Kathrin Cresswell

The impact of eHealth on the quality and safety of health care: a systematic overview.

Aziz Sheikh and colleagues report the findings of their systematic overview that assessed the impact of eHealth solutions on the quality and safety of health care.

The case study approach

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Organizational issues in the implementation and adoption of health information technology innovations: An interpretative review

PURPOSE Implementations of health information technologies are notoriously difficult, which is due to a range of inter-related technical, social and organizational factors that need to be considered. In the light of an apparent lack of empirically based integrated accounts surrounding these issues, this interpretative review aims to provide an overview and extract potentially generalizable findings across settings. METHODS We conducted a systematic search and critique of the empirical literature published between 1997 and 2010. In doing so, we searched a range of medical databases to identify review papers that related to the implementation and adoption of eHealth applications in organizational settings. We qualitatively synthesized this literature extracting data relating to technologies, contexts, stakeholders, and their inter-relationships. RESULTS From a total body of 121 systematic reviews, we identified 13 systematic reviews encompassing organizational issues surrounding health information technology implementations. By and large, the evidence indicates that there are a range of technical, social and organizational considerations that need to be deliberated when attempting to ensure that technological innovations are useful for both individuals and organizational processes. However, these dimensions are inter-related, requiring a careful balancing act of strategic implementation decisions in order to ensure that unintended consequences resulting from technology introduction do not pose a threat to patients. CONCLUSIONS Organizational issues surrounding technology implementations in healthcare settings are crucially important, but have as yet not received adequate research attention. This may in part be due to the subjective nature of factors, but also due to a lack of coordinated efforts toward more theoretically-informed work. Our findings may be used as the basis for the development of best practice guidelines in this area.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. Design A mixed methods, longitudinal, multisite, socio-technical case study. Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. Conclusions Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare

BackgroundActor-Network Theory (ANT) is an increasingly influential, but still deeply contested, approach to understand humans and their interactions with inanimate objects. We argue that health services research, and in particular evaluations of complex IT systems in health service organisations, may benefit from being informed by Actor-Network Theory perspectives.DiscussionDespite some limitations, an Actor-Network Theory-based approach is conceptually useful in helping to appreciate the complexity of reality (including the complexity of organisations) and the active role of technology in this context. This can prove helpful in understanding how social effects are generated as a result of associations between different actors in a network. Of central importance in this respect is that Actor-Network Theory provides a lens through which to view the role of technology in shaping social processes. Attention to this shaping role can contribute to a more holistic appreciation of the complexity of technology introduction in healthcare settings. It can also prove practically useful in providing a theoretically informed approach to sampling (by drawing on informants that are related to the technology in question) and analysis (by providing a conceptual tool and vocabulary that can form the basis for interpretations). We draw on existing empirical work in this area and our ongoing work investigating the integration of electronic health record systems introduced as part of Englands National Programme for Information Technology to illustrate salient points.SummaryActor-Network Theory needs to be used pragmatically with an appreciation of its shortcomings. Our experiences suggest it can be helpful in investigating technology implementations in healthcare settings.

The impact of telehealthcare on the quality and safety of care: a systematic overview.

Background Telehealthcare involves the use of information and communication technologies to deliver healthcare at a distance and to support patient self-management through remote monitoring and personalised feedback. It is timely to scrutinise the evidence regarding the benefits, risks and costs of telehealthcare. Methods and Findings Two reviewers searched for relevant systematic reviews published from January 1997 to November 2011 in: The Cochrane Library, MEDLINE, EMBASE, LILACS, IndMed and PakMed. Reviewers undertook independent quality assessment of studies using the Critical Appraisal Skills Programme (CASP) tool for systematic reviews. 1,782 review articles were identified, from which 80 systematic reviews were selected for inclusion. These covered a range of telehealthcare models involving both synchronous (live) and asynchronous (store-and-forward) interactions between provider and patients. Many studies showed no differences in outcomes between telehealthcare and usual care. Several reviews highlighted the large number of short-term (<12 months) feasibility studies with under 20 participants. Effects of telehealthcare on health service indicators were reported in several reviews, particularly reduced hospitalisations. The reported clinical effectiveness of telehealthcare interventions for patients with long-term conditions appeared to be greatest in those with more severe disease at high-risk of hospitalisation and death. The failure of many studies to adequately describe the intervention makes it difficult to disentangle the contributions of technological and human/organisational factors on the outcomes reported. Evidence on the cost-effectiveness of telehealthcare remains sparse. Patient safety considerations were absent from the evaluative telehealthcare literature. Conclusions Policymakers and planners need to be aware that investment in telehealthcare will not inevitably yield clinical or economic benefits. It is likely that the greatest gains will be achieved for patients at highest risk of serious outcomes. There is a need for longer-term studies in order to determine whether the benefits demonstrated in time limited trials are sustained.

Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems: England, the USA and Australia

As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera’s typology of national programmes – ‘top-down’, ‘bottom-up’ and ‘middle-out’ – to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy.

How safe is primary care? A systematic review

Importance Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. Objective We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. Evidence review We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. Findings Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2–3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patients well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. Conclusions and relevance Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. Systematic review registration This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

Implementing and adopting electronic health record systems

Purpose – This paper aims to outline an approach to study the implementation and adoption of information technology systems in healthcare.Design/methodology/approach – The authors use the introduction of electronic health records, part of the English National Programme of Information Technology, as an example to illustrate how theoretical lenses need to be effectively integrated with practical considerations in order to help researchers to overcome the theory‐practice gap in relation to research in this area.Findings – Integrating actor‐network theory (ANT) with other theoretical lenses can usefully inform the design of evaluation of the implementation of electronic health record systems into healthcare settings, but it is necessary that such deliberations are informed by guidance on how to use conceptual considerations in practice.Originality/value – The paper outlines how combining a case study‐based approach informed by multi‐sited ethnography and drawing on ANT offers a method for a theoretically‐base...

Adoption of electronic health records in UK hospitals: lessons from the USA

8 www.thelancet.com Vol 384 July 5, 2014 The UK–US Government Memorandum of Understanding on health information technology signed earlier this year could be the fi rst sign that the UK will fi nally develop a sustainable strategy to promote the adoption of hospital electronic health records (EHRs). This digital infrastructure is important to help hospitals deliver safer, more patient-centred, and effi cient care, and also to support audit, quality improvement initiatives, public health, health-service planning, and research. Although the UK and USA have diff erent health systems, the success of the Health Information Technology for Economic and Clinical Health (HITECH) Act in making information technology an integral part of US health care off ers the UK important, transferable lessons. Shortly after the UK Government launched the illfated National Programme for Information Technology (NPfIT), then President George W Bush promised in his 2004 State of the Union Address that most Americans would have EHRs within 10 years. Although that seemed ambitious at the time, this goal has largely been achieved. The focus of eff orts in the USA has now shifted from getting technology adopted, to how EHRs can be used to drive clinical and economic returns. By contrast—and despite being the fi rst mover on health information technology—the UK is still struggling with laying the foundations for hospital EHRs. What explains these contrasting experiences? A key factor is that the UK pursued a top-down implementation strategy, in which central Government signed substantial contracts with a handful of EHR vendors, whereas the USA pursued a more bottom-up strategy, in which hospitals and health professionals were given the choice of which EHRs to procure and then were incentivised to make their own choices. In the USA, the phased “meaningful use” strategy used the idea of an escalator to move from data capture (stage 1) to clinical processes (stage 2) to improved outcomes (stage 3); US hospitals that do not make the conversion receive lower reimbursements from federal payers, which incentivises even the slow adopters to move. Adoption of electronic health records in UK hospitals: lessons from the USA are still professionals and companies with genuine commitment to patients with rare diseases such as phenylketonuria. A strong movement is working towards centres of expertise for the treatment of patients with rare diseases, and opportunities exist to allow new and existing pharmaceutical companies to develop orphan drugs. Such developments will further improve treatment and outcomes in future generations of patients, although the risk remains that drug development might lead to a monopoly situation for any successfully developed products.