Sustaining e-health innovations in a complex hospital environment: learning through evidence.

Implementing and sustaining technological innovations in healthcare is a complex process. Commonly, innovations are abandoned due to unsuccessful attempts to sustain and scale-up post implementation. Limited information is available on what characterizes successful e-health innovations and the enabling factors that can lead to their sustainability in complex hospital environments. We present a successful implementation, sustainability and scale-up of a virtual care program consisting of three e-health applications (telemedicine, telehome monitoring, and interactive voice response) in a major cardiac care hospital in Canada. We describe their evolution and adaptation over time, present the innovative approach for their "business case" and funding that supported their implementation, and identify key factors that enabled their sustainability and success, which may inform future research and serve as a benchmark for other health care organizations. Despite resource constraints, e-health innovations can be deployed and successfully sustained in complex healthcare settings contingent key considerations: simplifying technology to make it intuitive for patients; providing significant value proposition that is research supported to influence policy changes; involving early supporters of adoption from administrative and clinical staff; engaging patients throughout the innovation cycle; and partnering with industry/technology providers.

Benefits, facilitators, and barriers of electronic medical records implementation in outpatient settings: A scoping review.

This scoping review examined the breadth and depth of evidence on Electronic Medical Record (EMR) implementation benefits in outpatient settings. Following PRISMA guidelines for scoping reviews, five databases were searched, and 24 studies were retained and reviewed. Benefits, facilitators, and barriers to EMR implementation were extracted. Direct benefits included improved communication/reporting, work efficiency, care process, healthcare outcomes, safety, and patient-centredness of care. Indirect benefits were improved financial performance and increased data accessibility, staff satisfaction, and decision-support usage. Barriers included time and financial constraints; design/technical issues; limited information technology resources, skills, and infrastructure capacity; increased workload and reduced efficiency during implementation; incompatibility of existing systems and local regulations; and resistance from healthcare professionals. Facilitators included training, change management, user-friendliness and alignment with workflow, user experience with EMRs, top management support, and sufficient resources. More rigorous, systematic research is needed, using relevant frameworks to inform healthcare policies and guide EMR projects in outpatient areas.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital.

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Older Adults' Quality of Life in Long-Term Care: A Cross-Sectional Comparison Before and During the COVID-19 Pandemic.

This study aims to assess changes in long-term care (LTC) residents' quality of life (QoL) before and during the COVID-19 pandemic. A pre-test post-test study of 49 QoL measures, across four dimensions from the interRAI self-reported QoL survey, was conducted. Secondary data from 2019 (n = 116) and 2020 (n = 128) were analysed to assess the change in QoL. A significant decline in 12 measures was observed, indicating a change in QoL of LTC residents during the pandemic. Social life was the dimension mostly affected with residents reporting less opportunities to spend time with like-minded residents, explore new skills and interests, participate in meaningful religious activities, and have enjoyable things to do in the evenings. Several measures of personal control, staff responsiveness and care, and safety also demonstrated a significant change. The results can inform future strategies for pandemic and outbreak preparedness. Balancing the safety of residents with attention to their QoL should be a priority moving forward.

IVR System Use by Patients with Heart Failure: Compliance and Services Utilization Patterns.

Heart failure (HF) is the leading cause of cardiovascular morbidity and health care utilization globally. Much of the cost for HF is related to hospitalization, strategies to decrease cost need to focus on avoiding unnecessary hospital readmission. Interactive voice response (IVR) is an automated telephony system that leverages existing telephone lines to monitor patients post-discharge, for early intervention. This study explores the pattern of IVR use by HF patients in the IVR program at the University of Ottawa Heart Institute (UOHI) and assesses IVR use by patients in relation to symptoms, compliance behavior, lifestyle, and hospital readmission. A total of 902 HF patients were considered; the mean age was 70 years, and 59.4% were male. Over a 12-week period of IVR use, there was an overall increase in medication adherence and a decrease in symptoms occurrence, weight gain and readmission rate. The highest and lowest compliance rates were associated with medication adherence and exercise, respectively. Overall, older, female patients from rural/community hospitals were more likely to complete the IVR calls, have less symptoms occurrence, comply with medications, weight, and lifestyle recommendations. The findings suggest that IVR system use can have a positive impact on HF patients' management. The increased use of IVR in remote patient monitoring will allow for a cheaper and more accessible form of home monitoring. Leveraging IVR technology to support other conditions, especially during a pandemic, may be beneficial for patients to avoid unnecessary visits to the hospital and complications due to delay in seeking care.

Implementation of smart supportive dementia technology in a hospital transitional care setting using human-centred design.

Supportive smart home technology, for older adults living with dementia and their informal care partners, has shown some benefits in private homes. In this study, a supportive smart home system is being implemented in a hospital alternative level of care setting. This case report describes how a team of researchers and healthcare managers are navigating the complexities of a hospital setting, using human-centred design and implementation strategies, to facilitate the implementation and adoption of the technology.

Comparison of Mobile Health Technology Use for Self-Tracking Between Older Adults and the General Adult Population in Canada: Cross-Sectional Survey.

BACKGROUND: The burden of population aging and chronic conditions has been reported worldwide. Older adults, especially those with high needs, experience social isolation and have high rates of emergency visits and limited satisfaction with the care they receive. Mobile health (mHealth) technologies present opportunities to address these challenges. To date, limited information is available on Canadian older adults' attitudes toward and use of mHealth technologies for self-tracking purposes-an area that is increasingly important and relevant during the COVID-19 era. OBJECTIVE: This study presents contributions to an underresearched area on older adults and mHealth technology use. The aim of this study was to compare older adults' use of mHealth technologies to that of the general adult population in Canada and to investigate the factors that affect their use. METHODS: A cross-sectional survey on mHealth and digital self-tracking was conducted. A web-based questionnaire was administered to a national sample of 4109 Canadian residents who spoke either English or French. The survey instrument consisted of 3 sections assessing the following items: (1) demographic characteristics, health status, and comorbidities; (2) familiarity with and use of mHealth technologies (ie, mobile apps, consumer smart devices/wearables such as vital signs monitors, bathroom scales, fitness trackers, intelligent clothing); and (3) factors influencing the continued use of mHealth technologies. RESULTS: Significant differences were observed between the older adults and the general adult population in the use of smart technologies and internet (P<.001). Approximately 47.4% (323/682) of the older adults in the community reported using smartphones and 49.8% (340/682) indicated using digital tablets. Only 19.6% (91/463) of the older adults using smartphones/digital tablets reported downloading mobile apps, and 12.3% (47/383) of the older adults who heard of smart devices/wearables indicated using them. The majority of the mobile apps downloaded by older adults was health-related; interestingly, their use was sustained over a longer period of time (P=.007) by the older adults compared to that by the general population. Approximately 62.7% (428/682) of the older adults reported tracking their health measures, but the majority did so manually. Older adults with one or more chronic conditions were mostly nontrackers (odds ratio 0.439 and 0.431 for traditional trackers and digital trackers, respectively). No significant differences were observed between the older adults and the general adult population with regard to satisfaction with mHealth technologies and their intention to continue using them. CONCLUSIONS: Leveraging mHealth technologies in partnership with health care providers and sharing of health/well-being data with health care professionals and family members remain very limited. A culture shift in the provision of care to older adults is deemed necessary to keep up with the development of mHealth technologies and the changing demographics and expectations of patients and their caregivers.

Factors that affect health information technology adoption by seniors: A systematic review.

The number of seniors and prevalence of chronic conditions are increasing worldwide, resulting in more pressure on health systems. Health Information Technologies (HIT) present opportunities to support the healthcare needs of seniors. Although prior studies have investigated HIT and seniors, it remains unclear what factors significantly affect the adoption of different HIT by elderly people in the community. A Systematic Review (SR) was conducted between December 2017 and February 2018 (with a search update in 2018-2019) to critically appraise and synthesise existing evidence on HIT adoption factors among seniors. Following the PRISMA guidelines, five major databases were consulted (PubMed, Medline, CINAHL, Scopus and Web of Science). The inclusion criteria consisted of empirical studies, published in English, and reporting impacts of specific factors on HIT adoption among seniors in the community. A total of 41 studies were included in this review, mostly published between 2014 and 2017 in Europe and the US; the level of evidence in these studies was low to moderate. The factors that affect HIT adoption did not differ across types of technologies or age groups. The findings reveal that seniors adopt HIT that are perceived as useful and requiring low effort commitment; price/cost value were reported as adoption barriers. Social influence, facilitating conditions, senior-friendly product design, self-efficacy, Intrinsic Technology Quality, experience/training and technology anxiety may affect HIT adoption by seniors, although the evidence on these impacts remains weak and limited. Mixed and inconclusive evidence was observed on the impacts of socio-demographic variables, health condition, habit and privacy/security. Given the reported low level of HIT adoption among seniors, we call for more rigorous research in this area using a 'senior-centred' approach, which takes into account the discourse/interaction between seniors and their collective environment to better understand the factors that affect their technology adoption and address their needs.

Adult Day Program services for seniors with dementia: An innovative model of community-college partnership (Innovative Practice).

This study presents the case of an innovative Adult Day Program model resulting from a community-college partnership, with a formative evaluation of its contributions. A triangulation of data sources were used (existing documents, seniors' records, survey of caregivers). An overview of the historical development of the Adult Day Program model, and its underlying partnership, is presented. The model demonstrated feasibility and satisfaction by the community served, and opportunities for students' training in real settings. Province-wide efforts should support the expansion of services based on this model, which may also be replicated in other environments to complement traditional long-term care services.

Rural-Urban Comparison of Telehome Monitoring for Patients with Chronic Heart Failure.

INTRODUCTION: Rural geographic isolation may act as a promoting or restraining variable to the diffusion of technology and healthy aging in the community. Telehome monitoring (TM) leverages technology to support seniors living in the community with chronic conditions. To date, limited research has investigated the utilization of TM in rural settings. This study assesses the comparative utilization of TM for patients with heart failure in rural versus urban environments. MATERIALS AND METHODS: We conducted a cross-sectional study involving chart reviews of all patients enrolled in the TM program at the University of Ottawa Heart Institute during 2014. Data were extracted on urban/rural status, demographic characteristics, and process and outcomes of care. Descriptive, bivariate, and multivariate analyses were conducted. RESULTS: More rural patients did not have a documented reason for emergency room visits compared to urban patients. There was no significant association between the urban/rural status and the process and outcome measures at the multivariate level. Being followed-up regularly by a family physician and a specialist, as opposed to a specialist or general practitioner only, was associated with significantly longer TM period and a higher number of diuretic adjustments and calls made by nurses. DISCUSSION: Although more urban patients were older and living alone, their profile did not affect their utilization of TM. The difference in diagnosis between urban and rural patients also did not contribute to such differences. Hence, there is no variation in the process and outcome measures associated with the utilization of TM between urban and rural environments. CONCLUSIONS: Rural patients may not be perceived as extensive users of resources nor patients who represent challenges in terms of feasibility of TM use.

A prospective evaluation of telemonitoring use by seniors with chronic heart failure: Adoption, self-care, and empowerment.

Telemonitoring leverages technology for the follow-up of patients with heart failure. Limited evidence exists on how telemonitoring influences senior patients' attitudes and self-care practices. This study examines telemonitoring impacts on patient empowerment and self-care, and explores adoption factors among senior patients. A longitudinal study design was used, involving three surveys of elderly with chronic heart failure (n = 23) 1 week, 3 months, and 6 months after beginning telemonitoring use. Self-care, patient empowerment, and adoption factors were assessed using existing scales. The patients involved in this study perceived value of using telemonitoring, did not expect it to be difficult to use, and did not encounter adoption barriers. There was a significant improvement in patients' confidence in their ability to evaluate their symptoms, address them, and evaluate the effectiveness of the measures taken to address these symptoms. Yet, patients performed less self-care maintenance activities, and the capability of involvement in the decision-making related to their condition decreased. Telemonitoring can improve seniors' confidence in evaluating and addressing their symptoms in relation to heart failure. This patient management approach should be coupled with targeted education geared toward self-maintenance and self-management practices.

Perceived healthcare workforce needs in Lebanon: a step towards informed human resources planning and professional development.

BACKGROUND: Research in various countries has previously investigated the competencies required for effective management of health care organizations. Yet, limited information is available on the skills and knowledge areas, which are currently lacking among the healthcare workforce employed in environments with limited resources. AIMS: The aim of this study was to assess the perceived healthcare workforce needs at the management and clinical/practice levels in Lebanon. METHODS: We conducted an exploratory Delphi study involving two panels of health care professionals and a nationwide survey of hospital directors to assess the skills needed and the healthcare occupations and specialties that are limited. RESULTS: Based on the Delphi study, the top five needed skills/knowledge areas were: professionalism, ethics, quality management and improvement, strategic planning, and communication. The need for information management and technology skills was reported by more than 50% of urban hospitals, and highlighted by the two panels in the Delphi study. Healthcare professionals reported willingness to take continuing education courses. Hospitals further indicated the availability of financial support and willingness to collaborate with educational institutions for employee training and continuing education. CONCLUSIONS: Our findings set the ground for future research investigating healthcare workforce issues in Lebanon and support evidence-based planning for health human resources. They may inform the development of national and local policies in the country, which address the human resources needs of the health care system to meet regional and national demands. Universities, professional syndicates, and nongovernmental organizations may leverage these findings to develop continuing education training and diplomas incorporating the competencies critical for the healthcare workforce.

Effectiveness of mHealth interventions for patients with diabetes: An overview of systematic reviews.

BACKGROUND: Diabetes is a common chronic disease that places an unprecedented strain on health care systems worldwide. Mobile health technologies such as smartphones, mobile applications, and wearable devices, known as mHealth, offer significant and innovative opportunities for improving patient to provider communication and self-management of diabetes. OBJECTIVE: The purpose of this overview is to critically appraise and consolidate evidence from multiple systematic reviews on the effectiveness of mHealth interventions for patients with diabetes to inform policy makers, practitioners, and researchers. METHODS: A comprehensive search on multiple databases was performed to identify relevant systematic reviews published between January 1996 and December 2015. Two authors independently selected reviews, extracted data, and assessed the methodological quality of included reviews using AMSTAR. RESULTS: Fifteen systematic reviews published between 2008 and 2014 were eligible for inclusion. The quality of the reviews varied considerably and most of them had important methodological limitations. Focusing on systematic reviews that offered the most direct evidence, this overview demonstrates that on average, mHealth interventions improve glycemic control (HbA1c) compared to standard care or other non-mHealth approaches by as much as 0.8% for patients with type 2 diabetes and 0.3% for patients with type 1 diabetes, at least in the short-term (≤12 months). However, limitations in the overall quality of evidence suggest that further research will likely have an important impact in these estimates of effect. CONCLUSIONS: Findings are consistent with clinically relevant improvements, particularly with respect to patients with type 2 diabetes. Similar to home telemonitoring, mHealth interventions represent a promising approach for self-management of diabetes.

Systematic review of telemedicine applications in emergency rooms.

CONTEXT: Despite the frequency of use of telemedicine in emergency care, limited evidence exists on its impacts at the patient, provider, organization, and system level. Hospital-based applications of telemedicine present a potentially important solution, particularly for small and rural hospitals where access to local specialists is rarely available. PURPOSE: We conducted a systematic review of telemedicine applications for hospital-based emergency care, which aims to synthesize the existing evidence on the impact of tele-emergency applications that could inform future efforts and research in this area. BASIC PROCEDURES: A search of four databases (PubMed, CINAHL, EMBASE, Cochrane) using a combination of telemedicine and emergency room (ER) keywords for publications yielded 340 citations. Four coders independently determined eligibility based on initial criteria and then extracted information on the 38 resulting articles based on four main categories: study setting, type of technology, research methods, and results. MAIN FINDINGS: Of the 38 articles, 11 studies focused on telemedicine for diffuse patient populations that typically present in ERs, 8 studies considered telemedicine in the context of minor treatment clinics for patients presenting with minor injuries or illnesses, and 19 studies focused on the use of telemedicine to connect providers in ERs to medical specialists for consultations on patients with specific conditions. Overwhelmingly, tele-emergency studies reported positive findings especially in terms of technical quality and user satisfaction. There were also positive findings reported for clinical processes and outcomes, throughput, and disposition, but the rigor of studies using these measures was limited. Studies of economic outcomes are particularly sparse. PRINCIPAL CONCLUSIONS: Despite limitations in their research methodology, the studies on tele-emergency indicate an application with promise to meet the needs of small and rural hospitals to address infrequent but emergency situations requiring specialist care. Similarly, studies indicate that tele-emergency has considerable potential to expand use of minor treatment clinics to address access issues in remote areas and overcrowding of urban ERs.

Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of systematic reviews.

BACKGROUND: Growing interest on the effects of home telemonitoring on patients with chronic heart failure (HF) has led to a rise in the number of systematic reviews addressing the same or very similar research questions with a concomitant increase in discordant findings. Differences in the scope, methods of analysis, and methodological quality of systematic reviews can cause great confusion and make it difficult for policy makers and clinicians to access and interpret the available evidence and for researchers to know where knowledge gaps in the extant literature exist. OBJECTIVE: This overview aims to collect, appraise, and synthesize existing evidence from multiple systematic reviews on the effectiveness of home telemonitoring interventions for patients with chronic heart failure (HF) to inform policy makers, practitioners, and researchers. METHODS: A comprehensive literature search was performed on MEDLINE, EMBASE, CINAHL, and the Cochrane Library to identify all relevant, peer-reviewed systematic reviews published between January 1996 and December 2013. Reviews were searched and screened using explicit keywords and inclusion criteria. Standardized forms were used to extract data and the methodological quality of included reviews was appraised using the AMSTAR (assessing methodological quality of systematic reviews) instrument. Summary of findings tables were constructed for all primary outcomes of interest, and quality of evidence was graded by outcome using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system. Post-hoc analysis and subgroup meta-analyses were conducted to gain further insights into the various types of home telemonitoring technologies included in the systematic reviews and the impact of these technologies on clinical outcomes. RESULTS: A total of 15 reviews published between 2003 and 2013 were selected for meta-level synthesis. Evidence from high-quality reviews with meta-analysis indicated that taken collectively, home telemonitoring interventions reduce the relative risk of all-cause mortality (0.60 to 0.85) and heart failure-related hospitalizations (0.64 to 0.86) compared with usual care. Absolute risk reductions ranged from 1.4%-6.5% and 3.7%-8.2%, respectively. Improvements in HF-related hospitalizations appeared to be more pronounced in patients with stable HF: hazard ratio (HR) 0.70 (95% credible interval [Crl] 0.34-1.5]). Risk reductions in mortality and all-cause hospitalizations appeared to be greater in patients who had been recently discharged (≤28 days) from an acute care setting after a recent HF exacerbation: HR 0.62 (95% CrI 0.42-0.89) and HR 0.67 (95% CrI 0.42-0.97), respectively. However, quality of evidence for these outcomes ranged from moderate to low suggesting that further research is very likely to have an important impact on our confidence in the observed estimates of effect and may change these estimates. The post-hoc analysis identified five main types of non-invasive telemonitoring technologies included in the systematic reviews: (1) video-consultation, with or without transmission of vital signs, (2) mobile telemonitoring, (3) automated device-based telemonitoring, (4) interactive voice response, and (5) Web-based telemonitoring. Of these, only automated device-based telemonitoring and mobile telemonitoring were effective in reducing the risk of all-cause mortality and HF-related hospitalizations. More research data are required for interactive voice response systems, video-consultation, and Web-based telemonitoring to provide robust conclusions about their effectiveness. CONCLUSIONS: Future research should focus on understanding the process by which home telemonitoring works in terms of improving outcomes, identify optimal strategies and the duration of follow-up for which it confers benefits, and further investigate whether there is differential effectiveness between chronic HF patient groups and types of home telemonitoring technologies.

IT strategic planning in hospitals: from theory to practice.

OBJECTIVES: To date, IT strategic planning has been mostly theory-based with limited information on "best practices" in this area. This study presents the process and outcomes of IT strategic planning undertaken at a pediatric hospital (PH) in Canada. METHODS: A five-stage sequential and incremental process was adopted. Various tools / approaches were used including review of existing documentation, internal survey (n = 111), fifteen interviews, and twelve workshops. RESULTS: IT strategic planning was informed by 230 individuals (12 percent of hospital community) and revealed consistency in the themes and concerns raised by participants (e.g., slow IT projects delivery rate, lack of understanding of IT priorities, strained communication with IT staff). Mobile and remote access to patients' information, and an integrated EMR were identified as top priorities. The methodology and used approach revealed effective, improved internal relationships, and ensured commitment to the final IT strategic plan. Several lessons were learned including: maintaining a dynamic approach capable of adapting to the fast technology evolution; involving stakeholders and ensuring continuous communication; using effective research tools to support strategic planning; and grounding the process and final product in existing models. CONCLUSIONS: This study contributes to the development of "best practices" in IT strategic planning, and illustrates "how" to apply the theoretical principles in this area. This is especially important as IT leaders are encouraged to integrate evidence-based management into their decision making and practices. The methodology and lessons learned may inform practitioners in other hospitals planning to engage in IT strategic planning in the future.

Evidence-based health care management: what is the research evidence available for health care managers?

In light of increasing interest in evidence-based management, we conducted a scoping review of systematic reviews (SRs) and meta-analyses (MAs) to determine the availability and accessibility of evidence for health care managers; 14 MAs and 61 SRs met the inclusion criteria. Most reviews appeared in medical journals (53%), originated in the United States (29%) or United Kingdom (22%), were hospital-based (55%), and targeted clinical providers (55%). Topics included health services organization (34%), quality/patient safety (17%), information technology (15%), organization/workplace management (13%), and health care workforce (12%). Most reviews addressed clinical topics of relevance to managers; management-related interventions were rare. The management issues were mostly classified as operational (65%). Surprisingly, 96.5% of search results were not on target. A better classification within PubMed is needed to increase the accessibility of meaningful resources and facilitate evidence retrieval. Health care journals should take initiatives encouraging the publication of reviews in relevant management areas.

Systematic reviews and meta-analyses of home telemonitoring interventions for patients with chronic diseases: a critical assessment of their methodological quality.

BACKGROUND: Systematic reviews and meta-analyses of home telemonitoring interventions for patients with chronic diseases have increased over the past decade and become increasingly important to a wide range of clinicians, policy makers, and other health care stakeholders. While a few criticisms about their methodological rigor and synthesis approaches have recently appeared, no formal appraisal of their quality has been conducted yet. OBJECTIVE: The primary aim of this critical review was to evaluate the methodology, quality, and reporting characteristics of prior reviews that have investigated the effects of home telemonitoring interventions in the context of chronic diseases. METHODS: Ovid MEDLINE, the Database of Abstract of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA) of the Cochrane Library were electronically searched to find relevant systematic reviews, published between January 1966 and December 2012. Potential reviews were screened and assessed for inclusion independently by three reviewers. Data pertaining to the methods used were extracted from each included review and examined for accuracy by two reviewers. A validated quality assessment instrument, R-AMSTAR, was used as a framework to guide the assessment process. RESULTS: Twenty-four reviews, nine of which were meta-analyses, were identified from more than 200 citations. The bibliographic search revealed that the number of published reviews has increased substantially over the years in this area and although most reviews focus on studying the effects of home telemonitoring on patients with congestive heart failure, researcher interest has extended to other chronic diseases as well, such as diabetes, hypertension, chronic obstructive pulmonary disease, and asthma. Nevertheless, an important number of these reviews appear to lack optimal scientific rigor due to intrinsic methodological issues. Also, the overall quality of reviews does not appear to have improved over time. While several criteria were met satisfactorily by either all or nearly all reviews, such as the establishment of an a priori design with inclusion and exclusion criteria, use of electronic searches on multiple databases, and reporting of studies characteristics, there were other important areas that needed improvement. Duplicate data extraction, manual searches of highly relevant journals, inclusion of gray and non-English literature, assessment of the methodological quality of included studies and quality of evidence were key methodological procedures that were performed infrequently. Furthermore, certain methodological limitations identified in the synthesis of study results have affected the results and conclusions of some reviews. CONCLUSIONS: Despite the availability of methodological guidelines that can be utilized to guide the proper conduct of systematic reviews and meta-analyses and eliminate potential risks of bias, this knowledge has not yet been fully integrated in the area of home telemonitoring. Further efforts should be made to improve the design, conduct, reporting, and publication of systematic reviews and meta-analyses in this area.

EMRs and clinical IS implementation in hospitals: a statewide survey.

PURPOSE: Present an overview of clinical information systems (IS) in hospitals and analyze the level of electronic medical records (EMR) implementation in relation to clinical IS capabilities and organizational characteristics. METHODS: We developed a survey instrument measuring clinical IS implementation and classified clinical IS across 5 EMR levels. The survey was administered to hospitals in a state with a large number of rural hospitals (84% response rate). FINDINGS: Clinical IS were classified across 5 EMR levels, a useful approach for understanding the gaps in clinical IS in hospitals. Almost half (43%) of hospitals in Iowa were at EMR Level 0, with at least 1 of the ancillary systems still absent; 12% were at Level 1 with all 3 ancillary systems in place; 16% were at Level 2 corresponding to an early EMR system; 18% were at Level 3 corresponding to an intermediate EMR system; and 10% were at Level 4 corresponding to an advanced EMR system. In contrast, 22% had no plans for EMR implementation at all. EMR level was lower in critical access hospitals and positively associated with more slack resources and staffed beds. Over a 3-year period, there were increases in ancillary systems and clinical documentation implementation. CONCLUSIONS: The survey performed well. There was agreement with published estimates of EMR penetration, sensitivity to change over time, and association with known organizational factors. It is well designed and can be used to map onto a comprehensive classification scheme capturing the EMR level and evaluating progress toward meaningful use.

Key IT management issues in hospitals: Results of a Delphi study in Canada.

PURPOSE: To develop an authoritative list of IT management issues faced by CIOs and IT directors in public hospitals. METHODS: The ranking-type Delphi method, which elicits the opinion of a panel of experts through iterative controlled feedback, was used in this study. Data collection involved three main steps during which three panels of experts in Ontario (n=13 in rural hospitals; n=9 in community hospitals; n=8 in academic hospitals) provided their input about the key IT management issues in hospitals and their relative importance. Attrition rate was minimal; 28 out of the 30 experts who participated in the study completed all three phases of the survey. RESULTS: During the brainstorming phase, the responses from the three panels were consolidated resulting in a list of 36 IT management issues; eleven were overlapping between the three panels. In the narrowing down phase, 18 issues were retained in the rural panel; 20 issues in the community panel; and 17 issues in the academic panel. The top issues retained in this phase included: managing demand and expectations for IT services (76% of participants); having sufficient funds (69% of participants); recognizing IT as a key stakeholder in major hospital decisions (65% of participants); and implementation of an EMR (62% of participants). In the ranking phase, a moderate level of consensus was obtained for all three panels: W=0.41 (rural panel); W=0.54 (community panel); and W=0.43 (academic panel). Despite the differences in the preoccupations between the three groups, there were similarities on certain IT management issues. Besides having sufficient funds, three of the top IT management issues relate to the strategic positioning of IT within the hospital: managing demands and expectations for IT services; IT competing with other clinical priorities for scarce resources; and recognizing IT as a key stakeholder in major hospital decisions. CONCLUSIONS: This study is the first to systematically and rigorously identify and prioritize critical IT management issues in hospitals, which may be generalizable to similar environments in other industrialized countries. The prioritized lists of IT management issues may be used as a benchmark and diagnostic tool to support internal strategic decision making related to IT. The broadening of understanding of the challenges faced by IT executives in hospitals would support a more systematic evaluation of these issues over time, and allow management, educational, and research resources to be invested in the appropriate areas.