSIONS: Results suggest that team practice does not entirely overcome coordination problems inherent to task (morbidity) interdependence. In considering the individual (especially the attending) physician as the main factor responsible for resource utilization, other factors related to team practice may too readily be overlooked.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.

Do children with PDDNOS have a theory of mind?

This study sought to differentiate PDDNOS from a similar nonautistic disorder (i.e., language impairment) on the basis of a cognitive deficit, theory-of-mind (ToM). ToM is an ability to infer mental states in others and has been found to be highly prevalent in autism, a disorder that shares many characteristics with PDDNOS (Baron-Cohen, 1985; Volkmar & Cohen, 1988). A sample of 28 children with either PDDNOS or a language impairment formed two groups (n = 14), matched on gender and verbal mental age. Participants were administered the brain function task (Baron-Cohen, 1989) and the false belief task (Perner, Frith, Leslie, & Leekam, 1989) to assess ToM. Results suggest that children with PDDNOS are deficient in a ToM ability, however, this relationship is not as strong as in previous studies with autistic samples, suggesting that children with PDDNOS may have a greater ToM ability. The existence of PDDNOS on the higher end of a spectrum of the Pervasive Developmental disorders as well as the construct of ToM itself existing on a continuum are discussed.

Teleconsultation: rejected and emerging uses.

OBJECTIVE: The aim of this paper is to analyse telemedicine as a new means to improve health care accessibility. METHOD: A case study design was used to understand how medical specialists perceived, made sense of, and appropriated a teleconsultation system. RESULTS AND CONCLUSIONS: The technology was used neither in the manner nor to the extent anticipated by its designers. A fundamental modification to the traditional medical consultation process has emerged. Unable to be used as a substitute to the traditional medical consultation process, the teleconsultation system imposes a greater burden on the shoulders of participating physicians who, after a few trials, returned to their traditional mode of practice.

Risk adjustment in outcome assessment: the Charlson comorbidity index.

To measure the burden of comorbid diseases using the MED-ECHO database (Quebec), the so-called Charlson index was adapted to International Classification of Disease (ICD-9) codes. The resulting comorbidity index was applied to the study of inpatient death in a group of 62,456 patients having one of the following conditions: ischemic heart disease, congestive heart failure, stroke, or bacterial pneumonia. Multiple logistic regression was used to relate inpatient death to its predictors, including gender, principal diagnosis, age, and the comorbidity index. Various transformations of the comorbidity score were performed, and their effect on predictive accuracy was assessed. The comorbidity index was constantly and strongly associated with death. When gender, age, comorbidity and the principal diagnoses were taken into account, the area under the receiver-operating curve was 0.83. Therefore, the Charlson Index is a useful approach to risk adjustment in outcomes research from administrative databases.

Information technology sophistication in health care: an instrument validation study among Canadian hospitals.

Several empirical studies have shown that the use of computer-based information systems could have positive impacts on organizational performance. Many agree to say that health care organizations are no exceptions. But if one wishes to identify the effects of information technology (IT) on the delivery of care, one must be able to characterize IT for operationalization purposes. The primary objective of this research project is to develop and validate a measurement instrument of IT sophistication in the hospital milieu. Such instrument should provide hospital managers with a diagnostic tool capable of indicating the profile of their respective institutions in regard to IT adoption and comparing this profile to those of other similar medical centers. Both qualitative and quantitative data were collected in order to assess the psychometric properties of the measurement instrument. Overall, findings suggest a high-moderate level of functional sophistication, a somewhat low level of technological sophistication, and an even lower level of integration sophistication in all of the sampled medical centers. Hence, future investments shall therefore be directed towards the integration of clinical and administrative applications and the acquisition of more advanced technological devices, more specifically those, which allow direct capture of clinical data at the bedside.

Using the handicap code of the ICIDH for classifying patients by intensity of nursing care requirements.

An 11-class patient classification system (PCS) has been built on a recode of two dimensions of the handicap code of the ICIDH: physical independence and mobility handicaps. The proposed system, called MAC XI, explains 78% of the variance of nursing care hours required by nursing-home residents and extended-care hospital patients. This percentage of variation is higher than the one explained by traditional dependency grids such as the Exton-Smith, Murphy, Kuntzmann and SMAF. MAC XI, based on two dimensions of the handicap code, is thus a powerful tool for predicting intensity of nursing care for staffing and budgeting purposes in long-term care institutions.

IT sophistication in hospitals : a field study in Quebec.

The Quebec health sector has been experiencing a period of great turmoil over the last five years and hospitals are faced with huge pressures from government funding cuts. Several empirical studies in the information systems field have shown that the use of computer-based information systems could have positive impacts on organizational performance. Many agree to say that health care institutions are no exceptions. But if one wishes to identify the effects of IT on the delivery of care, one must be able to characterize IT for operationalization purposes. Our main objective consists in developing and validating a measurement instrument of IT sophistication in hospitals. Such instrument should provide hospital managers with a diagnostic tool capable of indicating the profile of their respective institutions in regard to IT use and comparing this profile to those of other similar health institutions.

Theory of use behind telehealth applications.

A variety of telehealth applications have been implemented throughout the industrialized world. Given that telehealth has yet to become routine in the practices of physicians, the impact of such applications on health care management remains difficult to identify. Only by becoming integrated into the 'normal practice' of clinicians can telehealth facilitate smooth communications in health care delivery processes. In this paper we demonstrate the importance of developing a 'theory of use', describing how clinicians are expected to use teleconsultation in their daily activities. By employing Giddens' Structuration Theory, we can develop a clear vision of the utilization of telehealth, and a better framework with which to assess its added value for health care delivery. We illustrate this claim by referring to our research on the Quebec Inter-Regional Telemedicine Network. In this study we compare the 'theory of use' behind the telemedicine network with the perceptions of physicians regarding their needs in terms of communications and access to expert advice. The breach between the theory and the perceptions of physicians may help to explain how the utilization of telehealth could be enhanced, and how new and sustainable routines for its integration into the health care system might be created.

The effect of medical work groups on hospital resource use.

This study tests the ability of medical work groups to overcome coordination problems related to group decision-making in allocating clinical resources to inpatients. The study was conducted over a 32-month period in two medium-sized acute-care hospitals located in Montreal, Quebec, Canada. The data were collected by hand from the medical charts of 10,456 patients in the surgical and medical departments. The Linear Structural Relations (LISREL) approach was employed to address the work-group issue using a task contingent model of work-group organization. In this model, the nature of the task is fundamental because its level of complexity determines both the organization of the work group and the use of resources. Medical work-group mechanisms should be efficient to the extent that resource utilization is explained solely by task characteristics rather than by work-group structure. In this study, the following two major organizational concepts were used as factors to explain resource use: task characteristics and work-group characteristics. Our analysis confirmed the main points of the task contingency theory as applied to the field of medicine. First, the results confirm that resource utilization is explained mainly by task complexity. Second, they confirm that medical work groups modulate their structures on the basis of task characteristics and do not explain resource use. The results also reveal a more complex model in which, for instance, the concepts of medical task and medical professional work are not easy to separate. The results highlight the interest in conceptualizing and analysing medical practice in work groups. It raises important issues that have seldom been taken into account in the study of medical practice variations, which has tended to focus on attending physicians.

A task contingent model of medical practice organization.

The treatment of acute episodes of morbidities in hospitalized patients is a complex and uncertain task. To accomplish this task, physicians organize themselves into teams in an effort to overcome two constraints: the necessity to offer both complete care and continuous care. This study examines the extent to which the nature and size of medical teams is explained by task difficulty and task variability, which are two dimensions of task uncertainty. The results support globally the hypothesis that the organization of medical practice is contingent upon the nature of the task defined in terms of uncertainty. However, the results also suggest that the task contingent model should be adjusted to take into account the fact that formal organizational characteristics may have an a priori influence on team structure.

Physician influence in interorganizational relationships between academic medical centers and community hospitals.

This study analyzes cooperative interorganizational relationships (IORs) between two different types of health care organizations. It proposes a power perspective analysis to better understand why IORs which represented many rational advantages to both partners were so difficult to realize in practice and often with only modest results. Hypotheses are tested explaining how physicians, as groups, exert important controls and can largely determine the results that can be realized in any IOR aimed at modifying medical education and patient referrals.

A review of organizational performance assessment in health care.

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

[The concept of autonomy (synthetic and operation indicators of old age : a systemic approach).]. / Le concept d'autonomie : Indicateur synthétique et opérationnel du mode de vieillissement : une approche systémique.

The present study is a follow-up of a research project made in 1978 by the Equipe de Recherche Opérationnelle en Santé (EROS) of the Department of Health Administration at the Université de Montréal. The aims were a) firstly to construct a classification instrument by type for long-term care patients, enabling us, to identify these beneficiaries' needs, as well as to guide their placement in a health services' system. And b) to evaluate this instrument (realibility and validity), c) to initiate its implementation and d) to utilize it for evaluating the present placement system. This study constitutes the first stage in an approach aimed at producing, on the basis of a systematic scanning of data collected within the framework of the above-mentioned project; a comprehensive descriptive analysis of the social/health characteristics of an aged population (65 years and over) in one of Quebec's social/ health regions i.e. Montreal's South Shore. At first, the authors define the context and the objectives of the study undertaken; secondly, they define the concept of autonomy by showing how the latter is expressed concretely according to the observation instrument (evaluation form of the individual's functional autonomy). Thirdly, a presentation is made of the method of measurement, as well as certain results concerning an index of restricted autonomy directly released to situations of observable behaviour (e, g. daily-life activities, exploring the outside world, and housekeeping).

Hospital network performance: a survey of hospital stakeholders' perspectives.

Hospital networks are an emerging organizational form designed to face the new challenges of public health systems. Although the benefits introduced by network models in terms of rationalization of resources are known, evidence about stakeholders' perspectives on hospital network performance from the literature is scanty. Using the Competing Values Framework of organizational effectiveness and its subsequent adaptation by Minvielle et al., we conducted in 2009 a survey in five hospitals of an Italian network for oncological care to examine and compare the views on hospital network performance of internal stakeholders (physicians, nurses and the administrative staff). 329 questionnaires exploring stakeholders' perspectives were completed, with a response rate of 65.8%. Using exploratory factor analysis of the 66 items of the questionnaire, we identified 4 factors, i.e. Centrality of relationships, Quality of care, Attractiveness/Reputation and Staff empowerment and Protection of workers' rights. 42 items were retained in the analysis. Factor scores proved to be high (mean score>8 on a 10-item scale), except for Attractiveness/Reputation (mean score 6.79), indicating that stakeholders attach a higher importance to relational and health care aspects. Comparison of factor scores among stakeholders did not reveal significant differences, suggesting a broadly shared view on hospital network performance.

Exploring health information technology innovativeness and its antecedents in Canadian hospitals.

OBJECTIVES: The primary aim of this study was to assess the antecedents of health information technology (HIT) innovativeness in public hospitals. To do so, we built upon our own previous work to relate the level of HIT innovativeness to organizational capacity characteristics. METHODS: We conducted a survey of chief information officers (CIOs) in public hospitals in the two largest Canadian provinces to identify the level of HIT innovativeness in these settings and test nine research hypotheses derived from the proposed research model. RESULTS: A total of 106 completed questionnaires were received, which represents a response rate of 52%. Our findings indicate strong support for the research model. Seven out of nine hypotheses were supported indicating a significant relationship between HIT innovativeness and structural, financial, leadership, and knowledge sharing capacity characteristics. Results also reveal a moderate level of HIT innovativeness in the surveyed hospitals, with more emphasis on administrative systems and their integration than on clinical systems and emerging technologies. CONCLUSIONS: This study demonstrates that organizational characteristics are related to HIT innovativeness; this relationship holds irrespective of the public or private nature of hospitals.