Patterns of health information exchange strategies underlying health information technologies capabilities building.

The combination of electronic health records (EHRs), health information exchange (HIE), and telehealthholds a high potential for improving the coordination of care and saving lives. As well, the benefits of the three HIT on hospitals' depend on the patterns of capabilities that are available and used by clinicians. However, little is known about how the three HIT, actually empirically coexist and about the strategies underlying the use of HIE in hospital settings. Based on data from a European Union survey, we use a combination of hierarchical and non-hierarchical clustering and discriminant analysis to identify patterns of hospitals' HIT capabilities. Five statistically significantly separated configurations were derived from a data set of 1038 acute care hospitals. The actual empirical coexistence of the three HIT capabilities and associated HIE strategies revealed by this study can be counter-intuitive and shed light on misalignments that may impede the realisation of the potential benefits.

Developing and Sustaining an Open Source Electronic Health Record: Evidence from a Field Study in Japan.

Electronic Health Records (EHRs) are at the heart of reforms aimed at improving the efficiency and quality of healthcare services provided to citizens. Although there is still some skepticism, open source (OS) EHR is a growing phenomenon in health informatics. Given the widespread adoption of OS software (OSS) in several domains, including operating systems, and enterprise systems, the repeated shortfalls faced by healthcare organizations with dominant proprietary EHRs create an opportunity for other alternatives, such as OSS to demonstrate their abilities in addressing these well-documented problems, including inflexibility, high costs, and low interoperability. However, scholars have expressed extensive concerns about the sustainability of OS EHR. Recognizing that OSS project sustainability relies on their governance arrangements, this case study reports on the evolution of the governance and sustainability of a Japanese OS EHR project and provides rich insights to other open source EHR initiative stakeholders, including physicians, developers, researchers, and policy-makers.

Adoption and Performance of Complementary Clinical Information Technologies: Analysis of a Survey of General Practitioners.

BACKGROUND: The benefits from the combination of 4 clinical information systems (CISs)-electronic health records (EHRs), health information exchange (HIE), personal health records (PHRs), and telehealth-in primary care depend on the configuration of their functional capabilities available to clinicians. However, our empirical knowledge of these configurations and their associated performance implications is very limited because they have mostly been studied in isolation. OBJECTIVE: This study aims to pursue 3 objectives: (1) characterize general practitioners (GPs) by uncovering the typical profiles of combinations of 4 major CIS capabilities, (2) identify physician and practice characteristics that predict cluster membership, and (3) assess the variation in the levels of performance associated with each configuration. METHODS: We used data from a survey of GPs conducted throughout the European Union (N=5793). First, 4 factors, that is, EHRs, HIE, PHRs, and Telehealth, were created. Second, a cluster analysis helps uncover clusters of GPs based on the 4 factors. Third, we compared the clusters according to five performance outcomes using an analysis of variance (ANOVA) and a Tamhane T2 post hoc test. Fourth, univariate and multivariate multinomial logistic regressions were used to identify predictors of the clusters. Finally, with a multivariate multinomial logistic regression, among the clusters, we compared performance in terms of the number of patients treated (3 levels) over the last 2 years. RESULTS: We unveiled 3 clusters of GPs with different levels of CIS capability profiles: strong (1956/5793, 37.36%), medium (2764/5793, 47.71%), and weak (524/5793, 9.04%). The logistic regression analysis indicates that physicians (younger, female, and less experienced) and practice (solo) characteristics are significantly associated with a weak profile. The ANOVAs revealed a strong cluster associated with significantly high practice performance outcomes in terms of the quality of care, efficiency, productivity, and improvement of working processes, and two noncomprehensive medium and weak profiles associated with medium (equifinal) practice performance outcomes. The logistic regression analysis also revealed that physicians in the weak profile are associated with a decrease in the number of patients treated over the last 2 years. CONCLUSIONS: Different CIS capability profiles may lead to similar equifinal performance outcomes. This underlines the importance of looking beyond the adoption of 1 CIS capability versus a cluster of capabilities when studying CISs. GPs in the strong cluster exhibit a comprehensive CIS capability profile and outperform the other two clusters with noncomprehensive profiles, leading to significantly high performance in terms of the quality of care provided to patients, efficiency of the practice, productivity of the practice, and improvement of working processes. Our findings indicate that medical practices should develop high capabilities in all 4 CISs if they have to maximize their performance outcomes because efforts to develop high capabilities selectively may only be in vain.

Governance and Sustainability of an Open Source Electronic Health Record: An Interpretive Case Study of OpenDolphin in Japan.

Electronic Health Records (EHRs) are at the heart of reforms aiming for improving the efficiency and quality of citizens healthcare services. Although there is still some skepticism, open source (OS) EHR is a growing phenomenon in health informatics. Given the widespread adoption of OS software (OSS) in several domains, including operating systems, and enterprise systems, the repeated shortfalls faced by healthcare organizations with dominant proprietary EHRs create an opportunity for other alternatives, such as OSS to demonstrate their abilities in addressing these well-documented problems, including inflexibility, high costs, and low interoperability. However, scholars have expressed extensive concerns about the sustainability of OS EHR. Recognizing that OSS project sustainability relies on their governance arrangements, this case study reports on the evolution of the governance and sustainability of a Japanese OS EHR project and provides rich insights to other open source EHR initiative stakeholders, including physicians, developers, researchers, and policymakers.

European Hospitals' Transition Toward Fully Electronic-Based Systems: Do Information Technology Security and Privacy Practices Follow?

BACKGROUND: Traditionally, health information has been mainly kept in paper-based records. This has deeply changed throughout approximately the last three decades with the widespread use of multiple health information technologies. The digitization of health care systems contributes to improving health care delivery. However, it also exposes health records to security and privacy breaches inherently related to information technology (IT). Thus, health care organizations willing to leverage IT for improved health care delivery need to put in place IT security and privacy measures consistent with their use of IT resources. OBJECTIVE: In this study, 2 main objectives are pursued: (1) to assess the state of the implementation of IT security and privacy practices in European hospitals and (2) to assess to what extent these hospitals enhance their IT security and privacy practices as they move from paper-based systems toward fully electronic-based systems. METHODS: Drawing on data from the European Commission electronic health survey, we performed a cluster analysis based on IT security and privacy practices implemented in 1723 European hospitals. We also developed an IT security index, a compounded measure of implemented IT security and privacy practices, and compared it with the hospitals' level in their transition from a paper-based system toward a fully electronic-based system. RESULTS: A total of 3 clearly distinct patterns of health IT-related security and privacy practices were unveiled. These patterns, as well as the IT security index, indicate that most of the sampled hospitals (70.2%) failed to implement basic security and privacy measures consistent with their digitization level. CONCLUSIONS: Even though, on average, the most electronically advanced hospitals display a higher IT security index than hospitals where the paper system still dominates, surprisingly, it appears that the enhancement of IT security and privacy practices as the health information digitization advances in European hospitals is neither systematic nor strong enough regarding the IT-security requirements. This study will contribute to raising awareness among hospitals' managers as to the importance of enhancing their IT security and privacy measures so that they can keep up with the security threats inherently related to the digitization of health care organizations.

Electronic health record usage behaviors in primary care medical practices: A survey of family physicians in Canada.

OBJECTIVE: The importance and potential value of office-based electronic health record (EHR) systems is being recognized internationally. We thus sought to better understand how EHRs are actually being used by family physicians and what they perceive to be the main performance outcomes for themselves and their medical practices. METHODS: We conducted a survey of family physicians practicing in medical practices in Quebec, Canada (n =331). Bivariate and multivariate statistical analyses were conducted to characterize EHR usage behaviors and assess the perceived performance outcomes of these systems. RESULTS: EHR systems "as-used" vary substantively from one family physician to another in terms of the capabilities that are actually mobilized by them. Significant differences between "basic" and "advanced" users were observed in terms of the EHR system's characteristics and perceived performance outcomes. Physicians were also clustered under three profiles that could be clearly distinguished from one another, in terms of the extent to which their performance and their practice's performance was impacted by their EHR usage. Physicians that are "highly impacted" by their EHR system are those who have the longest usage experience and make the most extended use of their system's capabilities. CONCLUSIONS: Our study indicates that only a minority of family physicians in our sample use most of the features available in their EHR system. Consequently, few physicians perceive gaining significant performance improvements from such systems. Future research must identify the factors that motivate primary care physicians to assimilate EHR systems in a more extensive manner.

Improving performance in medical practices through the extended use of electronic medical record systems: a survey of Canadian family physicians.

BACKGROUND: Numerous calls have been made for greater assimilation of information technology in healthcare organizations in general, and in primary care settings in particular. Considering the levels of IT investment and adoption in primary care medical practices, a deeper understanding is needed of the factors leading to greater performance outcomes from EMR systems in primary care. To address this issue, we developed and tested a research model centered on the concept of Extended EMR Use. METHODS: An online survey was conducted of 331 family physicians in Canadian private medical practices to empirically test seven research hypotheses using a component-based structural equation modeling approach. RESULTS: Five hypotheses were partially or fully supported by our data. Family physicians in our sample used 67% of the clinical and 41% of the communicational functionalities available in their EMR systems, compared to 90% of the administrative features. As expected, extended use was associated with significant improvements in perceived performance benefits. Interestingly, the benefits derived from system use were mainly tied to the clinical support provided by an EMR system. The extent to which physicians were using their EMR systems was influenced by two system design characteristics: functional coverage and ease of use. The more functionalities that are available in an EMR system and the easier they are to use, the greater the potential for exploration, assimilation and appropriation by family physicians. CONCLUSIONS: Our study has contributed to the extant literature by proposing a new concept: Extended EMR Use. In terms of its practical implications, our study reveals that family physicians must use as many of the capabilities supported by their EMR system as possible, especially those which support clinical tasks, if they are to maximize its performance benefits. To ensure extended use of their software, vendors must develop EMR systems that satisfy two important design characteristics: functional coverage and system ease of use.

Barriers to organizational adoption of EMR systems in family physician practices: a mixed-methods study in Canada.

BACKGROUND: EMR system can provide three main types of benefits: it can solve the logistical organization problems associated with paper systems; it can improve the quality of professionals' clinical decisions; and it can improve physicians' return on their practices by reducing the cost of managing clinical information. According to the 2012 Commonwealth Fund International Health Policy Survey, Canada ranked 10th out of 11 countries in terms of family physicians' adoption of EMR systems. Our main purpose is to investigate the reasons why so many primary care medical practices in this country have not decided to invest in these systems yet. METHODS: To achieve our main objective, a mixed-methods study was performed. We first conducted a Delphi study with a panel of 21 experts made up of general practitioners with extensive professional experience and a very good understanding of the issues surrounding the introduction of health IT in private medical practices. As a second step, we collected and analyzed data from a large questionnaire survey of family physicians working in medical practices without EMR systems (n = 431). RESULTS: The Delphi study reveals that private medical practices are hindered by four types of barriers when faced with the initial decision to invest in an EMR system, namely, behavioral, cognitive or knowledge-based, economic, and technological. Survey findings then indicate that the key challenges preventing private medical practices from investing in an EMR system are mainly related to economic and knowledge barriers. Surprisingly, we also found a cluster of medical practices which, although they have not invested in an EMR system, perceive no such barriers to adoption. CONCLUSIONS: A thorough understanding of the barriers faced by family physician practices in adopting an EMR system would help governments and other key stakeholders target policies and measures in support of medical practices. The "one size fits all" approach to such policies and measures is clearly inappropriate, given this study's findings that many medical practices face practically no barriers to EMR adoption, and that others differ markedly as to the type of barriers faced, be they mostly "soft" such as knowledge barriers or "hard" such as economic barriers.

Home telemonitoring for chronic disease management: an economic assessment.

OBJECTIVES: There have been very few assessments of the economics of home telemonitoring, and the quality of evidence has often been weakened by methodological flaws. This has made it difficult to compare telehomecare with traditional home care for the chronic diseases studied. This economic analysis is an attempt to address this gap in the literature. METHODS: We have analyzed the consumption of healthcare services by 95 patients with various chronic diseases over a 21-month period, that is, 12 months before, 4 months during home telemonitoring use, and over 5 months after withdraw of the technology. RESULTS: Our findings indicate significant benefits to the home telemonitoring program as evidenced by large reductions in number of hospitalizations, length of average hospital stay, and, to a lesser extent, number of emergency room visits. Contrary to expectations, however, the number of home visits by nurses increased both during and after the telemonitoring intervention. In terms of the financial analysis, the telehomecare program resulted in significant savings: the equivalent of over CAD1,557 per patient as calculated on an annualized basis. This represents a net gain of 41 percent as compared to traditional home care. CONCLUSIONS: While the present economic analysis led to positive results, additional assessments should be conducted to confirm the cost-effectiveness of this mode of care delivery.

Mobile computing and the quality of home care nursing practice.

We investigated the effects of the introduction of mobile computing on the quality of home care nursing practice in Québec. The software, which structured and organized the nursing activities in patients' homes, was installed sequentially in nine community health centres. The completeness of the nursing notes was compared in 77 paper records (pre-implementation) and 73 electronic records (post-implementation). Overall, the introduction of the software was associated with an improvement in the completeness of the nursing notes. All 137 nurse users were asked to complete a structured questionnaire. A total of 101 completed questionnaires were returned (74% response rate). Overall, the nurses reported a very high level of satisfaction with the quality of clinical information collected. A total of 57 semi-structured interviews were conducted and most nurses believed that the new software represented a user-friendly tool with a clear and understandable structure. A postal questionnaire was sent to approximately 1240 patients. A total of 223 patients returned the questionnaire (approximately 18% response rate). Overall, patients felt that the use of mobile computing during home visits allowed nurses to manage their health condition better and, hence, provide superior care services. The use of mobile computing had positive and significant effects on the quality of care provided by home nurses.

Clinicians' perceptions of organizational readiness for change in the context of clinical information system projects: insights from two cross-sectional surveys.

BACKGROUND: The adoption and diffusion of clinical information systems has become one of the critical benchmarks for achieving several healthcare organizational reform priorities, including home care, primary care, and integrated care networks. However, these systems are often strongly resisted by the same community that is expected to benefit from their use. Prior research has found that early perceptions and beliefs play a central role in shaping future attitudes and behaviors such as negative rumors, lack of involvement, and resistance to change. In this line of research, this paper builds on the change management and information systems literature and identifies variables associated with clinicians' early perceptions of organizational readiness for change in the specific context of clinical information system projects. METHODS: Two cross-sectional surveys were conducted to test our research model. First, a questionnaire was pretested and then distributed to the future users of a mobile computing technology in 11 home care organizations. The second study took place in a large teaching hospital that had approved a budget for the acquisition of an electronic medical records system. Data analysis was performed using partial least squares. RESULTS: Scale items used in this study showed adequate psychometric properties. In Study 1, four of the hypothesized links in the research model were supported, with change appropriateness, organizational flexibility, vision clarity, and change efficacy explaining 75% of the variance in organizational readiness. In Study 2, four hypotheses were also supported, two of which differed from those supported in Study 1: the presence of an effective project champion and collective self-efficacy. In addition to these variables, vision clarity and change appropriateness also helped explain 75% of the variance in the dependent variable. Explanations for the similarities and differences observed in the two surveys are provided. CONCLUSIONS: Organizational readiness is arguably a key factor involved in clinicians' initial support for clinical information system initiatives. As healthcare organizations continue to invest in information technologies to improve quality and continuity of care and reduce costs, understanding the factors that influence organizational readiness for change represents an important avenue for future research.