The Impact of Digital Hospitals on Patient and Clinician Experience: Systematic Review and Qualitative Evidence Synthesis.

BACKGROUND: The digital transformation of health care is advancing rapidly. A well-accepted framework for health care improvement is the Quadruple Aim: improved clinician experience, improved patient experience, improved population health, and reduced health care costs. Hospitals are attempting to improve care by using digital technologies, but the effectiveness of these technologies is often only measured against cost and quality indicators, and less is known about the clinician and patient experience. OBJECTIVE: This study aims to conduct a systematic review and qualitative evidence synthesis to assess the clinician and patient experience of digital hospitals. METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and ENTREQ (Enhancing the Transparency in Reporting the Synthesis of Qualitative Research) guidelines were followed. The PubMed, Embase, Scopus, CINAHL, and PsycINFO databases were searched from January 2010 to June 2022. Studies that explored multidisciplinary clinician or adult inpatient experiences of digital hospitals (with a full electronic medical record) were included. Study quality was assessed using the Mixed Methods Appraisal Tool. Data synthesis was performed narratively for quantitative studies. Qualitative evidence synthesis was performed via (1) automated machine learning text analytics using Leximancer (Leximancer Pty Ltd) and (2) researcher-led inductive synthesis to generate themes. RESULTS: A total of 61 studies (n=39, 64% quantitative; n=15, 25% qualitative; and n=7, 11% mixed methods) were included. Most studies (55/61, 90%) investigated clinician experiences, whereas few (10/61, 16%) investigated patient experiences. The study populations ranged from 8 to 3610 clinicians, 11 to 34,425 patients, and 5 to 2836 hospitals. Quantitative outcomes indicated that clinicians had a positive overall satisfaction (17/24, 71% of the studies) with digital hospitals, and most studies (11/19, 58%) reported a positive sentiment toward usability. Data accessibility was reported positively, whereas adaptation, clinician-patient interaction, and workload burnout were reported negatively. The effects of digital hospitals on patient safety and clinicians' ability to deliver patient care were mixed. The qualitative evidence synthesis of clinician experience studies (18/61, 30%) generated 7 themes: inefficient digital documentation, inconsistent data quality, disruptions to conventional health care relationships, acceptance, safety versus risk, reliance on hybrid (digital and paper) workflows, and patient data privacy. There was weak evidence of a positive association between digital hospitals and patient satisfaction scores. CONCLUSIONS: Clinicians' experience of digital hospitals appears positive according to high-level indicators (eg, overall satisfaction and data accessibility), but the qualitative evidence synthesis revealed substantive tensions. There is insufficient evidence to draw a definitive conclusion on the patient experience within digital hospitals, but indications appear positive or agnostic. Future research must prioritize equitable investigation and definition of the digital clinician and patient experience to achieve the Quadruple Aim of health care.

The typing is on the wall: Australia's healthcare future needs a digitally capable workforce.

Digital health technologies are a proposed solution to improve healthcare delivery and reduce pressures on the healthcare system, but these technologies are new to much of the health workforce. This perspective paper highlights lessons learned from the global experience of rapid digital transformation of health workforces, including fostering a culture of learning, ensuring accreditation and recognition, and adopting a transdisciplinary approach. Evidence-based actions are proposed to address recommendations to (1) ensure foundational workforce digital health capability and (2) build specialist digital health career pathways. Australia must take a national approach and strategically leverage strong collaborations across sectors including healthcare, education and government to ensure a consistent, regulated and sustainable digital workforce capability.

Perceived Impact of Digital Health Maturity on Patient Experience, Population Health, Health Care Costs, and Provider Experience: Mixed Methods Case Study.

BACKGROUND: Health care organizations understand the importance of new technology implementations; however, the best strategy for implementing successful digital transformations is often unclear. Digital health maturity assessments allow providers to understand the progress made toward technology-enhanced health service delivery. Existing models have been criticized for their lack of depth and breadth because of their technology focus and neglect of meaningful outcomes. OBJECTIVE: We aimed to examine the perceived impacts of digital health reported by health care staff employed in health care organizations across a spectrum of digital health maturity. METHODS: A mixed methods case study was conducted. The digital health maturity of public health care systems (n=16) in Queensland, Australia, was examined using the quantitative Digital Health Indicator (DHI) self-assessment survey. The lower and upper quartiles of DHI scores were calculated and used to stratify sites into 3 groups. Using qualitative methods, health care staff (n=154) participated in interviews and focus groups. Transcripts were analyzed assisted by automated text-mining software. Impacts were grouped according to the digital maturity of the health care worker's facility and mapped to the quadruple aims of health care: improved patient experience, improved population health, reduced health care cost, and enhanced provider experience. RESULTS: DHI scores ranged between 78 and 193 for the 16 health care systems. Health care systems in the high-maturity category (n=4, 25%) had a DHI score of ≥166.75 (the upper quartile); low-maturity sites (n=4, 25%) had a DHI score of ≤116.75 (the lower quartile); and intermediate-maturity sites (n=8, 50%) had a DHI score ranging from 116.75 to 166.75 (IQR). Overall, 18 perceived impacts were identified. Generally, a greater number of positive impacts were reported in health care systems of higher digital health maturity. For patient experiences, higher maturity was associated with maintaining a patient health record and tracking patient experience data, while telehealth enabled access and flexibility across all digital health maturity categories. For population health, patient journey tracking and clinical risk mitigation were reported as positive impacts at higher-maturity sites, and telehealth enabled health care access and efficiencies across all maturity categories. Limited interoperability and organizational factors (eg, strategy, policy, and vision) were universally negative impacts affecting health service delivery. For health care costs, the resource burden of ongoing investments in digital health and a sustainable skilled workforce was reported. For provider experiences, the negative impacts of poor usability and change fatigue were universal, while network and infrastructure issues were negative impacts at low-maturity sites. CONCLUSIONS: This is one of the first studies to show differences in the perceived impacts of digital maturity of health care systems at scale. Higher digital health maturity was associated with more positive reported impacts, most notably in achieving outcomes for the population health aim.

Which one? A suggested approach for evaluating digital health maturity models.

Background: Digital health maturity models allow healthcare organizations to evaluate digital health capability and to develop roadmaps for improving patient care through technology. There are many models available commercially for healthcare providers to use to assess their digital health maturity. Currently, there are limited evidence-based methods to assess the quality, utility, and efficacy of maturity models to select the most appropriate model for the given context. Objective: To develop a framework to assess digital maturity models and facilitate recommendations for digital maturity model selection. Methods: A systematic, consultative, and iterative process was used. Literature analyses and a stakeholder needs analysis (n = 23) was conducted to develop content and design considerations. These considerations were incorporated into the initial version of the framework developed by researchers in a design workshop. External stakeholder review (n = 20) and improvements strengthened and finalized the framework. Results: The criteria of the framework include assessment of healthcare context, feasibility, integrity, completeness and actionability. Users can compare model performance in order to select the most appropriate model for their context. Conclusion: The framework provides healthcare stakeholders with a consistent and objective methodology to compare digital health maturity models, informing approaches to choosing a suitable model. This is a critical step as healthcare evolves towards a digital health system focused on improving the quality of care, reducing costs and improving the provider and consumer experience.

Evaluating Digital Health Capability at Scale Using the Digital Health Indicator.

BACKGROUND: Health service providers must understand their digital health capability if they are to drive digital transformation in a strategic and informed manner. Little is known about the assessment and benchmarking of digital maturity or capability at scale across an entire jurisdiction. The public health care system across the state of Queensland, Australia has an ambitious 10-year digital transformation strategy. OBJECTIVE: The aim of this research was to evaluate the digital health capability in Queensland to inform digital health strategy and investment. METHODS: The Healthcare Information and Management Systems Society Digital Health Indicator (DHI) was used via a cross-sectional survey design to assess four core dimensions of digital health transformation: governance and workforce; interoperability; person-enabled health; and predictive analytics across an entire jurisdiction simultaneously. The DHI questionnaire was completed by each health care system (n = 16) within Queensland in February to July 2021. DHI is scored 0 to 400 and dimension score is 0 to 100. RESULTS: The results reveal a variation in DHI scores reflecting the diverse stages of health care digitization across the state. The average DHI score across sites was 143 (range 78-193; SD35.3) which is similar to other systems in the Oceania region and global public systems but below the global private average. Governance and workforce was on average the highest scoring dimension (x̅= 54), followed by interoperability (x̅ = 46), person-enabled health (x̅ = 36), and predictive analytics (x̅ = 30). CONCLUSION: The findings were incorporated into the new digital health strategy for the jurisdiction. As one of the largest single simultaneous assessments of digital health capability globally, the findings and lessons learnt offer insights for policy makers and organizational managers.

The Effect of Digitization on the Safe Management of Anticoagulants.

BACKGROUND: Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalized inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting that novel approaches are required to address this persistent issue. Electronic medication management systems (eMMSs) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types. OBJECTIVE: Our objective was to evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management. METHODS: A retrospective, observational pre-/poststudy was conducted, analyzing real-world data across five hospital sites in a single health service. Four metrics were compared 1-year pre- and 1-year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs), and rate of heparin-induced thrombocytopenia. Further subanalyses of patients experiencing HACs in the post-EMR period identified key opportunities for intervention to maximize safety and quality of anticoagulation within an eMMS. RESULTS: A significant reduction in HACs was observed in the post-EMR implementation period (mean [standard deviation [SD]] =12.1 [4.4]/month vs. mean [SD] = 7.8 [3.5]/month; p = 0.01). The categorization of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia was observed in the post-EMR implementation period. CONCLUSION: The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimizing eMMSs.

Precision Public Health for Non-communicable Diseases: An Emerging Strategic Roadmap and Multinational Use Cases.

Non-communicable diseases (NCDs) remain the largest global public health threat. The emerging field of precision public health (PPH) offers a transformative opportunity to capitalize on digital health data to create an agile, responsive and data-driven public health system to actively prevent NCDs. Using learnings from digital health, our aim is to propose a vision toward PPH for NCDs across three horizons of digital health transformation: Horizon 1-digital public health workflows; Horizon 2-population health data and analytics; Horizon 3-precision public health. This perspective provides a high-level strategic roadmap for public health practitioners and policymakers, health system stakeholders and researchers to achieving PPH for NCDs. Two multinational use cases are presented to contextualize our roadmap in pragmatic action: ESP and RiskScape (USA), a mature PPH platform for multiple NCDs, and PopHQ (Australia), a proof-of-concept population health informatics tool to monitor and prevent obesity. Our intent is to provide a strategic foundation to guide new health policy, investment and research in the rapidly emerging but nascent area of PPH to reduce the public health burden of NCDs.

Synthesizing Dimensions of Digital Maturity in Hospitals: Systematic Review.

BACKGROUND: Digital health in hospital settings is viewed as a panacea for achieving the "quadruple aim" of health care, yet the outcomes have been largely inconclusive. To optimize digital health outcomes, a strategic approach is necessary, requiring digital maturity assessments. However, current approaches to assessing digital maturity have been largely insufficient, with uncertainty surrounding the dimensions to assess. OBJECTIVE: The aim of this study was to identify the current dimensions used to assess the digital maturity of hospitals. METHODS: A systematic literature review was conducted of peer-reviewed literature (published before December 2020) investigating maturity models used to assess the digital maturity of hospitals. A total of 29 relevant articles were retrieved, representing 27 distinct maturity models. The articles were inductively analyzed, and the maturity model dimensions were extracted and consolidated into a maturity model framework. RESULTS: The consolidated maturity model framework consisted of 7 dimensions: strategy; information technology capability; interoperability; governance and management; patient-centered care; people, skills, and behavior; and data analytics. These 7 dimensions can be evaluated based on 24 respective indicators. CONCLUSIONS: The maturity model framework developed for this study can be used to assess digital maturity and identify areas for improvement.

Economic evaluation and analyses of hospital-based electronic medical records (EMRs): a scoping review of international literature.

Digital transformation is expensive and rarely smooth, often leading to higher costs than anticipated. It is challenging to demonstrate the contribution of digital health investment in achieving the healthcare aims of population health and workforce sustainability. We conducted a scoping review to understand how electronic medical record (EMR) implementations in the hospital setting have been evaluated using cost-benefit analysis (CBA) approaches. The review search resulted in 1184 unique articles, a final list of 28 was collated of which 20 were US-based studies. All studies were published in 2010-2019, with fewer studies published in more recent years. The data used to estimate benefits and costs were dated from 1996 to 2016, with most data from 2000 to 2010. Only three studies were qualified as using cost-benefit analysis approaches. While studies indicated that there is a positive impact from the EMR implementation, the impacts measured varied greatly. We concluded that the current literature demonstrates a lack of appropriate and comprehensive economic frameworks to understand the value of digital hospital implementations. Additionally, most studies failed to align fully to the quadruple aims of healthcare: they focused either on cost savings and/or improved patient outcomes and population health, none investigated healthcare-workforce sustainability.

Methodology for the Development of the Australian National Nursing and Midwifery Digital Health Capability Framework.

Internationally healthcare organisations and governments are grappling with the issue of upskilling healthcare workforces in relation to digital health. Significant research has been undertaken in relation to documenting essential digital health capability requirements for the workforce. In 2019 the Australian Digital Health Agency funded work by the Australasian Institute of Digital Health to develop a National Nursing and Midwifery Digital Health Capability Framework. This paper describes the methodological approach used in the development of the Framework.

Co-Design of a Mobile Health App for Heart Failure: Perspectives from the Team.

Using a Design Thinking and co-design methodology, hospital staff and consumers developed a novel mobile health app for heart failure self-management. Various stakeholders engaged in three development stages: interviews, design workshops and prototype iterations. Eleven of 18 co-design team members reflected on the co-design process and design outcomes. A total of 144 data points were collected: 96 about the co-design process and 48 about the design outcomes. Successes and failures reflect the strengths and weaknesses of operationalising co- design in practice. Overall, participants were surprised the design outcomes were achieved. The app was considered a supportive tool for meaningful self-monitoring and patients believed the app would be applicable to their situations. Our findings suggest that local co-design can be achieved through meaningful partnerships, and managing stakeholders was key to the projectâAZs success.

Evaluating the Development Processes of Consumer mHealth Interventions for Chronic Condition Self-management: A Scoping Review.

Innovative, patient-centered mHealth interventions have the potential to help with the burden of chronic conditions. This review aims to describe the development of consumer mHealth interventions for chronic condition self-management. A scoping review methodology was used to search medical databases for eligible reports, published between January 1, 2010, and December 31, 2017, that provided information on consumer mHealth interventions for respiratory disease, cancer, diabetes, and cardiovascular disease. Twenty-one reports were included, representing the development of 14 mHealth interventions. Most were developed collaboratively, using user-centered and participatory design processes. Predesign work involved a thorough needs assessment, and redesign processes were described as iterative, engaging with usability testing and design improvements. Tensions from competing priorities between patients and healthcare professionals were uncovered, with the intention to develop a useful product for the patient while ensuring clinical relevance. This review provides clear evidence that consumer mHealth interventions are developed inconsistently even when engaging with participatory or user-centered design principles, sometimes without direct involvement of patients themselves. Further, the incomplete description of the development processes presents challenges to furthering the knowledge base as healthcare professionals need timely access to quality information on mHealth products in order to recommend safe, effective consumer mHealth interventions.

Patients' Experiences of Using a Consumer mHealth App for Self-Management of Heart Failure: Mixed-Methods Study.

BACKGROUND: To support the self-management of heart failure, a team of hospital clinicians, patients, and family caregivers have co-designed the consumer mobile health app, Care4myHeart. OBJECTIVE: This research aimed to determine patient experiences of using the app to self-manage heart failure. METHODS: Patients with heart failure used the app for 14 days on their own smart device in a home setting, following which a mixed-methods evaluation was performed. Eight patients were recruited, of whom six completed the Mobile Application Rating Scale and attended an interview. RESULTS: The overall app quality score was "acceptable" with 3.53 of 5 points, with the aesthetics (3.83/5) and information (3.78/5) subscales scoring the highest. The lowest mean score was in the app-specific subscale representing the perceived impact on health behavior change (2.53/5). Frequently used features were weight and fluid restriction tracking, with graphical representation of data particularly beneficial for improved self-awareness and ongoing learning. The use of technology for self-management will fundamentally differ from current practices and require a change in daily routines. However, app use was correlated with potential utility for daily management of illness with benefits of accurate recording and review of personal health data and as a communication tool for doctors to assist with care planning, as all medical information is available in one place. Technical considerations included participants' attitudes toward technology, functionality and data entry issues, and relatively minor suggested changes. CONCLUSIONS: The findings from this usability study suggest that a significant barrier to adoption is the lack of integration of technology into everyday life in the context of already established disease self-management routines. Future studies should explore the barriers to adoption and sustainability of consumer mobile health interventions for chronic conditions, particularly whether introducing such apps is more beneficial at the commencement of a self-management regimen.

Design of a Consumer Mobile Health App for Heart Failure: Findings From the Nurse-Led Co-Design of Care4myHeart.

BACKGROUND: Consumer health care technology shows potential to improve outcomes for community-dwelling persons with chronic conditions, yet health app quality varies considerably. In partnership with patients and family caregivers, hospital clinicians developed Care4myHeart, a mobile health (mHealth) app for heart failure (HF) self-management. OBJECTIVE: The aim of this paper was to report the outcomes of the nurse-led design process in the form of the features and functions of the developed app, Care4myHeart. METHODS: Seven patients, four family caregivers, and seven multidisciplinary hospital clinicians collaborated in a design thinking process of innovation. The co-design process, involving interviews, design workshops, and prototype feedback sessions, incorporated the lived experience of stakeholders and evidence-based literature in a design that would be relevant and developed with rigor. RESULTS: The home screen displays the priority HF self-management components with a reminder summary, general information on the condition, and a settings tab. The health management section allows patients to list health care team member's contact details, schedule medical appointments, and store documents. The My Plan section contains nine important self-management components with a combination of information and advice pages, graphical representation of patient data, feedback, and more. The greatest strength of the co-design process to achieve the design outcomes was the involvement of local patients, family caregivers, and clinicians. Moreover, incorporating the literature, guidelines, and current practices into the design strengthened the relevance of the app to the health care context. However, the strength of context specificity is also a limitation to portability, and the final design is limited to the stakeholders involved in its development. CONCLUSIONS: We recommend health app development teams strategically incorporate relevant stakeholders and literature to design mHealth solutions that are rigorously designed from a solid evidence base and are relevant to those who will use or recommend their use.

Conceptual Design and Iterative Development of a mHealth App by Clinicians, Patients and Their Families.

Heart failure self-management can be challenging but appropriately designed, user-centred mobile health (mHealth) innovations may help. We have built a consumer mHealth application which we plan to implement as an adjunct to existing specialist multidisciplinary heart failure care at our health service. We have the double aim to meet the needs of patients and ensure clinical relevance in order to be recommended by clinicians. This paper reports the participatory, user-centred co-design process of the conceptual design and iterative development of the application. Two nurse-led participatory design workshops were conducted with six clinicians and a patient, which determined user-experience opinions, key features and priority functions. The iterative development phase encompassed two application wireframe feedback cycles with seven clinicians, three patients and a family member. Workshops and wireframe feedback activities took place on the hospital campus predominantly using resources available to clinicians. Software build was outsourced and was followed by the design team reaching consensus with features and functions of the app. Further development and evaluation of flexible participatory, user-centred methods for use by clinicians to facilitate co-design with consumers will advance consumer digital health strategies.

Partnering in Digital Health Design: Engaging the Multidisciplinary Team in a Needs Analysis.

Using participatory co-design methods and in partnership with consumers we have developed a mHealth application to support heart failure self-management. In the first phase of the research we conducted a needs analysis with clinicians. The objectives were to define the features to perceivably support self-management and the clinical requirements in preparation for its implementation as an adjunct to existing multidisciplinary care. Interviews were conducted using the 'Rose, Thorn, Bud' technique from Design Thinking together with a brainstorming session with post-it notes. Six sixty-minute interviews and one email exchange with seven clinicians produced 154 data points in total; 97 relating to self-management support and 57 to clinical relevance. Analysis of these data points resulted in design implications articulated in a design brief for use in subsequent co-design workshops. Our discussion focuses on a critique of the technique, which appears to be useful for this stakeholder group although concerns of adequately representing complexity emerged. This method was considered inadequately comprehensive for use in the needs analysis with patients and family. The authors encourage further research evaluating in-hospital processes for co-designed health technologies.

Design Thinking for mHealth Application Co-Design to Support Heart Failure Self-Management.

Heart failure is a prevalent, progressive chronic disease costing in excess of $1billion per year in Australia alone. Disease self-management has positive implications for the patient and decreases healthcare usage. However, adherence to recommended guidelines is challenging and existing literature reports sub-optimal adherence. mHealth applications in chronic disease education have the potential to facilitate patient enablement for disease self-management. To the best of our knowledge no heart failure self-management application is available for safe use by our patients. In this paper, we present the process established to co-design a mHealth application in support of heart-failure self-management. For this development, an interdisciplinary team systematically proceeds through the phases of Stanford University's Design Thinking process; empathise, define, ideate, prototype and test with a user-centred philosophy. Using this clinician-led heart failure app research as a case study, we describe a sequence of procedures to engage with local patients, carers, software developers, eHealth experts and clinical colleagues to foster rigorously developed and locally relevant patient-facing mHealth solutions. Importantly, patients are engaged in each stage with ethnographic interviews, a series of workshops and multiple re-design iterations.