'Kindling the fire' of NHS patient data exploitations: The care.data controversy in news media discourses.

This paper explores news media discourse about care.data: an NHS England programme of work for amalgamating and sharing patient data from primary care for planning and research. It was scrapped in 2016 after three years of public outcry, delays and around 1.5 million opt-outs. I examine UK news media coverage of this programme through the 'fire object' metaphor, focusing upon the visions of purpose and value it inspired, the abrupt discontinuities, juxtapositions and transformations it performed, and the matters of concern that went unheeded. Findings suggest that, in care.data's pursuit of a societal consensus on NHS patient data exploitations, various visions for new and fluid data flows brought to presence narratives of transforming the NHS, saving lives, and growing the economy. Other realities and concerns that mattered for certain stakeholders, such as data ownership and commercialisation, public engagement and informed consent, commitment and leadership, operational capabilities, and NHS privatisation agendas, remained absent or unsettled. False dichotomies kept the controversy alive, sealing its fate. I conclude by arguing that such failed programmes can turn into phantom-like objects, haunting future patient data schemes of similar aspirations. The paper highlights the role news media can have in understanding such energetic public controversies.

E-Infrastructures and the divergent assetization of public health data: Expectations, uncertainties, and asymmetries.

In this article, we examine some of the expectations, frictions and uncertainties involved with the assetization of de-identified NHS patient data by (primary care) research services in UK. Pledges to Electronic Health Record (EHR) data-driven research attempt to reconfigure public health data as an asset for realizing multiple values across healthcare, research and finance. We introduce the concept of 'asymmetrical divergence' in public health data assetization to study the various practices of configuring and using this data, both as a continuously generated resource to be extracted and as an asset to be circulated in the knowledge economy. As data assetization and exploitations grow bigger and more diverse, the capitalization of these datasets may constitute EHR data-driven research in healthcare as an attractive technoscientific activity, but one limited to those actors with specific sociotechnical resources in place to fully exploit them at the required scale.

Resisting big data exploitations in public healthcare: free riding or distributive justice?

We draw on findings from qualitative interviews with health data researchers, GPs and citizens who opted out from NHS England's care.data programme to explore controversies and negotiations around data sharing in the NHS. Drawing on theoretical perspectives from science and technology studies, we show that the new socio-technical, ethical and economic arrangements were resisted not only on the basis of individual autonomy and protection from exploitation, but also as a collective effort to protect NHS services and patient data. We argue that the resulting opt-outs were a call for more personal control over data use. This was not because these citizens placed their personal interests above those of society. It was because they resisted proposed arrangements by networks of stakeholders, not seen as legitimate, to control flows and benefits of NHS patient data. Approaching informed consent this way helps us to explore resistance as a collective action for influencing the direction of such big data programmes towards the preservation of public access to healthcare as well as the distribution of ethical decision-making between independent, trustworthy institutions and individual citizens.

Trialling technologies to reduce hospital in-patient falls: an agential realist analysis.

This paper analyses the 'failure' of a patient safety intervention. Our study was part of a randomised controlled trial (RCT) of bed and bedside chair pressure sensors linked to radio pagers to prevent bedside falls in older people admitted to hospital. We use agential realism within science and technology studies to examine the fall and its prevention as a situated phenomenon of knowledge that is made and unmade through intra-actions between environment, culture, humans and technologies. We show that neither the intervention (the pressure sensor system), nor the outcome (fall prevention) could be disentangled from the broader sociomaterial context of the ward, the patients, the nurses and (especially) their work through the RCT. We argue that the RCT design, by virtue of its unacknowledged assumptions, played a part in creating the negative findings. The study also raises wider questions about the kind of subjectivities, agencies and power relations these entanglements might effect and (re)produce in the hospital ward.

Market-driven production of biospecimens and the role of NHS hospital-led biobanks.

Biobanks are vital for biospecimen production in research, despite the regulatory, recruitment and commercial difficulties they face. We conducted interviews with clinicians, researchers, volunteers who recruit biobank participants, regulators and NHS managers about the integration of a biobank into an NHS hospital. We show that medical waste collected for biomedical research acquires its socio-ethical and economic value from the level of integration (both technologically and organisationally) of the biobank into the NHS hospital. There is extensive investment in a range of intellectual and commercial relationships and labour among stakeholders involved in the production of biospecimens. It is not only the boundaries of research, clinical care and commercialisation of biospecimens that blur but also those of volunteerism and citizenship. Hospital-led biobanks provide an opportunity to study the intertwining of biomedical innovation and healthcare.

Dissenting from care.data: an analysis of opt-out forms.

BACKGROUND: Care.data was a programme of work led by NHS England for the extraction of patient-identifiable and coded information from general practitioner (GP) records for secondary uses. This study analyses the forms (on the websites of GP practices) which enabled patients to opt out. METHODS: Theoretical sampling and summative content analysis were used to collect and analyse dissent forms used by patients to opt out from care. DATA: Domains included basic information about the programme, types of objections and personal details required for identification purposes. RESULTS: One hundred opt-out forms were analysed. Fifty-four forms mentioned that this programme was run by NHS England. 81 forms provided two types of objections to data-sharing, and 15 provided only one objection. Only 26 forms mentioned that direct care would not be affected and 32 that patients maintain their right to opt back anytime. All but one of the opt-out forms we reviewed requested the name of the person wishing to opt out. 94 required a date of birth and 33 an NHS number. 82 required an address, 42 a telephone number and 7 an email address. CONCLUSIONS: Numbers of patients (not) opting out should be treated with caution, because the variability of information provided and the varied options for dissent may have caused confusion among patients. To ensure that dissent is in accordance with individual preferences and moral values, we recommend that well-designed information material and standardised opt-out forms be developed for such data-sharing initiatives.

Evolution of primary care databases in UK: a scientometric analysis of research output.

OBJECTIVE: To identify publication and citation trends, most productive institutions and countries, top journals, most cited articles and authorship networks from articles that used and analysed data from primary care databases (CPRD, THIN, QResearch) of pseudonymised electronic health records (EHRs) in UK. METHODS: Descriptive statistics and scientometric tools were used to analyse a SCOPUS data set of 1891 articles. Open access software was used to extract networks from the data set (Table2Net), visualise and analyse coauthorship networks of scholars and countries (Gephi) and density maps (VOSviewer) of research topics co-occurrence and journal cocitation. RESULTS: Research output increased overall at a yearly rate of 18.65%. While medicine is the main field of research, studies in more specialised areas include biochemistry and pharmacology. Researchers from UK, USA and Spanish institutions have published the most papers. Most of the journals that publish this type of research and most cited papers come from UK and USA. Authorship varied between 3 and 6 authors. Keyword analyses show that smoking, diabetes, cardiovascular diseases and mental illnesses, as well as medication that can treat such medical conditions, such as non-steroid anti-inflammatory agents, insulin and antidepressants constitute the main topics of research. Coauthorship network analyses show that lead scientists, directors or founders of these databases are, to various degrees, at the centre of clusters in this scientific community. CONCLUSIONS: There is a considerable increase of publications in primary care research from EHRs. The UK has been well placed at the centre of an expanding global scientific community, facilitating international collaborations and bringing together international expertise in medicine, biochemical and pharmaceutical research.

Workplace violence against clinicians in Cypriot emergency departments: a national questionnaire survey.

AIMS AND OBJECTIVES: To identify perceived prevalence, characteristics, precipitating factors and suggestions for improving workplace violence in all nine public emergency departments in the Cyprus Republic. BACKGROUND: Workplace violence is a common phenomenon in emergency departments, but little is known about this phenomenon in Cyprus. DESIGN: A retrospective cross-sectional survey. METHODS: Two hundred and twenty of 365 emergency nurses (85·7%) and doctors (14·3%) participated in this study, of which 62% were female. Data were collected via a Greek language version of the Violent Incident Form. Additional questions examined perceived frequencies, encouragement for reporting, satisfaction with actions taken and suggestions for improvement. Descriptive analysis, chi-square tests and multiple logistic regression analyses were used to describe and associate characteristics with workplace prevalence. RESULTS: During the previous 12 months, the vast majority of nurses and doctors (76·2%) were exposed to verbal abuse (88·8%), mainly by relatives or friends of the patient (59·1%). Relatively inexperienced clinicians were at greater risk. Waiting time was identified as the most significant organisational factor. Alcohol intoxication, substance abuse and mental illness were individual factors for workplace violence. Severe underreporting (72·2%) and a belief that workplace violence is part of the work (74·1%) were also identified. Workplace violence was highly correlated with several factors, including a lack of encouragement for reporting, a feeling in advance that a violent incident was about to happen and having to handle the incident personally. Suggestions for improvement included more security measures (26·7%) and public education about the proper use of emergency services (15·2%). CONCLUSION: Verbal abuse is common in Cypriot emergency departments, but clinicians are increasingly worried about physical assaults. RELEVANCE TO CLINICAL PRACTICE: Training, security policies, encouragement of reporting and support for staff after a violent incident are needed. Future research should try to include the perpetrator's viewpoint.

Implementing lean methods in the emergency department: the role of professions and professional status.

PURPOSE: The purpose of this paper is to examine the implementation of lean methods in an Emergency Department (ED) and the role of the professions in this process. DESIGN/METHODOLOGY/APPROACH: Qualitative, semi-structured interviews with ED staff in a UK NHS hospital. FINDINGS: Lean was met with more engagement and enthusiasm by the professionals than is usually reported in the literature. The main reasons for this were a combination of a national policy, the unique clinical environment and the status of the professional project for doctors in emergency medicine. RESEARCH LIMITATIONS/IMPLICATIONS: Single site, one-off study. PRACTICAL IMPLICATIONS: The status and development of professionals involved may play a big part in the acceptability of initiatives like lean methods in health care. The longer-term sustainability of the organisational changes introduced remains open to question. ORIGINALITY/VALUE: This paper analyses the success of lean methods in health care with reference to the professional status and stage of development of the professions involved, using the sociology of professions. This approach has not been used elsewhere.

National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study.

BACKGROUND: In the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues. METHODS: A qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes. RESULTS: The wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients. CONCLUSIONS: The imposition of a wait-target in response to a perceived "crisis" of patients' dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians' experience and satisfaction.

Implementation of an emergency department information system: a qualitative study of nurses' attitudes and experience.

This article explores the reactions of nurses toward the implementation of an emergency department information system. Semistructured interviews were conducted with 22 nurses, and data were analyzed using thematic analysis. The results suggest that despite some initial apprehensions nurses were positive in their attitudes and interactions with clinical information systems supportive of their practice, especially in respect of performance targets. Issues of digital work environment design, system availability, and peer support during preliminary interactions were also involved in the formation of their views. Implementation teams addressing these issues have greater chances of maintaining the attitudes that contribute to the successful use of these systems.

The importance of vital signs in the triage of injured patients.

BACKGROUND: Vital signs are indicators of a patient presenting to an emergency department (ED). Abnormal vital signs have been associated with an increased likelihood of admission to the hospital. Physicians have long recognized the importance of vital sign observations, and vital sign measurement has proven to be useful for detecting serious diseases during triage in EDs. METHODS: The study included all patients with injuries presented to the ED of a general hospital in Greece. For these patients, sex, age, cause of injury, vital signs at the time of admission to ED (systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, and oxygen saturation), and the course of the patient (admission to hospital, discharge from ED) were recorded. The statistical analysis of data was done by the statistical package SPSS 15. It was performed using univariate regression and Spearman correlation coefficient. RESULTS: A total of 2703 patients were registered, of which 71% were men aged 31.9 ± 0.38 years and 29% were women aged 45.7 ± 0.79 years. The main causes of injury were car accident, motor accident, pedestrian accident, fall from a height, and assault. By logistic regression, the correlation was found between mean blood pressure, systolic blood pressure, oxygen saturation, and hospitalization or discharge of the patients. CONCLUSIONS: The measurement of mean blood pressure, systolic blood pressure, and oxygen saturation of the injured patients during the admission to the ED can predict the disease course of patients.

Going paperless at the emergency department: a socio-technical study of an information system for patient tracking.

PURPOSE: The purpose of this study was to examine nurses' attitudes and reflection on the transformation of their workpractices after the implementation of an Emergency Department Information System (EDIS). METHODS: A qualitative study using interviews, mainly with nurses, conducted four years after the implementation of an EDIS at the emergency department (ED) of a large university hospital in Midlands, UK. RESULTS: The introduction of waiting time targets for patients attending EDs and the spatial expansion of these clinical settings so as to support increasing numbers of attendances challenged the viability of paper records and whiteboards in the management of patient flows within the department. They also fostered the use of an information system for accumulating information and coordinating the activities of the multidisciplinary team. While whiteboards were abolished, paper still plays a role in nursing practice in response to issues of confidentiality, personal safety, ergonomics, computer literacy, interoperability, relationship with patients and overdependence on EDIS. CONCLUSIONS: ED information systems can have a major impact on organisational practices particularly as new service models of care are gradually introduced in EDs. Considering their spatio-temporal implications while treating the technology as an artifact with transformative, rather than supportive or substitutive, power enhances our understanding of the implementation challenges that need to be addressed during the reshaping of the sociotechnical network.