Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review.

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Computerisation in general practice: lessons for Canada from the UK and Australia.

In 2000 Shaw and Kidd published an article on the lessons that could be learned from the UK in general practice computerization. Over a decade later many of these lessons remain yet to be learned. Hence Shaw & Bainbridge felt that it was time to revisit these issues and review progress made against each in both the UK and Australia in an effort to help Canada learn the lessons as it follows behind both countries. Nine lessons are identified, reviewed and discussed in the hope that Canada will choose to take note and leapfrog these jurisdictions by learning from history, rather than being doomed to repeat it.

Identification by families of pediatric adverse events and near misses overlooked by health care providers.

BACKGROUND: Identifying adverse events and near misses is essential to improving safety in the health care system. Patients are capable of reliably identifying and reporting adverse events. The effect of a patient safety reporting system used by families of pediatric inpatients on reporting of adverse events by health care providers has not previously been investigated. METHODS: Between Nov. 1, 2008, and Nov. 30, 2009, families of children discharged from a single ward of British Columbia's Children's Hospital were asked to respond to a questionnaire about adverse events and near misses during the hospital stay. Rates of reporting by health care providers for this period were compared with rates for the previous year. Family reports for specific incidents were matched with reports by health care providers to determine overlap. RESULTS: A total of 544 familes responded to the questionnaire. The estimated absolute increase in reports by health care providers per 100 admissions was 0.5% (95% confidence interval -1.8% to 2.7%). A total of 321 events were identified in 201 of the 544 family reports. Of these, 153 (48%) were determined to represent legitimate patient safety concerns. Only 8 (2.5%) of the adverse events reported by families were also reported by health care providers. INTERPRETATION: The introduction of a family-based system for reporting adverse events involving pediatric inpatients, administered at the time of discharge, did not change rates of reporting of adverse events and near misses by health care providers. Most reports submitted by families were not duplicated in the reporting system for health care providers, which suggests that families and staff members view safety-related events differently. However, almost half of the family reports represented legitimate patient safety concerns. Families appeared capable of providing valuable information for improving the safety of pediatric inpatients.

Perceptions about complementary and alternative medicine use among Chinese immigrant parents of children with cancer.

PURPOSE: Research indicates complementary and alternative medicine (CAM) use among children with cancer is common and widespread. CAM use, particularly traditional Chinese medicine (TCM), is prevalent in the country of origin of Chinese immigrant families, yet little is known about its use after immigrating to Canada. This paper describes 25 Chinese immigrant parents' perception about the use of CAM in their child with cancer in Canada. METHODS: This qualitative grounded theory study is part of a larger study of the caregiving experiences of first generation Chinese and South Asian parents of children with cancer. Chinese parents of children at least 6 months post-diagnosis were recruited from four Canadian pediatric oncology centers. Interviews were conducted in English, Cantonese, or Mandarin and transcribed into English. Analysis involved coding and the use of the constant comparison method to identify important themes. RESULTS: In discussing their caregiving experiences, CAM emerged as an important theme. The following sub-themes were identified: (1) trust in conventional medicine to cure cancer; (2) use of dietary modifications and restrictions; (3) extent of communication with healthcare providers about TCM use; and (4) limited availability of culturally relevant information. CONCLUSIONS: While Chinese immigrant parents in this study placed their trust in conventional medicine to treat their child, the use of food as therapy is part of their daily cultural practice. To ensure safe cancer treatment and more culturally sensitive care, it is essential for health providers to offer reliable information and encourage open discussions about CAM use with Chinese immigrant parents.

Understanding the health impact of caregiving: a qualitative study of immigrant parents and single parents of children with cancer.

PURPOSE: Research looking at the health of parents of children with cancer typically uses outcome measures focused on symptoms of anxiety, depression, or post-traumatic stress. Our team builds on this literature to provide a more comprehensive understanding of the health impact of caregiving. METHODS: Interviews were conducted with 79 Canadian parents of children with cancer at least 6 months post-diagnosis. Line-by-line coding was used to establish categories and themes. Constant comparison was used to examine relationships within and across codes and categories. Interviewing continued until no new themes emerged. RESULTS: Parents described health concerns as including sleep disturbance, daytime fatigue, anxiety, depression, social isolation, and changes in social roles. Parents described the positive impacts of caregiving as including gaining a greater appreciation for child and family and developing compassion, empathy, patience, inner strength, and new perspectives on life. CONCLUSION: Parents of children with cancer can experience a range of health problems due to the emotional impact of a cancer diagnosis and the intensive and often prolonged nature of treatment and aftercare. Given the central role parents play as caregivers, it is crucial to understand the health impact of caregiving so that supportive interventions can be implemented as necessary.

Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study.

BACKGROUND: Electronic documentation handling may facilitate information flows in health care settings to support better coordination of care among Health Care Providers (HCPs), but evidence is limited. Methods that accurately depict changes to the workflows of HCPs are needed to assess whether the introduction of a Critical Care clinical Information System (CCIS) to two Intensive Care Units (ICUs) represents a positive step for patient care. To evaluate a previously described method of quantifying amounts of time spent and interruptions encountered by HCPs working in two ICUs. METHODS: Observers used PDAs running the Work Observation Method By Activity Timing (WOMBAT) software to record the tasks performed by HCPs in advance of the introduction of a Critical Care clinical Information System (CCIS) to quantify amounts of time spent on tasks and interruptions encountered by HCPs in ICUs. RESULTS: We report the percentages of time spent on each task category, and the rates of interruptions observed for physicians, nurses, respiratory therapists, and unit clerks. Compared with previously published data from Australian hospital wards, interdisciplinary information sharing and communication in ICUs explain higher proportions of time spent on professional communication and documentation by nurses and physicians, as well as more frequent interruptions which are often followed by professional communication tasks. CONCLUSIONS: Critical care workloads include requirements for timely information sharing and communication and explain the differences we observed between the two datasets. The data presented here further validate the WOMBAT method, and support plans to compare workflows before and after the introduction of electronic documentation methods in ICUs.

Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

What are the barriers to conducting international research using routinely collected primary care data?

BACKGROUND: Primary care is computerized with routine data recorded at the point or care. Secondary use of these data includes: genetic study, epidemiology and clinical trials. However, there are relatively few international studies. OBJECTIVE: To identify the concepts that might predict readiness to collaborate in international research using routinely collected primary care data METHOD: Literature review and data gathering exercise, from international Primary Care Informatics working group workshops, and email modified Delphi exercise. RESULTS: To establish whether primary care data are fit for use in a collaborative study information is needed at the micro-, meso-, and macro-level. At the micro- or data level we need to use documented standards for interoperability, computerized records, to facilitate linkage of data. At the meso-level we need to understand the nature of the electronic patient record (EPR) and specific study requirements. At the macro-level: health system, social and cultural context constrain what data are available. The framework defines the information needed at the point of expression of interest, and joining a study. The initial assessment of readiness should be by self-assessment followed by an in depth appraisal more immediately prior to the start of the study. Finally, a sensitivity analysis should be conducted to test the robustness of the data model. CONCLUSIONS: The literature focuses on technical issues: interoperability, EPR and modeling; the workshops on socio-cultural and organizational. This framework will form the basis for developing a survey instrument of the initial assessment of readiness for collaboration in international research.

Impact of a critical care clinical information system on interruption rates during intensive care nurse and physician documentation tasks.

Computerized documentation methods in Intensive Care Units (ICUs) may assist Health Care Providers (HCP) with their documentation workload, but evaluating impacts remains problematic. A Critical Care clinical Information System (CCIS) is an electronic charting tool designed for ICUs that may fit seamlessly into HCP work. Observers followed ICU nurses and physicians in two ICUs in Edmonton, Canada, in which a CCIS had recently been introduced. Observers recorded amounts of time HCPs spent on documentation related tasks, interruptions encountered by HCPs, and contextual information in field notes. Interruption rates varied depending on the charting medium used, with physicians being interrupted less frequently when performing documentation tasks using the CCIS, than when performing documentation tasks using other methods. In contrast, nurses were interrupted more frequently when charting using the CCIS than when using other methods. Interruption rates coupled with qualitative observations suggest that physicians utilize strategies to avoid interruptions if interfaces for entering textual notes are not well adapted to interruption-rich environments such as ICUs. Potential improvements are discussed such that systems like the CCIS may better integrate into ICU work.

Whose record is it anyway? Putting patients' interests at the heart of the implementation and use of electronic medical records.

With the dawn of electronic medical records (EMRs) and patient portals, there is an unprecedented opportunity to provide truly collaborative patient-centred care. These tools can promote communication between healthcare providers and patients, improve chronic disease management and enable patients to become active members in the healthcare delivery system, but only if the tools work for everyone involved--including patients. Without patient consultation and input, there will be limitations in the ways in which physicians and patients are able to capitalize on these tools. Decision-makers must begin to enact their commitment to collaborative patient-centred care by engaging patients in discussions related to EMR design, implementation and use.

Electronic health records and patient safety: what lessons can Canada learn from the experience of others?

It is recognized that the Electronic Health Record (EHR) has significant potential to improve patient safety in Canada. However, the scientific evidence connecting EHRs to improvements in patient safety is incomplete. Additionally, international experience has demonstrated that EHRs trigger profound cultural and organizational changes in healthcare delivery. Consequently, Canada has a unique opportunity to learn from these experiences.

'CHEATS': a generic information communication technology (ICT) evaluation framework.

This paper describes a generic framework for the evaluation of information communication technologies. This framework, CHEATS, utilises both qualitative and quantitative research methods and has proved appropriate in multiple clinical settings including telepsychiatry, teledermatology and teleeducation. The paper demonstrates how a multidisciplinary approach is essential when evaluating new and emerging technologies, particularly when such systems are implemented in real service as opposed to a research setting.

Geographical information systems and health: current state and future directions.

This paper provides an introduction to Geographical Information Systems (GIS) and how they can be used. It reviews the current state of GIS use in health care before identifying the barriers to more pervasive use of GIS in health. Finally, it makes recommendations for the direction of health GIS research over the next decade and concludes with a call to action to health informatics researchers to stop ignoring a tool and methodology that has such immense potential for improving the health of our communities.

A human factors and survey methodology-based design of a web-based adverse event reporting system for families.

PURPOSE: Adverse event reporting systems allow healthcare institutions to detect and prevent recurrence of avoidable patient harm. It is known that standard reporting systems, which are initiated by clinicians, detect only a minority of chart-documented adverse events. The objective of the study was to develop a web-based system, the Family Reporting System (FRS), to elicit adverse event reports from families of children admitted to hospital through survey methodology and human factors engineering techniques. MEASUREMENTS: Face validity and usability were measured via standardized survey instruments. Utility was measured via the rate, typology, degree of harm, likelihood of recurrence, quality of information, and inter-rater agreement analysis of the reported events. RESULTS: The FRS has good face validity, excellent usability, and good clinical utility. CONCLUSION: The application of survey and human factors methodologies to the design of an electronic system is an effective means of developing an electronic adverse event reporting system for the use of families of pediatric patients.

The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: a review of the literature.

PURPOSE: The introduction of a Critical Care Information System (CCIS) into an intensive care unit (ICU) is purported to reduce the time health care providers (HCP) spend on documentation and increase the time available for direct patient care. However, there is a paucity of rigorous empirical research that has investigated these assertions. Moreover, those studies that have sought to elucidate the relationship between the introduction of a CCIS and the time spent by staff on in/direct patient care activities have published contradictory findings. The objective of this literature review is to establish the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. METHODS: Five electronic databases were searched including PubMed Central, EMBASE, CINAHL, IEEE Xplore, and the Cochrane Database of Systematic Reviews. Reference lists of all published papers were hand searched, and citations reviewed to identify extra papers. We included studies that were empirical articles, published in English, and provided original data on the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. RESULTS: In total, 12 articles met the inclusion criteria. Workflow analysis (66%) and time-and-motion analysis (25%) were the most common forms of data collection. Three (25%) studies found an increase in time spent charting, five (42%) found no difference, and four (33%) studies reported a decrease. Results on the impact of a CCIS on direct patient care were similarly inconclusive. CONCLUSIONS: Due to the discrepant findings and several key methodological issues, the impact of a CCIS on time spent charting and in direct patient care remains unclear. This review highlights the need for an increase in rigorous empirical research in this area and provides recommendations for the design and implementation of future studies.

Mapping the sociotechnical healthcare ecosystem: expanding the horizons of sociotechnical inquiry.

In recent years, sociotechnical approaches have become increasingly popular for understanding the design, implementation and evaluation of information technology in health informatics. On the whole, these approaches have sought to unite essential knowledge from the domains of the social sciences and information technology in the study of health informatics, with the central assertion that health information technology cannot be properly understood apart from its social and systemic contexts. This perspective has been enormously beneficial, as it has provided a solid and sophisticated theoretical basis from which health informatics researchers have begun to describe, study, and understand human-IT interactions and their consequences at a microsystemic level. As this theory continues to be applied, however, it has become increasingly clear that these human-IT microsystems are themselves imbedded within larger systemic contexts, and that both these contexts--as well as the interactions and change processes both between and among them--need to be clearly conceptualized and explored in greater detail. In this workshop, sponsored by the AMIA Working Group on People and Organizational Issues, we present human ecological theory as means for facilitating this theoretical growth and invite health informaticians from all disciplines to actively explore the emerging Sociotechnical Healthcare Ecosystem.

Interruptions in workflow prior to the implementation of a Critical Care Information System (CCIS) in two intensive care settings.

Interruptions in clinician workflow are believed to contribute to preventable medical errors, and ICUs have been noted as frequent sites of these errors. Emerging research suggests that a CCIS may assist in reducing or preventing interruptions. However, there is a paucity of research that has empirically investigated these assertions. As part of a longitudinal study, results of the frequency and nature of interruptions in workflow before the implementation of a CCIS will be reported.

Clinical governance and laboratory medicine: is the electronic medical record our best friend or sworn enemy?

This review attempts to address the question: is the Electronic Medical Record (EMR) our best friend or sworn enemy in the context of Clinical Governance and Laboratory Medicine? It provides a brief overview of the history and development of Clinical Governance before going on to define an EMR. It considers how EMRs could assist in delivering quality care in laboratory medicine. A number of outstanding issues regarding EMRs and electronic health records (EHRs) are identified and discussed briefly before the author provides a brief outlook on the future of clinical governance and EMRs in laboratory medicine.