Assessing metabolic risk factors for psychiatric patients: An IT-supported task shift from physician to pharmacist.

BACKGROUND: Psychiatric medication can have adverse effects such as weight gain, which is a metabolic risk factor for the development of cardiovascular disease and diabetes. This study aimed to assess whether an IT-supported task shift from physicians to pharmacists could improve clinical guideline compliance in assessing metabolic risk factors for psychiatric patients. METHOD: An IT tool was designed and implemented in the electronic health record to enable pharmacists to efficiently screen patients for metabolic risk factors. The tool provided a risk score for each patient based on criteria from the cross-regional guideline. All admitted patients with a score were assessed by the pharmacists, who referred and discussed the patients with a physician when deemed relevant. We measured guideline compliance during baseline (manual screening) and intervention (automated screening) after implementing the IT tool and pharmacist assessment. After the intervention period, we conducted follow-up interviews with all participating pharmacists. RESULTS: Guideline compliance increased significantly from 26 % (baseline) to 63 % (intervention) (Fisher's exact test p < .001, N = 98). The task shift from physicians to pharmacists was also significant (Fisher's exact test, p < .001, N = 40). Interviews revealed that the pharmacists found the task shift meaningful and received positive feedback from the physicians. The facilitators of the task shift included interprofessional collaboration, physician shortage, provider empowerment, and the manageable nature of the task. The barriers included a need for further competence development and lack of pharmacist authorization. The IT tool was considered useful and suggestions for improvements emerged. CONCLUSION: The IT-supported task shift from physician to pharmacist significantly improved guideline compliance in the assessment of metabolic risk factors in psychiatric patients. The findings support increasing the pharmacist's role in psychiatric care to improve patient outcomes.

Medication Reconciliation as Repair Work.

In Norway, the process of developing a national shared medication list has been underway for several years. The shared medication list provides an overview of all the medications used by a patient. However, its proper use requires that it be maintained regularly through so-called medication reconciliation processes in which health personnel clarify - and ask patients - what and how much medication they use. We explore the work embedded in the bedside medication reconciliation process at a hospital, the health personnel conducting this work and the implications for the shared medication list. We argue that reconciliation processes can be conceptualized as collective repair work that needs to be continued after the shared medication list is implemented.

Configuring Secretarial Workflows in the Epic EHR Suite.

The primary goal of large-scale electronic health record (EHR) suites is to meet the needs of a broad range of users in healthcare institutions. EHR suites are extensively configurable, which makes it possible to tailor them to diverse professional practices and users. However, while users such as physicians and nurses may have clearly defined responsibilities, clerical personnel (i.e. secretaries) conduct "in-between" or invisible work that is not as easily defined. Therefore, it may be more difficult to tailor EHR suites to their needs. Moreover, because secretaries are quite low in the hospital hierarchy, it is difficult for them to obtain satisfactory solutions. In this paper, we explore the challenges of configuring the EHR suite for secretary workflows in the Health Platform program in central Norway.

Me-to-We Design: A Blueprint for Enriching Welfare Technologies.

Current technologies for ambient assisted living leave underexploited that social interaction is key to human wellbeing. Me-to-we design provides a blueprint for enriching such welfare technologies with social interaction. We present the five stages of me-to-we design, illustrate how it may transform a common class of welfare technologies, and discuss the distinguishing features of me-to-we design. These features include scaffolding social interaction around an activity and supporting transitions among the five stages. In contrast, most current welfare technologies support only some of the five stages and, thereby, either bypass social interaction or presuppose that social relations already exist. Me-to-we design offers a blueprint for building social relations stage by stage if they do not exist up front. It is for future work to validate whether the blueprint in practice delivers welfare technologies that are enriched by its profoundly sociotechnical approach.

Implementing Large-Scale Electronic Health Records: Experiences from implementations of Epic in Denmark and Finland.

BACKGROUND: With the still larger scale of electronic health records (EHRs), their implementation has become increasingly complex. In this study, we focus on one large-scale EHR - Epic. PURPOSE: We analyze the Epic implementations in Denmark and Finland to understand how healthcare professionals experience this large-scale EHR. METHOD: The study is based on documentary analysis. The analyzed documents include user surveys, assessment reports, material from project partners, and research papers. RESULTS: The Danish and Finnish Epic implementations are still troubled five and three years, respectively, after the first go-live. In Denmark, the business case and implementation process have been sharply criticized. The correction of usability problems and unstable system integrations have been slow, the time required to perform common clinical tasks has increased, and 32% of the users remain dissatisfied or very dissatisfied with the system. In Finland, the physicians and nurses experience improved technical performance but inferior usability and reduced work support compared to the EHR they used before Epic; only 4.7% (physicians) and 7.3% (nurses) agree that patient information is easy to access, and only 9.3% (physicians) and 26.2% (nurses) agree that Epic helps improve the quality of care. CONCLUSION: The post-implementation experiences from the two implementations contradict pre-implementation expectations. Specifically, the consequences of using Epic have become salient only after go-live. As a result, the implementing organizations and their users have predominantly found themselves in a reactive mode of fending off problems rather than a proactive mode of realizing benefits.

Large-Scale EHR Suites and Path-Dependence.

Large-scale electronic health record (EHR) suites are expected to cover a broad range of use scenarios for healthcare workers in hospitals, nursing homes, home-care services, and general practitioner (GP) clinics. However, preparation for the implementation of EHR suites requires years of detailed planning and consumes considerable financial and human resources. A key problem, then, is that there is less room for decision-makers to consider promising alternative solutions both before and after the implementation of EHR suites. On this basis, we explore how past decisions on EHR suites limit future technological alternatives. Empirically, we focus on the Health Platform program in Central Norway, where the goal is to implement the U.S. Epic EHR suite in 2022, following similar implementations in Denmark in 2016 and Finland in 2018.

National Integration Components Challenge the Epic Implementation in Central Norway.

Electronic health record (EHR) suites cover a broad range of cross-sectoral use scenarios. Thereby, they streamline information flows but also require that healthcare professionals with diverse responsibilities must adapt to one and the same system. In the region of Central Norway, the EHR suite from Epic is being implemented at hospitals as well as in municipal healthcare. However, the 64 municipalities in the region are increasingly exploring the option of bypassing Epic by supplementing their existing systems with national integration components. These components provide integration and data exchange across systems for selected healthcare information. We discuss whether they are a viable alternative to Epic. The three components are the summary care record, the shared medication list, and the national welfare technology hub.

The Tension between National and Local Concerns in Preparing for Large-Scale Generic Systems in Healthcare.

Large-scale generic systems are typically adapted to local practice through configuration. This is especially important in healthcare, which involves a plurality of institutions and users. However, the decision to acquire a generic system in public healthcare is typically founded on regional and national health policy goals, which often are translated into various forms of standardization. As a result, national and regional health policy interests may stand in contrast to interests on the local level. Therefore, we analyze how national and local concerns are weighed against each other in the preparations for implementing large-scale generic systems in healthcare. We explore what role configuration plays and what the prospects are for long-term development. We contribute with insight into how the organizational consequences of generic systems are formed already in the preparation phase and point to how configuration easily results in standardization, thereby basically privileging national and regional health goals at the expense of local needs. Empirically, we focus on the preparations for implementing the Epic electronic health record in Central Norway.

Persuasion Tactics in the Implementation of Large-Scale EHR Suites in Public Healthcare.

Large-scale electronic health record (EHR) suites have the potential to cover a broad range of use needs across various healthcare domains. However, a challenge that must be solved is the distributed governance structure of public healthcare: Regional health authorities regulate hospitals, municipalities are responsible for first-line healthcare services, and general practitioners (GPs) have an independent entrepreneurial role. In such settings, EHR program owners cannot enforce municipalities and GPs to come on board. Thus, we examine what tactics owners of large-scale EHR suite programs apply to persuade municipalities to participate, how strongly these tactics are enforced, and the consequences. Empirically, we focus on the Health Platform program in Central Norway where the goal is to implement the U.S. Epic EHR suite in 2022. Theoretically, the paper is positioned in the socio-technical literature.

How Demanding Is Healthcare Work? A Meta-Analytic Review of TLX Scores.

This study establishes how demanding healthcare work is experienced to be and whether nurses and physicians experience different levels of workload. A meta-analytic review was conducted of 87 studies that reported Task Load Index (TLX) scores for healthcare work. Of these studies, 37 were conducted in real-life settings and 50 in lab settings without real patients. In real-life settings, clinicians experienced a workload with a mean TLX of 49 (on a 0-100 scale). Divided onto staff groups, the mean TLX for nurses was 63, which was significantly higher than the mean of 40 for physicians. Among the six TLX subscales, the main contributors to workload were mental demand, temporal demand, and effort. They were higher than physical demand and frustration. The clinicians experienced their performance - the last subscale - as closer to poor than good in 38% of the studies conducted in real-life settings. The difference between nurses and physicians was consistent across all subscales, except mental demand. Finally, it is methodologically important that TLX scores appeared not to transfer directly from lab to real-life settings. To reduce the risk of errors and burnout, new healthcare procedures and technologies should be evaluated for their impact on workload.

Reference values and subscale patterns for the task load index (TLX): a meta-analytic review.

The Task Load Index (TLX) is the predominant instrument for self-reporting workload. On the basis of a meta-analytic review of 556 studies, this paper supplies reference values for TLX and its six subscales across domains, technologies, regions, and real-life/lab settings. Across domains, TLX spans mean values from 35 for leisure to 56 for manual labour. TLX tends to be driven upward by the subscales of mental demand and effort and downward by the subscales of physical demand and frustration. For technologies, handheld devices are associated with lower TLX, possibly because they are simpler and more task-specific. TLX also varies across regions in that it is higher for studies in Asia than in Europe and North America. This variation is only partly explained by co-variation in domains. Furthermore, TLX is higher and its subscales more inter-correlated when it is studied in real-life rather than lab settings. Practitioner summary: Practitioners can use the reference values supplied in this paper to benchmark their TLX measurements against those from the corpus of TLX research. Furthermore, the reported subscale patterns add to the diagnostic power of the TLX instrument. Abbreviations: TLX: task load index; MD: mental demand; PD: physical demand; TD: temporal demand; EF: effort; PE: performance; FR: frustration.

Drivers of expectations: Why are Norwegian general practitioners skeptical of a prospective electronic health record?

While expectations are well-known drivers of electronic health record (EHR) adoption, the drivers of expectations are more elusive. On the basis of interviews with general practitioners (GPs), we investigate how the early implementation process drives their expectations of an EHR that is being implemented in Norway. The GPs' expectations of the prospective EHR are driven by (a) satisfying experiences with their current system, (b) the transfer of others' experiences with the prospective EHR, (c) a sense of alignment, or lack thereof, with those in charge of the implementation process, (d) uncertainty about the inclusion of GP needs, and (e) competing technological futures. To manage expectations, starting early is important. Mismanaged expectations produce a need for convincing people to reverse their expectations. This appears to be the situation in Norway, where the GPs are currently skeptical of the prospective EHR.

Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care, Medication, and Consent.

BACKGROUND: Electronic health records (EHRs) are used in long-term care to document the patients' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals. OBJECTIVE: This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons. METHOD: The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]). RESULTS: As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes. CONCLUSION: Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients' condition and care are more prevalent and that issues about their consent are also common.

User Requirements Meet Large-Scale EHR Suites: Norwegian Preparations for Epic.

Electronic health records (EHRs) are becoming the norm in healthcare. Typically, these EHRs are large-scale suite systems. The up-front presence of ready-for-use EHR suites changes the role of user requirements and the conditions for deciding which requirements to include in the final contract. In this paper, we investigate how user requirements are negotiated in the ongoing preparations for the implementation of Epic throughout the region of Central Norway. User requirements shape vendor selection but they are also shaped by the vendors' existing EHRs and by the requirements of the selected vendor's other customers.

How Come Nothing Changed? Reflections on the Fasting-Time Project.

Many healthcare interventions fail to produce the intended effect. In this paper we look back at the fasting-time project, which aimed to shorten patients' preoperative fasting times. However, the project failed to achieve this effect, even though it had been identified and prioritized by the clinicians at the studied hospital. A set of mutually reinforcing factors collectively explain why the project failed to produce change. The four main factors are: lack of urgency, risk aversion, day-to-day busyness, and lack of managerial commitment at the department level. The simultaneous presence of these factors complicates efforts to counter them.

The Handover from Intensive Care Unit to General Ward: Baseline Performance and Participatory Design of an Electronic Follow-Up Plan.

The transfer of patients from intensive care unit (ICU) to general ward involves risk to patient health. To mitigate this risk the present study investigates the current use of follow-up plans in the handover from ICU to general ward and proposes a novel design of follow-up plans. On the basis of a record audit we find that follow-up plans exist for only 16% of the audited transfers, that these plans are rarely used, and that 25% of the patients with a plan die within 24 hours of their transfer. In a subsequent series of participatory-design workshops with ICU and ward nurses we devised an electronic follow-up plan that consists of an attend-to list rather than a checklist. The attend-to list specifies the issues of concern but leaves the process of attaining them for the general-ward nurses to decide, thereby acknowledging and utilizing their expertise.

The implementation of an electronic health record: Comparing preparations for Epic in Norway with experiences from the UK and Denmark.

BACKGROUND: The implementation of electronic health records (EHRs) requires careful preparations but may still cause trouble. In this study we focus on one EHR - Epic. PURPOSE: We compare the experiences from implementing Epic in the UK and Denmark with the preparations for implementing it in Norway. METHOD: The study is based on document analysis (UK and Denmark) and interviews (Norway). RESULTS: Epic had a troubled start in both the UK and Denmark with malfunctions in the interfaces to other clinical systems, disruptions in the continuity of care, and drops in performance. While the state of routine use has subsequently been reached in the UK, the transition process is still ongoing in Denmark. In Norway experiences from, especially, Denmark are heeded in planning the implementation of Epic, which is expected to deliver better care more efficiently. We discuss six pitfalls to achieving these benefits. CONCLUSION: Experiences from, especially, Denmark inform the Norwegian preparations, but these experiences point toward more challenges than solutions. The implementation of Epic in Norway is currently in a state of considerable uncertainty.

Grappling with the future: The messiness of pilot implementation in information systems design.

Pilot implementation is a method for avoiding unintended consequences of healthcare information systems. This study investigates how learning from pilot implementations is situated, messy, and therefore difficult. We analyze two pilot implementations by means of observation and interviews. In the first pilot implementation, the involved porters saw their improved overview of pending patient transports as an opportunity for more self-organization, but this opportunity hinged on the unclear prospects of extending the system with functionality for the porters to reply to transport requests. In the second pilot implementation, the involved paramedics had to print the data they had entered into the system because it had not yet been integrated with the electronic patient record. This extra work prolonged every dispatch and influenced the paramedics' experience of the entire system. We discuss how pilot implementations, in spite of their realism, leave room for uncertainty about the implications of the new system.

How Do Experienced Physicians Access and Evaluate Laboratory Test Results for the Chronic Patient? A Qualitative Analysis.

BACKGROUND: Electronic health records may present laboratory test results in a variety of ways. Little is known about how the usefulness of different visualizations of laboratory test results is influenced by the complex and varied process of clinical decision making. OBJECTIVE: The purpose of this study was to investigate how clinicians access and utilize laboratory test results when caring for patients with chronic illness. METHODS: We interviewed 10 attending physicians about how they access and assess laboratory tests when following up patients with chronic illness. The interviews were audio-recorded, transcribed verbatim, and analyzed qualitatively. RESULTS: Informants preferred different visualizations of laboratory test results, depending on what aspects of the data they were interested in. As chronic patients may have laboratory test results that are permanently outside standardized reference ranges, informants would often look for significant change, rather than exact values. What constituted significant change depended on contextual information (e.g., the results of other investigations, intercurrent diseases, and medical interventions) spread across multiple locations in the electronic health record. For chronic patients, the temporal relations between data could often be of special interest. Informants struggled with finding and synthesizing fragmented information into meaningful overviews. CONCLUSION: The presentation of laboratory test results should account for the large variety of associated contextual information needed for clinical comprehension. Future research is needed to improve the integration of the different parts of the electronic health record.

Participatory Continuing Design: "Living with" Videoconferencing in Rehabilitation.

While much research emphasizes design-before-use, we here study design-in-use. The notion of participatory continuing design is introduced to draw attention to the ongoing work of incorporating information and communication technology into work processes in healthcare institutions. Through an empirical case study of how telemedicine, in the form of videoconferencing, was taken up in a rehabilitation hospital in Norway, the nature of such ongoing experimentation, learning, and redesign is described. When contrasted with traditional design-before-use practices, participatory continuing design differs in terms of its timing, object, process, outcome, and participants. We offer recommendations for how such processes can be supported in healthcare organizations.