Optimising ePrescribing in hospitals through the interoperability of systems and processes: a qualitative study in the UK, US, Norway and the Netherlands.

BACKGROUND: Investment in the implementation of hospital ePrescribing systems has been a priority in many economically-developed countries in order to modernise the delivery of healthcare. However, maximum gains in the safety, quality and efficiency of care are unlikely to be fully realised unless ePrescribing systems are further optimised in a local context. Typical barriers to optimal use are often encountered in relation to a lack of systemic capacity and preparedness to meet various levels of interoperability requirements, including at the data, systems and services levels. This lack of systemic interoperability may in turn limit the opportunities and benefits potentially arising from implementing novel digital heath systems. METHODS: We undertook n = 54 qualitative interviews with key stakeholders at nine digitally advanced hospital sites across the UK, US, Norway and the Netherlands. We included hospitals featuring 'standalone, best of breed' systems, which were interfaced locally, and multi-component and integrated electronic health record enterprise systems. We analysed the data inductively, looking at strategies and constraints for ePrescribing interoperability within and beyond hospital systems. RESULTS: Our thematic analysis identified 4 main drivers for increasing ePrescribing systems interoperability: (1) improving patient safety (2) improving integration & continuity of care (3) optimising care pathways and providing tailored decision support to meet local and contextualised care priorities and (4) to enable full patient care services interoperability in a variety of settings and contexts. These 4 interoperability dimensions were not always pursued equally at each implementation site, and these were often dependent on the specific national, policy, organisational or technical contexts of the ePrescribing implementations. Safety and efficiency objectives drove optimisation targeted at infrastructure and governance at all levels. Constraints to interoperability came from factors such as legacy systems, but barriers to interoperability of processes came from system capability, hospital policy and staff culture. CONCLUSIONS: Achieving interoperability is key in making ePrescribing systems both safe and useable. Data resources exist at macro, meso and micro levels, as do the governance interventions necessary to achieve system interoperability. Strategic objectives, most notably improved safety, often motivated hospitals to push for evolution across the entire data architecture of which they formed a part. However, hospitals negotiated this terrain with varying degrees of centralised coordination. Hospitals were heavily reliant on staff buy-in to ensure that systems interoperability was built upon to achieve effective data sharing and use. Positive outcomes were founded on a culture of agreement about the usefulness of access by stakeholders, including prescribers, policymakers, vendors and lab technicians, which was reflected in an alignment of governance goals with system design.

Finding the 'sweet spot' between customisation and workflows when optimising ePrescribing systems: a multisite qualitative study.

OBJECTIVES: The introduction of ePrescribing systems offers the potential to improve the safety, quality and efficiency of prescribing, medication management decisions and patient care. However, an ePrescribing system will require some customisation and configuration to capture a range of workflows in particular hospital settings. This can be part of an optimisation strategy, which aims at avoiding workarounds that lessen anticipated safety and efficiency benefits. This paper aims to identify ePrescribing optimisation strategies that can be translated into hospitals in different national settings. We will explore the views of professionals on the impact of configuration and customisation on workflow. DESIGN: This paper draws on 54 qualitative interviews with clinicians, pharmacists and informatics professionals with experience of optimising ePrescribing systems in eight hospital sites and one health system, in four different countries. Interview transcripts were analysed using an inductive thematic analysis. SETTING: Secondary and tertiary care hospitals in the UK, USA and mainland Europe. PARTICIPANTS: Fifty-four healthcare workers with expertise in clinical informatics. RESULTS: Five identified themes following thematic analysis showed that optimisation of ePrescribing systems can involve configuration and/or customisation. This can be a strategy to combat workarounds and to respond to local policy, safety protocols and workflows for particular patient populations. However, it can result in sites taking on responsibility for training and missing out on vendor updates. Working closely with vendors and other users can mitigate the need for extensive system modification and produce better outcomes. CONCLUSIONS: Modifying an ePrescribing system remains key to enhancing patient safety, and better captured workflow remains key to optimisation. However, we found evidence of an increasingly cautious approach to both customisation and configuration among system users. This has led to users seeking to make less changes to the system.

Policy parameters for optimising hospital ePrescribing: An exploratory literature review of selected countries of the Organisation for Economic Co-operation and Development.

Objective: Electronic prescribing systems offer considerable opportunities to enhance the safety, effectiveness and efficiency of prescribing and medicines management decisions but, despite considerable investments in health IT infrastructure and healthcare professional training, realising these benefits continues to prove challenging. How systems are customised and configured to achieve optimal functionality is an increasing focus for policymakers. We sought to develop an overview of the policy landscape currently supporting optimisation of hospital ePrescribing systems in economically developed countries with a view to deriving lessons for the United Kingdom (UK). Methods: We conducted a review of research literature and policy documents pertaining to optimisation of ePrescribing within hospitals across Organisation for Economic Co-operation and Development (OECD) countries on Embase, Medline, National Institute for Health (NIH), Google Scholar databases from 2010 to 2020 and the websites of organisations with international and national health policy interests in digital health and ePrescribing. We designed a typology of policies targeting optimisation of ePrescribing systems that provides an overview of evidence relating to the level at which policy is set, the aims and the barriers encountered in enacting these policies. Results: Our database searches retrieved 11 relevant articles and other web resources mainly from North America and Western Europe. We identified very few countries with a national level strategy for optimisation of ePrescribing in hospitals. There were hotspots of digital maturity in relation to ePrescribing at institutional, specialisation, regional and national levels in the US and Europe. We noted that such countries with digital maturity fostered innovations such as patient involvement. Conclusions: We found that, whilst helpful to achieve certain aims, coordinated strategies within and across countries for optimisation of ePrescribing systems are rare, even in countries with well-established ePrescribing and digital health infrastructures. There is at present little policy focus on maximising the utility of ePrescribing systems.

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review.

OBJECTIVE: Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures. METHODS: We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts. RESULTS: We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process. DISCUSSION: We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

Problems and promises: How to tell the story of a Genome Wide Association Study?

The promise of treatments for common complex diseases (CCDs) is understood as an important force driving large scale genetics research over the last few decades. This paper considers the phenomenon of the Genome Wide Association Study (GWAS) via one high profile example, the Wellcome Trust Case Control Consortium (WTCCC). The WTCCC despite not fulfilling promises of new health interventions is still understood as an important step towards tackling CCDs clinically. The 'sociology of expectations' has considered many examples of failure to fulfil promises and the subsequent negative consequences including disillusionment, disappointment and disinvestment. In order to explore why some domains remain resilient in the face of apparent failure, I employ the concept of the 'problematic' found in the work of Giles Deleuze. This alternative theoretical framework challenges the idea that the failure to reach promised goals results in largely negative outcomes for a given field. I will argue that collective scientific action is motivated not only by hopes for the future but also by the drive to create solutions to the actual setbacks and successes which scientists encounter in their day-to-day work. I draw on eighteen interviews.

Utilizing health information technology in the treatment and management of patients during the COVID-19 pandemic: Lessons from international case study sites.

OBJECTIVE: The study sought to develop an in-depth understanding of how hospitals with a long history of health information technology (HIT) use have responded to the COVID-19 (coronavirus disease 2019) pandemic from an HIT perspective. MATERIALS AND METHODS: We undertook interviews with 44 healthcare professionals with a background in informatics from 6 hospitals internationally. Interviews were informed by a topic guide and were conducted via videoconferencing software. Thematic analysis was employed to develop a coding framework and identify emerging themes. RESULTS: Three themes and 6 subthemes were identified. HITs were employed to manage time and resources during a surge in patient numbers through fast-tracked governance procedures, and the creation of real-time bed capacity tracking within electronic health records. Improving the integration of different hospital systems was identified as important across sites. The use of hard-stop alerts and order sets were perceived as being effective at helping to respond to potential medication shortages and selecting available drug treatments. Utilizing information from multiple data sources to develop alerts facilitated treatment. Finally, the upscaling/optimization of telehealth and remote working capabilities was used to reduce the risk of nosocomial infection within hospitals. DISCUSSION: A number of the HIT-related changes implemented at these sites were perceived to have facilitated more effective patient treatment and management of resources. Informaticians generally felt more valued by hospital management as a result. CONCLUSIONS: Improving integration between data systems, utilizing specialized alerts, and expanding telehealth represent strategies that hospitals should consider when using HIT for delivering hospital care in the context of the COVID-19 pandemic.

Protocol for a qualitative study to identify strategies to optimise hospital ePrescribing systems.

INTRODUCTION: Electronic prescribing (ePrescribing) is a key area of development and investment in the UK and across the developed world. ePrescribing is widely understood as a vehicle for tackling medication-related safety concerns, improving care quality and making more efficient use of health resources. Nevertheless, implementation of an electronic health record does not itself ensure benefits for prescribing are maximised. We examine the process of optimisation of ePrescribing systems using case studies to provide policy recommendations based on the experiences of digitally mature hospital sites. METHODS AND ANALYSIS: Qualitative interviews within six digitally mature sites will be carried out. The aim is to capture successful optimisation of electronic prescribing (ePrescribing) in particular health systems and hospitals. We have identified hospital sites in the UK and in three other developed countries. We used a combination of literature reviews and advice from experts at Optimising ePrescribing in Hospitals (eP Opt) Project round-table events. Sites were purposively selected based on geographical area, innovative work in ePrescribing/electronic health (eHealth) and potential transferability of practices to the UK setting. Interviews will be recorded and transcribed and transcripts coded thematically using NVivo software. Relevant policy and governance documents will be analysed, where available. Planned site visits were suspended due to the COVID-19 pandemic. ETHICS AND DISSEMINATION: The Usher Research Ethics Group granted approval for this study. Results will be disseminated via peer-reviewed journals in medical informatics and expert round-table events, lay member meetings and the ePrescribing Toolkit (http://www.eprescribingtoolkit.com/)-an online resource supporting National Health Service (NHS) hospitals through the ePrescribing process.

Technological Capabilities to Assess Digital Excellence in Hospitals in High Performing Health Care Systems: International eDelphi Exercise.

BACKGROUND: Hospitals worldwide are developing ambitious digital transformation programs as part of broader efforts to create digitally advanced health care systems. However, there is as yet no consensus on how best to characterize and assess digital excellence in hospitals. OBJECTIVE: Our aim was to develop an international agreement on a defined set of technological capabilities to assess digital excellence in hospitals. METHODS: We conducted a two-stage international modified electronic Delphi (eDelphi) consensus-building exercise, which included a qualitative analysis of free-text responses. In total, 31 international health informatics experts participated, representing clinical, academic, public, and vendor organizations. RESULTS: We identified 35 technological capabilities that indicate digital excellence in hospitals. These are divided into two categories: (a) capabilities within a hospital (n=20) and (b) capabilities enabling communication with other parts of the health and social care system, and with patients and carers (n=15). The analysis of free-text responses pointed to the importance of nontechnological aspects of digitally enabled change, including social and organizational factors. Examples included an institutional culture characterized by a willingness to transform established ways of working and openness to risk-taking. The availability of a range of skills within digitization teams, including technological, project management and business expertise, and availability of resources to support hospital staff, were also highlighted. CONCLUSIONS: We have identified a set of criteria for assessing digital excellence in hospitals. Our findings highlight the need to broaden the focus from technical functionalities to wider digital transformation capabilities.

Balancing the local and the universal in maintaining ethical access to a genomics biobank.

BACKGROUND: Issues of balancing data accessibility with ethical considerations and governance of a genomics research biobank, Generation Scotland, are explored within the evolving policy landscape of the past ten years. During this time data sharing and open data access have become increasingly important topics in biomedical research. Decisions around data access are influenced by local arrangements for governance and practices such as linkage to health records, and the global through policies for biobanking and the sharing of data with large-scale biomedical research data resources and consortia. METHODS: We use a literature review of policy relevant documents which apply to the conduct of biobanks in two areas: support for open access and the protection of data subjects and researchers managing a bioresource. We present examples of decision making within a biobank based upon observations of the Generation Scotland Access Committee. We reflect upon how the drive towards open access raises ethical dilemmas for established biorepositories containing data and samples from human subjects. RESULTS: Despite much discussion in science policy literature about standardisation, the contextual aspects of biobanking are often overlooked. Using our engagement with GS we demonstrate the importance of local arrangements in the creation of a responsive ethical approach to biorepository governance. We argue that governance decisions regarding access to the biobank are intertwined with considerations about maintenance and viability at the local level. We show that in addition to the focus upon ever more universal and standardised practices, the local expertise gained in the management of such repositories must be supported. CONCLUSIONS: A commitment to open access in genomics research has found almost universal backing in science and health policy circles, but repositories of data and samples from human subjects may have to operate under managed access, to protect privacy, align with participant consent and ensure that the resource can be managed in a sustainable way. Data access committees need to be reflexive and flexible, to cope with changing technology and opportunities and threats from the wider data sharing environment. To understand these interactions also involves nurturing what is particular about the biobank in its local context.

An "Ethical Moment" in Data Sharing.

This study draws on interviews with forty-nine members of a biomedical research community in the UK that is involved in negotiating data sharing and access. During an interview, an interviewee used the words "ethical moment" to describe a confrontation between collaborators in relation to data sharing. In this article, I use this as a lens for thinking about relations between "the conceptual and the empirical" in a way that allows both analyst and actor to challenge the status quo and consider other ethical possibilities. Drawing on actor network theory (ANT), I approach "the empirical" using the concepts of controversy and ontological uncertainty as methodological tools to tackle the problem of ethics. I suggest that these concepts also provide a bridge for understanding the ontological structure of the virtual and the actual, as described in Deleuze's Difference and Repetition. While other science and technology studies scholars have sought to draw on Deleuze, this article addresses the integration of ethics and empirical research. It arises as a critical reaction to existing treatments of this problem as found in empirical ethics, especially in the sociology of bioethics, and indirectly in ANT texts.

Perspectives on Open Science and scientific data sharing:an interdisciplinary workshop.

Looking at Open Science and Open Data from a broad perspective. This is the idea behind "Scientific data sharing: an interdisciplinary workshop", an initiative designed to foster dialogue between scholars from different scientific domains which was organized by the Istituto Italiano di Antropologia in Anagni, Italy, 2-4 September 2013.We here report summaries of the presentations and discussions at the meeting. They deal with four sets of issues: (i) setting a common framework, a general discussion of open data principles, values and opportunities; (ii) insights into scientific practices, a view of the way in which the open data movement is developing in a variety of scientific domains (biology, psychology, epidemiology and archaeology); (iii) a case study of human genomics, which was a trail-blazer in data sharing, and which encapsulates the tension that can occur between large-scale data sharing and one of the boundaries of openness, the protection of individual data; (iv) open science and the public, based on a round table discussion about the public communication of science and the societal implications of open science. There were three proposals for the planning of further interdisciplinary initiatives on open science. Firstly, there is a need to integrate top-down initiatives by governments, institutions and journals with bottom-up approaches from the scientific community. Secondly, more should be done to popularize the societal benefits of open science, not only in providing the evidence needed by citizens to draw their own conclusions on scientific issues that are of concern to them, but also explaining the direct benefits of data sharing in areas such as the control of infectious disease. Finally, introducing arguments from social sciences and humanities in the educational dissemination of open data may help students become more profoundly engaged with Open Science and look at science from a broader perspective.

Planning for translational research in genomics.

Translation of research findings into clinical practice is an important aspect of medical progress. Even for the early stages of genomics, research aiming to deepen understandings of underlying mechanisms of disease, questions about the ways in which such research ultimately can be useful in medical treatment and public health are of key importance. Whilst some research data may not apparently lend themselves to immediate clinical benefit, being aware of the issues surrounding translation at an early stage can enhance the delivery of the research to the clinic if a medical application is later found. When simple steps are taken during initial project planning, the pathways towards the translation of genomic research findings can be managed to optimize long-term benefits to health. This piece discusses the key areas of collaboration agreements, distribution of revenues and recruitment and sample collection that are increasingly important to successful translational research in genomics.

Data sharing in genomics--re-shaping scientific practice.

Funding bodies have recently introduced a requirement that data sharing must be a consideration of all funding applications in genomics. As with all new developments this condition has had an impact on scientific practice, particularly in the area of publishing and in the conduct of research. We discuss the challenges that must be addressed if the full benefits of data sharing, as envisaged by funders, are to be realized.