The perceived quality of video consultations in geriatric outpatient care by early adopters.

PURPOSE: The COVID-19 pandemic caused rapid implementation and upscaling of video consulting. This study examined the perceived quality of care delivered through video consulting at a geriatric outpatient clinic, and how this related to adoption issues and barriers early adopting professionals found themselves confronted with. METHODS: We performed a qualitative study using semi-structured interviews with healthcare professionals complemented by the views of geriatric patients, family caregivers and medical secretaries. Participants from five academic centers and six teaching hospitals were included. Three researchers conducted the interviews, coded the data, and used thematic analysis. RESULTS: Interviews were conducted with 13 healthcare professionals, 8 patients, 7 family caregivers, and 4 medical secretaries. From these early adopters, we infer five criteria positively contributing to perceived quality of care provided by video consulting: (1) the patient has an intact cognitive function; (2) a family caregiver with digital literacy can be present; (3) doctor and patient already have an established relationship; (4) no immediate need for physical examination or intervention; and (5) the prior availability of a comprehensive and concise medical history. Overall, the uptake of video consulting in geriatric outpatient care appeared to be slow and laborious due to several implementation barriers. CONCLUSION: The implementation of video consulting use among geriatricians and geriatric patients at the geriatric outpatient clinic was slow due to the absence of many facilitating factors, but video consulting might be offered as an alternative to face-to-face follow-up to suitable patients in geriatric outpatient clinics.

Persisting workarounds in Electronic Health Record System use: types, risks and benefits.

BACKGROUND: Electronic Health Records (EHRs) are now widely used to create a single, shared, and reliable source of patient data throughout healthcare organizations. However, health professionals continue to experience mismatches between their working practices and what the EHR allows or directs them to do. Health professionals adopt working practices other than those imposed by the EHR to overcome such mismatches, known as workarounds. Our study aims to inductively develop a typology of enduring EHR workarounds and explore their consequences by answering the question: What types of EHR workarounds persist, and what are the user-perceived consequences? METHODS: This single case study was conducted within the Internal Medicine department of a Dutch hospital that had implemented an organization-wide, commercial EHR system over two years ago. Data were collected through observations of six EHR users (see Additional file 1, observation scheme) and 17 semi-structured interviews with physicians, nurses, administrators, and EHR support staff members. Documents were analysed to contextualize these data (see Additional file 2, interview protocol). RESULTS: Through a qualitative analysis, 11 workarounds were identified, predominantly performed by physicians. These workarounds are categorized into three types either performed while working with the system (in-system workflow sequence workarounds and in-system data entry workarounds) or bypassing the system (out-system workarounds). While these workarounds seem to offer short-term benefits for the performer, they often create threats for the user, the patient, the overall healthcare organization, and the system. CONCLUSION: This study increases our understanding of the enduring phenomenon of working around Electronic Health Records by presenting a typology of those workarounds that persist after adoption and by reflecting on the user-perceived risks and benefits. The typology helps EHR users and their managers to identify enduring types of workarounds and differentiate between the harmful and less harmful ones. This distinction can inform their decisions to discourage or obviate the need for certain workarounds, while legitimating others.

The influence of electronic health record use on collaboration among medical specialties.

BACKGROUND: One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics. METHODS: We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating. RESULTS: Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because: (a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use. (b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital. (c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow. (d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration. (e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority. CONCLUSIONS: For the optimal actualization of EHRs' collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

Reasons That Dutch Dentists and Dental Hygienists Oppose or Support an Extended Scope of Practice for Dental Hygienists.

BACKGROUND: In the Netherlands, the scope of dental hygiene practice was expanded in 2006. The objective of this study was to explore reasons among dentists and dental hygienists for supporting or opposing an extended scope of practice and to find explanatory factors. METHODS: A questionnaire containing pre-defined reasons and an open-ended question was distributed among 1,674 randomly selected members of two Dutch professional associations (874 dentists, 800 dental hygienists). Data were analyzed with binary logistic regression with Bayesian information criterion (BIC) model selection. RESULTS: Response were obtained from 541 practitioners (32.3%): i.e., 233 dentists (43.1%) and 308 dental hygienists (56.9%). Non-response analysis revealed no differences, and representativeness analysis showed similarities between samples and target populations. Most often, dentists reported flexible collaboration (50.2%) and dental hygienists indicated task variation (71.1%) as supportive reasons. As opposing reasons, dentists generally reported quality of care (41.2%) and dental hygienists' self-competence (22.7%). Reasons were explained by profession, gender, and new-style practitioners. CONCLUSION: Dentists and dental hygienists conveyed different reasons for supporting or opposing an extended scope of dental hygiene practice. Outcomes can be categorized as reasons related to economic, professional status, quality, job satisfaction, and flexible collaboration and are not only explained by profession.

Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care.

BACKGROUND: Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients' health behavior. METHODS: This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n = ± 70). Higher fidelity scores indicate a more complete implementation of the program's core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes. RESULTS: Three trajectories were identified as the following: 'stable high fidelity' (n = 9), 'moderate and improving fidelity' (n = 6), and 'unstable fidelity' (n = 2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period's start and end, support from physicians and physiotherapists, professionals' appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p < .05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients' self-reported physical activity outcomes (adjusted model ß = - 651.6, t(613) = - 1032, p = .303). CONCLUSIONS: Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization's conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program's standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations' starting position, size, and circumstances. TRIAL REGISTRATION: The Netherlands National Trial Register NTR3961 . Registered 18 April 2013.

Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review.

BACKGROUND: An ageing population is seen as a threat to the quality of life and health in rural communities, and it is often assumed that e-Health services can address this issue. As successful e-Health implementation in organizations has proven difficult, this systematic literature review considers whether this is so for rural communities. This review identifies the critical implementation factors and, following the change model of Pettigrew and Whipp, classifies them in terms of "context", "process", and "content". Through this lens, we analyze the empirical findings found in the literature to address the question: How do context, process, and content factors of e-Health implementation influence its adoption in rural communities? METHODS: We conducted a systematic literature review. This review included papers that met six inclusion and exclusion criteria and had sufficient methodological quality. Findings were categorized in a classification matrix to identify promoting and restraining implementation factors and to explore whether any interactions between context, process, and content affect adoption. RESULTS: Of the 5,896 abstracts initially identified, only 51 papers met all our criteria and were included in the review. We distinguished five different perspectives on rural e-Health implementation in these papers. Further, we list the context, process, and content implementation factors found to either promote or restrain rural e-Health adoption. Many implementation factors appear repeatedly, but there are also some contradictory results. Based on a further analysis of the papers' findings, we argue that interaction effects between context, process, and content elements of change may explain these contradictory results. More specifically, three themes that appear crucial in e-Health implementation in rural communities surfaced: the dual effects of geographical isolation, the targeting of underprivileged groups, and the changes in ownership required for sustainable e-Health adoption. CONCLUSIONS: Rural e-Health implementation is an emerging, rapidly developing, field. Too often, e-Health adoption fails due to underestimating implementation factors and their interactions. We argue that rural e-Health implementation only leads to sustainable adoption (i.e. it "sticks") when the implementation carefully considers and aligns the e-Health content (the "clicks"), the pre-existing structures in the context (the "bricks"), and the interventions in the implementation process (the "tricks").

Redrawing medical professional domains: new doctors, shifting boundaries, and traditional force fields.

PURPOSE: This paper aims to investigate the forces that influence the shifting of professional boundaries on the entry of a new medical occupation in Dutch hospitals - non-specialist emergency physicians. DESIGN/METHODOLOGY/APPROACH: Five case studies of Dutch hospitals were conducted and the emergency physicians' implementation process was analyzed by means of force field analysis. FINDINGS: Emergency physicians were conceptualized as being the answer to unequivocal contextual changes. However, their contribution to better performance varies due to problems in the implementation process. Strong socio-political forces between traditional specialties and these new doctors mediate the intended improvement. The emergency physicians aim to establish their own organizational-, patient- and knowledge-domain by redrawing professional boundaries but they are not on a par with the specialists who set these boundaries. Consequently, emergency physicians only gradually redraw the existing boundaries, resulting in limited added value. Their reaction is to obtain power by striving to develop into a recognized specialty; ironically, by becoming an additional layer in the traditional medical hierarchy they might lose their envisaged added value. RESEARCH LIMITATIONS/IMPLICATIONS: This paper is based on the first Dutch hospitals that implemented emergency physicians. The number of cases is therefore limited. Moreover, the study took place at an early stage of emergency physician implementation. PRACTICAL IMPLICATIONS: The extent of successful redrawing depends on the implementation's transition logic, the existing degree of differentiation and boundary permeability and on the ideological power developed by the leaders. ORIGINALITY/VALUE: The introduction of emergency physicians is currently being discussed in many countries worldwide, and some countries consider following the Dutch example of non-specialist doctors. This paper supports health professionals and hospital managers in not falling prey to the same pitfalls as some Dutch hospitals.

Does telehomeconsultation lead to substitution of home visits? Analysis and implications of a telehomecare program.

This study's objective was to determine and to explain the potential substitution effects of a nurse-led video teleconsultation service for homecare clients. To that end the largest program in the Netherlands up till 2009 was analyzed. This program's aim was to realize partly substitution of homecare visits by telecare for carefully selected clients. The study was multi-method. Each video contact was registered, and a sample was described on forms during an 8- month period starting half a year after implementation. (Changes in) the homecare visit consumption of the subscribing (n=335) and of a non-subscribing group (n=288) were compared. Moreover, we interviewed care coordinators, clients, managers, and telenurses and observed the latter's work. Results show that the frequency of telehomecare contacts varied greatly. For this homecare client population the sheer provision of a video channel to nurses does not lead to substitution. Only for a few clients substitution of the regular homecare visits proved feasible The discussion section explains this disappointing outcome by technology push and an inconsistent implementation mode. It is argued that telehomecare can potentially serve four different goals, including substitution. For future research we propose consistent implementation modes to realize these goals.

The compatibility of future doctors' career intentions with changing health care demands.

BACKGROUND: In the Netherlands the medical education system is in the process of being transformed to establish a more demand-oriented health care system. This transformation may entail the occupational restructuring of the medical profession. Meanwhile, on the supply side, the career intentions of future doctors are also changing. OBJECTIVES: We aimed to categorise medical students' prevailing career intentions and to examine to what extent newly proposed medical occupations that may be part of the transformation process correspond with these career intentions. METHODS: We carried out expert interviews and a feedback round to gain input for a survey among students. From the demand perspective, 11 experts proposed non-traditional medical occupations and evaluated these on the basis of job characteristics relevant to a doctor's career choice. Subsequently, students from 5 universities filled out a questionnaire to rate these job characteristics by their importance and the proposed occupations' attractiveness. Results Four different clusters of career intentions were categorised as patient-oriented expert, career-oriented specialist, lifestyle-oriented generalist, and balance-seeking realist. These clusters differ in terms of the ways in which students feel attracted to the proposed occupations. The career-oriented specialists feel least attracted and the lifestyle-oriented generalists most attracted to the occupations. DISCUSSION: The experts' call for shorter postgraduate programmes to educate patient-oriented doctors partly matches students' career intentions. Most students share the intention of obtaining a direct care position that provides ample task variation, which may explain the appeal of the occupations 'emergency doctor' and 'basic specialist'. The limited interest in specific patient groups suggests a need for more exposure to the occupations linked to these groups.

Realising integrative care by delegation: the hospital physician.

Hospital managers are constantly confronted with capacity and continuity problems that tempt them to investigate the possibility of further job differentiation. In The Netherlands, the hospital physician represents a new breed of physicians who are not oriented towards a medical specialism but towards a patient domain. The hospital physician represents a controversial kind of job differentiation that is expected to stimulate more continuity. This case study shows how medical specialists themselves are starting to address the fragmentation caused by specialization. According to the professionals involved, the hospital physician constitutes a solution that does not threaten their professional values. They report a number of ways in which this job type can contribute to solving the problems reported. However, concerns have been raised about the risks of developing these new jobs without changing the existing professional and work structures.

The organizational and performance effects of nurse practitioner roles.

BACKGROUND: Most studies evaluating the roles of Nurse Practitioners have compared the care delivered by individual Nurse Practitioners with that provided by other professionals. These studies should be complemented by research focusing on a higher unit of analysis, namely the organization of the care process for a specific patient group. The most important reason is that Nurse Practitioners are increasingly involved in direct, multiprofessional care in complex health care organizations and networks. In these work settings, their roles may, in both positive and negative ways, lead to changes in the organization of the entire care delivery system. AIM: The aim of this paper is to stimulate awareness and evaluation of these organizational changes and their potential impact on the effectiveness of the care process. APPROACH: A conceptual model based on patterned systems contingency theory is proposed. With the help of this model, attention is drawn to issues at the level of the organization and the effectiveness of the care processes that merit attention when Nurse Practitioner positions are being introduced. These issues are derived from case studies in Dutch hospitals. RESULTS: According to the model, a Nurse Practitioner position will change the work structure of the care process involved. Therefore, the effectiveness of a Nurse Practitioner position will be dependent on the changes realized in the work structure. The resulting structure should fit the task characteristics of the care services demanded by the specific patient group. On the basis of this model and the examples presented, questions for further study are formulated. CONCLUSIONS: Nurse Practitioner roles can only enhance the effectiveness of care processes when embedded in a work structure that is internally consistent and adjusted to the task environment and available skill-mix. A structural contingency framework may be helpful in identifying relevant organizational issues. To determine the effects of Nurse Practitioner roles, cross-sectional as well as longitudinal studies are needed.