Emma Byrne

Introduction of shared electronic records: multi-site case study using diffusion of innovation theory

Objective To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care. Design Multi-site, mixed method case study applying utilisation focused evaluation. Setting Four early adopter sites for the SCR in England—three in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR’s material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters’ concerns (especially about workload and the ethicality of sharing “confidential” information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension for change, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme). Conclusion Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the micro-level by the material properties of the technology, individuals’ attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care.

Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

Objective To evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. Design Mixed-method, multilevel case study. Setting English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively. Results Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme’s fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. Conclusions Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

Recognizing rhetoric in health care policy analysis

Critiques of the ‘naïve rationalist’ model of policy-making abound in the sociological and political science literature. Yet academic debate on health care policy-making continues to be couched in the dominant discourse of evidence-based medicine, whose underlying assumptions - that policies are driven by facts rather than values and these can be clearly separated; that ‘evidence’ is context-free, can be objectively weighed up and placed unproblematically in a ‘hierarchy’; and that policy-making is essentially an exercise in decision science - have constrained both thinking and practice. In this paper, drawing on theoretical work from political science and philosophy, and innovative empirical work in the health care sector, we argue that health care is well overdue for a re-defining of what policy-making is. Policy-making is the formal struggle over ideas and values, played out by the rhetorical use of language and the enactment of social situations. While the selection, evaluation and implementation of research evidence are important in the policy-making process, they do not equate to that process. The study of argument in the construction of policy has the potential to illuminate dimensions of the process that are systematically occluded when policy-making is studied through a naïve rationalist lens. In particular, a rhetorical perspective highlights the struggle over ideas, the ‘naming and framing’ of policy problems, the centrality of audience and the rhetorical use of language in discussion to increase the audiences adherence to particular framings and proposals. Rhetorical theory requires us to redefine what counts as ‘rationality’ - which must extend from what is provably true (by logic) and probably true (by Bayesian reasoning) to embrace, in addition, that which is plausibly true (i.e. can convince a reasonable audience). Future research into health care policy-making needs to move beyond the study of ‘getting evidence into practice’ and address the language, arguments and discourse through which policy is constructed and enacted.

Virtual online consultations: advantages and limitations (VOCAL) study.

Introduction Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations. Methods To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel—audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel—interviews, ethnographic observations and analysis of documents within the trust; macrolevel—key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory. Ethics approval City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883. Planned outputs We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: ‘what to expect in your virtual consultation’. Discussion The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.

Man bites dog: looking for interesting inconsistencies in structured news reports

Much useful information in news reports is often that which is surprising or unexpected. In other words, we harbour many expectations about the world, and when any of these expectations are violated (i.e. made inconsistent) by news, we have a strong indicator of some information that is interesting for us. In this paper we present a framework for identifying interesting information in news reports by finding interesting inconsistencies. An implemented system based on this framework (1) accepts structured news reports as inputs, (2) translates each report to a logical literal, (3) identifies the story of which the report is a part, (4) looks for inconsistencies between the report, the background knowledge, and a set of expectations, (5) classifies and evaluates those inconsistencies, and (6) outputs news reports of interest to the user together with associated explanations of why they are interesting.

SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context

Introduction Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth-generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of peoples experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies’ credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users.

Optimising the flow of experiments to a robot scientist with multi-objective evolutionary algorithms

A Robot Scientist is a physically implemented system that applies artificial intelligence to autonomously discover new knowledge through cycles of scientific experimentation. Additionally, our Robot Scientist is able to execute experiments that have been requested by human biologists. There arises a multi-objective problem in the selection of batches of trials to be run together on the robot hardware. We describe the use of the jMetal framework to assess the suitability of a number of multi-objective metaheuristics to optimise the flow of experiments run on a Robot Scientist. Experiments are selected in batches, chosen in order to maximise the information gain and minimise the use of resources. The evolutionary multi-objective algorithms evaluated here perform well in finding solutions to this problem, either finding a long, fairly efficient Pareto optimal front, or a shorter, highly efficient Pareto optimal front.

Evaluating violations of expectations to find exceptional information

Much useful new information (e.g. information in news reports) is often that which is surprising or unexpected. In other words, we harbour many expectations about the world, and when any of these expectations are violated (i.e. made inconsistent) by new information, we have a strong indicator that the information is interesting for us. An expectation can be compared with an integrity constraint. Both an expectation and integrity constraint can be represented by an implicational formula in classical logic, and every time we get new information, we compare it with the implicational formula. However, with an integrity constraint, we are primarily seeking information that is consistent with the implicational formula. In constrast, with an expectation, we are primarily seeking information that is inconsistent with the implicational formula. In this paper, we present a framework for representing and analysing expectations. We consider for an application language the syntax of expectations, the accuracy and validity of expectations, and we explore relationships between these issues. We also consider representing and reasoning with expectations as part of an application in merging information.

A Logical Framework for Template Creation and Information Extraction

Information extraction is the process of automatically identifying facts of interest from pieces of text, and so transforming free text into a structured database. Past work has often been successful but ad hoc, and in this paper we propose a more formal basis from which to discuss information extraction. We introduce a framework which will allow researchers to compare their methods as well as their results, and will help to reveal new insights into information extraction and text mining practices.

Webcam consultations for diabetes: findings from four years of experience in Newham

Newham diabetes service supports an ethnically diverse population in a deprived urban area and exemplifies challenges faced throughout the NHS with rising demand, high outpatient ‘did not attend’ (DNA) rates (33–50% depending on age) and poor health outcomes.