Usefulness of videoconferencing in psychiatric emergencies -- a qualitative study.

High quality health services for psychiatric emergencies are difficult to maintain 24 h a day in sparsely populated areas, where the availability of specialists are limited. To overcome this challenge, the University Hospital of North Norway implemented an on-call system in psychiatric emergencies, by which psychiatrists are accessible 24/7 for telephone and videoconferencing consultations with patients and nurses at three regional psychiatric centers. The purpose of this study was to explore the usefulness of videoconferencing consultations in psychiatric emergencies. The on-call psychiatrists and nurses at the regional psychiatric centers who participated in at least one videoconferencing consultation were recruited for semi-structured interviews: 5 psychiatrists and 19 nurses for a total of 24 participants. The interviews were performed from July of 2012 to June of 2013. The interviews were transcribed and analyzed using a stepwise-deductive-inductive approach supported by the HyperRESEARCH analysis software. After the introduction of the videoconferencing system, telephone consultations were still used for straightforward situations when further treatment or admission decisions were obvious. Videoconferencing consultations, during which patients were present, were useful for challenging situations when there was 1) uncertainty regarding the degree of illness or the level of treatment, 2) a need to clarify the severity of the patient condition, 3) a need to build an alliance with the patient, and 4) disagreement either between health personnel or between the patient and health personnel. Videoconferencing is useful for challenging and complex psychiatric emergencies and is a suitable tool for building high quality, decentralized psychiatric services.

The symbolic affordances of a video-mediated gaze in emergency psychiatry.

While mental illness is a significant health challenge worldwide, the availability of specialists is limited, especially in rural areas and for psychiatric emergencies. Although tele-psychiatry, via real-time videoconferencing (VC), is used to provide consultative services in areas that lack psychiatrists, there are a paucity of studies on the use of VC for psychiatric emergencies. We examine how VC matters for patient involvement and professional practice in the first Norwegian emergency tele-psychiatric service. Through a decentralised on-call system, psychiatrists are accessible 24/7 by telephone and VC for patients and nurses in regional psychiatry centres. Based on 29 interviews with patients, psychiatrists and nurses, this article addresses how participation is fostered by VC, and how it may change the social dynamics of therapeutic emergency encounters. We identified four contributions of the 'video-mediated gaze' in the therapeutic encounter including those of the: (1) immediacy of assessment, (2) increased transparency, (3) sense of access to the 'real' expert, and (4) fostering of the patient's 'voice' in therapeutic decisions. These VC inflections of the therapeutic encounter are a mix of the pragmatic (1 and 2) and the symbolic (3 and 4), assembling in these contexts to foster patient-centeredness. With a sociological approach to video-conferenced emergency psychiatry, the identification of symbolic affordances adds necessary nuances to the application of new technologies into fragile therapeutic communication.

Barriers to and facilitators for implementing quality improvements in palliative care - results from a qualitative interview study in Norway.

BACKGROUND: Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EU-funded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway. METHODS: Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied. RESULTS: Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care. CONCLUSION: When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.

A collective clinical gaze: Negotiating decisions in a surgical ward.

This article explores collaborative aspects of clinical decision-making, based on a focused ethnography and video recordings of meetings in clinical practices in two wards for gastro-intestinal diseases at the surgical department of a large Norwegian university hospital. By studying clinicians' communication during patient introduction, handling uncertainties and surprises, collecting information, and negotiating acceptance, we elaborate on how collaborative teamwork in the hospital ward is developed. Further, by drawing on detailed studies of meetings, in which patients are not physically represented, we explore ways in which a 'collective clinical gaze' of each patient is constructed on the basis of documents, memory, and a consensus-directed discussion among clinicians who are present. Although electronic patient record systems and the like are expected to produce firm bases for clinical decision-making, our analysis suggests that more emphasis should be put on how clinicians in their daily practice establish collectively based validity of any decision being made.

Survival of the project: a case study of ICT innovation in health care.

From twenty years of information and communication technology (ICT) projects in the health sector, we have learned one thing: most projects remain projects. The problem of pilotism in e-health and telemedicine is a growing concern, both in medical literature and among policy makers, who now ask for large-scale implementation of ICT in routine health service delivery. In this article, we turn the question of failing projects upside down. Instead of investigating the obstacles to implementing ICT and realising permanent changes in health care routines, we ask what makes the temporary ICT project survive, despite an apparent lack of success. Our empirical material is based on Norwegian telemedicine. Through a case study, we take an in-depth look into the history of one particular telemedical initiative and highlight how ICT projects matter on a managerial level. Our analysis reveals how management tasks were delegated to the ICT project, which thus contributed to four processes of organisational control: allocating resources, generating and managing enthusiasm, system correction and aligning local practice and national policies. We argue that the innovation project in itself can be considered an innovation that has become normalised in health care, not in clinical, but in management work. In everyday management, the ICT project appears to be a convenient tool suited to ease the tensions between state regulatory practices and claims of professional autonomy that arise in the wake of new public management reforms. Separating project management and funding from routine practice handles the conceptualised heterogeneity between innovation and routine within contemporary health care delivery. Whilst this separation eases the execution of both normal routines and innovative projects, it also delays expected diffusion of technology.

The peace of paper: patient lists as work tools.

INTRODUCTION: Paper-based documents are subject to problems related to storage, loss, distribution and editing. Many organizations have introduced ICT-based processes to reduce the use of paper as primary documentation. Nevertheless, paper documents are still being used in healthcare. PURPOSE: To better understand this situation, we have studied the use of paper-based patient lists in two wards in a Norwegian hospital that has 'gone digital'. We seek to answer the question: "Why is it that paper-based patient lists are maintained in the ward of a hospital going digital?" METHODS: Participant observations and semi-structured interviews with stakeholders. RESULTS: Patient lists allow nurses to immediately record, retrieve, and share relevant patient information at the point of care in a way that is not immediately available through the EPR system. Paper-based tools continue to serve purposes beyond and outside what is currently supported by current electronic information systems.

Video-confidence: a qualitative exploration of videoconferencing for psychiatric emergencies.

BACKGROUND: In psychiatric emergencies in rural areas the availability of psychiatrists are limited. Therefore, tele-psychiatry, via real-time videoconferencing (VC), has been developed to provide advanced consultative services to areas that lack psychiatrists. However, there is limited research on the use of VC for psychiatric emergencies. The University Hospital of North Norway has been the first hospital in Norway to implement this type of service by developing a new on-call system for psychiatric emergency practice through which psychiatrists are accessible by telephone and VC 24 hours a day for consultations with patients and nurses at three regional psychiatric centres. This study explores patients', psychiatrists' and nurses' experiences of using VC for psychiatric emergencies, as well as how the technology influenced their confidence. METHODS: In this study, we used a qualitative explorative research design. With a particular focus on users' experiences of VC, we conducted 29 semi-structured interviews with patients, psychiatrists and nurses who had participated in a VC consultation in at least one psychiatric emergency. RESULTS: Our findings show that access to the VC system increased the experience of confidence in challenging psychiatric emergencies in four ways: (1) by strengthening patient involvement during the psychiatric specialist's assessment, (2) by reducing uncertainty, (3) by sharing responsibility for decisions and (4) by functioning as a safety net even when VC was not used. CONCLUSIONS: This study has demonstrated that an emergency psychiatric service delivered by VC may improve the confidence of psychiatrists, nurses and patients in challenging psychiatric emergencies. VC can serve as an effective tool for ensuring decentralised high-quality psychiatric services for emergency care.

Communal normalization in an online self-help group for adolescents with a mentally ill parent.

Although implications of parental mental illness are well documented, most children of mentally ill parents are left to manage their family situation with limited information and support. We explored the role of a Norwegian online self-help group for adolescents (aged 15 to 18) with a mentally ill parent. Through in-depth interviews with 13 participants, we found that the online self-help group provided "communal normalization" by which participants, through communication in the forum, made sense of everyday experiences and emotions arising from having a mentally ill parent. We identified three main aspects of this process-recognizability, openness, and agency-all of which were important for the adolescents' efforts to obtain support, to be supportive, and to handle everyday life situations better. Communal normalization might provide resources for significantly improving the participants' life situations, and could demonstrate similar potential for users in other situations characterized by stigma, loneliness, silence, and health worries.

From fatness to badness: the modern morality of obesity.

Obesity (or being overweight) is now considered a by-product of membership of developed societies. Moreover, it is considered a growing 'global' health problem. This article reports on a small qualitative study of adults who fell into one or other of these categories in Norway in 2010, and who have been faced with decisions about lifestyle versus surgical remedies. This decision making is contextualized and the principal criteria examined. Embodiment, bodywork, self- and social identity, stigma, deviance and issues around the idea of personal responsibility and public health emerge as key themes. The concluding paragraphs commend incorporation of a macro- or social structural perspective to the conceptualization and investigation of obesity.

VIDEOCARE: decentralised psychiatric emergency care through videoconferencing.

BACKGROUND: Today the availability of specialists is limited for psychiatric patients in rural areas, especially during psychiatric emergencies. To overcome this challenge, the University Hospital of North Norway has implemented a new decentralised on-call system in psychiatric emergencies, by which psychiatrists are accessible by videoconference 24/7. In September 2011, the new on-call system was established in clinical practice for patients and health staff at three regional psychiatric centres in Northern Norway. Although a wide variety of therapies have been successfully delivered by videoconference, there is limited research on the use of videoconferenced consultations with patients in psychiatric emergencies. The aim of this study is to explore the use of videoconference in psychiatric emergencies based on the implementation of this first Norwegian tele-psychiatric service in emergency care. METHODS/DESIGN: The research project is an exploratory case study of a new videoconference service in operation. By applying in-depth interviews with patients, specialists and local health-care staff, we will identify factors that facilitate and hinder use of videoconferencing in psychiatric emergencies, and explore how videoconferenced consultations matter for patients, professional practice and cooperation between levels in psychiatric care. By using an on-going project as the site of research, the case is especially well-suited for generating reliable and valid empirical data. DISCUSSION: Results from the study will be of importance for understanding of how videoconferencing may support proper treatment and high-quality health care services in rural areas for patients in psychiatric emergencies.

Getting the aorta pants in place: a 'community of guidance' in the evolving practice of vascular implant surgery.

The evolving nature of surgical treatments creates gaps between evidence-based guidelines and actual clinical practice.This article addresses the emerging clinical practice of the EndoVascular Aneurysm Repair (EVAR), a surgical treatment of patients with Abdominal Aortic Aneurysm (AAA). Drawing on a qualitative study across three hospitals, we identified three interplaying expertise traits: the collective, the interpersonal and the technical, each being present to promote surgical work. The evolvement of EVAR is contextualized within technical artefacts and patient characteristics, along with a joint decision approach. The intertwinement between various expertise traits and contextual factors forms a 'community of guidance', nourishing further EVAR innovation without formalized institutions, evidence, training or guidelines. However, the lack of a shared context limits the transfer of evolving knowledge across hospital boundaries.

Beyond the EPR: complementary roles of the hospital-wide electronic health record and clinical departmental systems.

BACKGROUND: Many hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR. METHODS: Semi-structured interviews with users of 16 clinicians using 15 different clinical departmental systems (CDS) at a Medium-sized University hospital in Norway. Inductive analysis of transcriptions from the audio taped interviews. RESULTS: The roles of CDSs were complementary to those of the hospital-wide EPR system. The use of structured patient data was a characteristic feature. This facilitated quality development and supervision, tasks that were poorly supported by the EPR system. The structuring of the data also improved filtering of information to better support clinical decision-making. Because of the high value of the structured patient data, the users put much effort in maintaining their integrity and representativeness. Employees from the departments were also engaged in the funding, development, implementation and maintenance of the systems. CONCLUSION: Clinical departmental systems are vital to the activities of a clinical hospital department. The development, implementation and clinical use of such systems can be seen as bottom-up, user-driven innovations.

Square pegs in round holes: information systems, hospitals and the significance of contextual awareness.

The considerable emphasis in the development and implementation of clinical information systems in hospitals internationally seems to have had a limited effect. In particular, the implementation of electronic patient record (EPR) systems has been slower and more difficult than anticipated and with little change in efficiency and security. This paper suggests why this might be the case. Well established research findings within the field of computer supported cooperative work (CSCW--an interdisciplinary research field between informatics and the social sciences) are cited to construct a case for greater awareness of (1) inter- and intra-professional interests, and (2) broader social and health policy contexts. We draw on Gouldner's work [(1957). Cosmopolitans and locals: toward an analysis of latent social roles--I. Administrative Science Quarterly, 2(3), 281-306; (1958). Cosmopolitans and locals: toward an analysis of latent social roles--II. Administrative Science Quarterly, 2 (4), 444-480] on organisational roles to develop a discussion of professional awareness; a pivotal notion is also the interactionist one of the hospital as a 'negotiated order'. Drawing for illustrative purposes on the Norwegian experience (that is, reviewing research on hospital information systems in Norway), we contend that enhanced awareness of the hospital itself as a social system may be a precondition of cost-effective hospital information and communication technologies.

No paper, but the same routines: a qualitative exploration of experiences in two Norwegian hospitals deprived of the paper based medical record.

BACKGROUND: It has been shown that implementation of electronic medical records (EMR) and withdrawal of the paper-based medical record is feasible, but represents a drastic change in the information environment of hospital physicians. Previous investigations have revealed considerable inter-hospital variations in EMR system use and user satisfaction. The aim of this study was to further explore changes of clinicians' work after the EMR system implementation process and how they experienced working in a paper-deprived information environment. METHODS: Qualitative study based on 18 semi-structured interviews with physicians in two Norwegian hospitals. RESULTS: Ten different but related characteristics of work within the EMR-based practice were identified; (1) there was closer clinical and administrative cooperation during the implementation processes; (2) there were greater benefits when everybody used the system; (3) systems supported freshmen better than experienced physicians; (4) the EMR was useful in regard to professional learning; (5) new users were given an introduction to the system by experienced; (6) younger clinicians reported different attitudes than senior clinicians, but this might be related to more than age and previous experience with computers; (7) the EMR made it easier to generate free-text notes, but this also created a potential for information overflow; (8) there is little or no support for mobile work; (9) instances of downtime are still experienced, and this influenced the attitude towards the system and (10) clinicians preferred EMR-only compared to combined paper and electronic systems. CONCLUSION: Despite the removal of paper-based records from clinical workflow (a change that hospital clinicians perceived as highly useful), many of the old routines remained unchanged, limiting the potential of the EMR system. Thus, there is a need to not only remove paper in the physical sense, but also to established routines to fully achieve the benefits of an EMR system.

Privacy vs usability: a qualitative exploration of patients' experiences with secure Internet communication with their general practitioner.

BACKGROUND: Direct electronic communication between patients and physicians has the potential to empower patients and improve health care services. Communication by regular email is, however, considered a security threat in many countries and is not recommended. Systems which offer secure communication have now emerged. Unlike regular email, secure systems require that users authenticate themselves. However, the authentication steps per se may become barriers that reduce use. OBJECTIVES: The objective was to study the experiences of patients who were using a secure electronic communication system. The focus of the study was the users' privacy versus the usability of the system. METHODS: Qualitative interviews were conducted with 15 patients who used a secure communication system (MedAxess) to exchange personal health information with their primary care physician. RESULTS: Six main themes were identified from the interviews: (1) supporting simple questions, (2) security issues, (3) aspects of written communication, (4) trust in the physician, (5) simplicity of MedAxess, and (6) trouble using the system. By using the system, about half of the patients (8/15) experienced easier access to their physician, with whom they tended to solve minor health problems and elaborate on more complex illness experiences. Two thirds of the respondents (10/15) found that their physician quickly responded to their MedAxess requests. As a result of the security barriers, the users felt that the system was secure. However, due to the same barriers, the patients considered the log-in procedure cumbersome, which had considerable negative impact on the actual use of the system. CONCLUSIONS: Despite a perceived need for secure electronic patient-physician communication systems, security barriers may diminish their overall usefulness. A dual approach is necessary to improve this situation: patients need to be better informed about security issues, and, at the same time, their experiences of using secure systems must be studied and used to improve user interfaces.

Three-dimensional teleradiology for surveillance following endovascular aortic aneurysm repair: a feasibility study.

PURPOSE: To study the feasibility of 3-dimensional (3D) teleradiology in surveillance of patients treated with stent-grafts for abdominal aortic aneurysm (AAA). METHODS: Between April 2002 and November 2003, 8 AAA patients (7 men; median age 73 years, range 62-84) with stent-grafts had follow-up computed tomograms (CT) performed at their local hospital and transmitted without loss across a broadband connection to the university hospital. On both monitors, the radiologists were presented with the complete CT axial dataset, sagittal and coronal reformatted slices, and a 3D volume-rendered reconstruction. The two radiologists were then able to simultaneously perform measurements and real-time manipulations of the axial and 3D pictures, which were discussed over the telephone or using a videoconferencing unit. Patient satisfaction, the radiologists' evaluation of the method, and the potential cost savings were explored. RESULTS: Twelve follow-up CT scans were performed on the 8 patients. The time for transmission over the teleradiological network averaged 5 minutes, and the evaluation required 15 minutes at the university hospital. The overall technical quality of the images was rated as good by the university radiologist. In 11 studies, the stent-grafts were satisfactory, but a type III endoleak was detected in one 5.5-year-old stent-graft. Neither radiologist had a problem identifying the endoleak. Patients had confidence that the examination at the local hospital was of good quality; they all felt that they received good care and were pleased with avoiding travel to the university hospital. From the economic analysis, an annual savings of 40,000 Euros (USD 52,304) was projected, mostly due to avoiding hospital stays and outpatient consultations at the university hospital. CONCLUSIONS: The experiences from this study are encouraging, but a larger series will be necessary for a thorough evaluation of 3D teleradiology as a surveillance method for aortic stent-graft patients.