A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre-post implementation.

The purpose was to study users' attitudes towards an electronic medical record (EMR) closely integrated into the clinicians' cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real-time support to the coordination of shared care processes involving all the care personnel. Mixed method pre-post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users' attitudes towards the EMR (response rate of 71%) measured after the go-live were positive ranging from 3.42 to 3.95 on a 5-point scale. Besides, the content analysis of 33 pre-post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users' expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Hospital network performance: a survey of hospital stakeholders' perspectives.

Hospital networks are an emerging organizational form designed to face the new challenges of public health systems. Although the benefits introduced by network models in terms of rationalization of resources are known, evidence about stakeholders' perspectives on hospital network performance from the literature is scanty. Using the Competing Values Framework of organizational effectiveness and its subsequent adaptation by Minvielle et al., we conducted in 2009 a survey in five hospitals of an Italian network for oncological care to examine and compare the views on hospital network performance of internal stakeholders (physicians, nurses and the administrative staff). 329 questionnaires exploring stakeholders' perspectives were completed, with a response rate of 65.8%. Using exploratory factor analysis of the 66 items of the questionnaire, we identified 4 factors, i.e. Centrality of relationships, Quality of care, Attractiveness/Reputation and Staff empowerment and Protection of workers' rights. 42 items were retained in the analysis. Factor scores proved to be high (mean score>8 on a 10-item scale), except for Attractiveness/Reputation (mean score 6.79), indicating that stakeholders attach a higher importance to relational and health care aspects. Comparison of factor scores among stakeholders did not reveal significant differences, suggesting a broadly shared view on hospital network performance.

Exploring health information technology innovativeness and its antecedents in Canadian hospitals.

OBJECTIVES: The primary aim of this study was to assess the antecedents of health information technology (HIT) innovativeness in public hospitals. To do so, we built upon our own previous work to relate the level of HIT innovativeness to organizational capacity characteristics. METHODS: We conducted a survey of chief information officers (CIOs) in public hospitals in the two largest Canadian provinces to identify the level of HIT innovativeness in these settings and test nine research hypotheses derived from the proposed research model. RESULTS: A total of 106 completed questionnaires were received, which represents a response rate of 52%. Our findings indicate strong support for the research model. Seven out of nine hypotheses were supported indicating a significant relationship between HIT innovativeness and structural, financial, leadership, and knowledge sharing capacity characteristics. Results also reveal a moderate level of HIT innovativeness in the surveyed hospitals, with more emphasis on administrative systems and their integration than on clinical systems and emerging technologies. CONCLUSIONS: This study demonstrates that organizational characteristics are related to HIT innovativeness; this relationship holds irrespective of the public or private nature of hospitals.

Replacing an inpatient electronic medical record. Lessons learned from user satisfaction with the former system.

OBJECTIVE: Since it is important to develop strategies for the successful implementation of electronic clinical information systems, the aim of this study is to explore where, and to what extent, users' attitudes toward the former system that is being replaced may vary. METHODS: A cross-sectional survey of 346 nurses and physicians practicing in two Canadian teaching hospitals resulted in a total response rate of 63%. User attitudes were measured in three dimensions: a) user satisfaction with the system's quality attributes, b) perceived system usefulness, and c) perceived impact on quality of care and patient safety. The current system (the one being replaced) was analyzed as a dual system composed of both paper-based and electronic records. RESULTS: The results on user satisfaction demonstrate a wide variation in opinions, with satisfaction ranging from 4.2 to 7.7 on a 10-point disagree-agree, Likert scale. The quality attributes varied by record type, with differences that were systematically in favor of the electronic record component, which received higher scores. The results also highlighted large differences by user group. Physicians and nurses systematically rated the two record formats differently. The nurses were more satisfied with the attributes of the paper-based record. Multivariate regression analyses results also revealed strong interdependencies among the three dimensions of user attitudes, to the extent that perceived system usefulness was strongly correlated with system quality attributes and the system outcomes were also correlated, although less strongly, with the two former system dimensions. CONCLUSION: Understanding users' attitudes toward a clinical information system in use, both in its paper and electronic aspects, is crucial for developing more successful implementation strategies for electronic record systems.

Prioritizing the risk factors influencing the success of clinical information system projects. A Delphi study in Canada.

OBJECTIVE: The aim of this study is to gain a better understanding of the risk factors influencing the success of clinical information system projects. METHODS: This study addresses this issue by first reviewing the extant literature on information technology project risks, and second conducting a Delphi survey among 21 experts highly involved in clinical information system projects in Québec, Canada, a region where government have invested heavily in health information technologies in recent years. RESULTS: Twenty-three risk factors were identified. The absence of a project champion was the factor that experts felt most deserves their attention. Lack of commitment from upper management was ranked second. Our panel of experts also confirmed the importance of a variable that has been extensively studied in information systems, namely, perceived usefulness that ranked third. Respondents ranked project ambiguity fourth. The fifth-ranked risk was associated with poor alignment between the clinical information systems' characteristics and the organization of clinical work. The large majority of risk factors associated with the technology itself were considered less important. This finding supports the idea that technology-associated factors rarely figure among the main reasons for a project failure. CONCLUSIONS: In addition to providing a comprehensive list of risk factors and their relative importance, the study presents a major contribution by unifying the literature on information systems and medical informatics. Our checklist provides a basis for further research that may help practitioners identify the effective countermeasures for mitigating risks associated with the implementation of clinical information systems.

Teleconsultation: rejected and emerging uses.

OBJECTIVE: The aim of this paper is to analyse telemedicine as a new means to improve health care accessibility. METHOD: A case study design was used to understand how medical specialists perceived, made sense of, and appropriated a teleconsultation system. RESULTS AND CONCLUSIONS: The technology was used neither in the manner nor to the extent anticipated by its designers. A fundamental modification to the traditional medical consultation process has emerged. Unable to be used as a substitute to the traditional medical consultation process, the teleconsultation system imposes a greater burden on the shoulders of participating physicians who, after a few trials, returned to their traditional mode of practice.

The theory of use behind telemedicine: how compatible with physicians' clinical routines?

Since the early 1990s, telemedicine, or the use of information technology to support the delivery of health care from a distance, has increasingly gained the support of clinicians, administrators and policymakers across industrialised countries. However, the "theory of use" behind telemedicine-its rationale and the manner in which clinicians are expected to use it in their daily activities--has been only marginally investigated. In this paper we present the results of a qualitative study which examines the theory of use behind teleconsultation from the viewpoint of physicians (n = 37) in six specialities, practising in Quebec (Canada) hospitals. We employ Giddens' Structuration Theory (1984) to analyse the views, communications needs and referral strategies of physicians. Two questions are explored: (1) To what extent can teleconsultation be integrated into the routines of diverse medical specialities'? and (2) Why and how might clinicians use this technology? Our research indicates that specialities relying on either thorough physical examinations or specialised investigative techniques are unlikely to restructure their work routines to accommodate teleconsultation, which they view as limited. Specialities that primarily exploit images or numerical data tend to perceive teleconsultation as more useful. The perceived enabling properties of teleconsultation increase as a function of the distance the patient would have to travel to be seen directly by a consultant. The constraining properties are linked to the type of information transmitted, since physicians believe that only objective data can be safely consulted from a distance, whereas relying on the remote physician's interpretation of subjective information is deemed inappropriate. We thus conclude that the development of teleconsultation should be consolidated around applications whose theory of use is compatible with existing clinical routines, or offers opportunities to restructure clinical work according to the needs of providers and remote communities.

IT sophistication in hospitals : a field study in Quebec.

The Quebec health sector has been experiencing a period of great turmoil over the last five years and hospitals are faced with huge pressures from government funding cuts. Several empirical studies in the information systems field have shown that the use of computer-based information systems could have positive impacts on organizational performance. Many agree to say that health care institutions are no exceptions. But if one wishes to identify the effects of IT on the delivery of care, one must be able to characterize IT for operationalization purposes. Our main objective consists in developing and validating a measurement instrument of IT sophistication in hospitals. Such instrument should provide hospital managers with a diagnostic tool capable of indicating the profile of their respective institutions in regard to IT use and comparing this profile to those of other similar health institutions.

The effect of medical work groups on hospital resource use.

This study tests the ability of medical work groups to overcome coordination problems related to group decision-making in allocating clinical resources to inpatients. The study was conducted over a 32-month period in two medium-sized acute-care hospitals located in Montreal, Quebec, Canada. The data were collected by hand from the medical charts of 10,456 patients in the surgical and medical departments. The Linear Structural Relations (LISREL) approach was employed to address the work-group issue using a task contingent model of work-group organization. In this model, the nature of the task is fundamental because its level of complexity determines both the organization of the work group and the use of resources. Medical work-group mechanisms should be efficient to the extent that resource utilization is explained solely by task characteristics rather than by work-group structure. In this study, the following two major organizational concepts were used as factors to explain resource use: task characteristics and work-group characteristics. Our analysis confirmed the main points of the task contingency theory as applied to the field of medicine. First, the results confirm that resource utilization is explained mainly by task complexity. Second, they confirm that medical work groups modulate their structures on the basis of task characteristics and do not explain resource use. The results also reveal a more complex model in which, for instance, the concepts of medical task and medical professional work are not easy to separate. The results highlight the interest in conceptualizing and analysing medical practice in work groups. It raises important issues that have seldom been taken into account in the study of medical practice variations, which has tended to focus on attending physicians.

Information technology sophistication in health care: an instrument validation study among Canadian hospitals.

Several empirical studies have shown that the use of computer-based information systems could have positive impacts on organizational performance. Many agree to say that health care organizations are no exceptions. But if one wishes to identify the effects of information technology (IT) on the delivery of care, one must be able to characterize IT for operationalization purposes. The primary objective of this research project is to develop and validate a measurement instrument of IT sophistication in the hospital milieu. Such instrument should provide hospital managers with a diagnostic tool capable of indicating the profile of their respective institutions in regard to IT adoption and comparing this profile to those of other similar medical centers. Both qualitative and quantitative data were collected in order to assess the psychometric properties of the measurement instrument. Overall, findings suggest a high-moderate level of functional sophistication, a somewhat low level of technological sophistication, and an even lower level of integration sophistication in all of the sampled medical centers. Hence, future investments shall therefore be directed towards the integration of clinical and administrative applications and the acquisition of more advanced technological devices, more specifically those, which allow direct capture of clinical data at the bedside.

Do children with PDDNOS have a theory of mind?

This study sought to differentiate PDDNOS from a similar nonautistic disorder (i.e., language impairment) on the basis of a cognitive deficit, theory-of-mind (ToM). ToM is an ability to infer mental states in others and has been found to be highly prevalent in autism, a disorder that shares many characteristics with PDDNOS (Baron-Cohen, 1985; Volkmar & Cohen, 1988). A sample of 28 children with either PDDNOS or a language impairment formed two groups (n = 14), matched on gender and verbal mental age. Participants were administered the brain function task (Baron-Cohen, 1989) and the false belief task (Perner, Frith, Leslie, & Leekam, 1989) to assess ToM. Results suggest that children with PDDNOS are deficient in a ToM ability, however, this relationship is not as strong as in previous studies with autistic samples, suggesting that children with PDDNOS may have a greater ToM ability. The existence of PDDNOS on the higher end of a spectrum of the Pervasive Developmental disorders as well as the construct of ToM itself existing on a continuum are discussed.

Theory of use behind telehealth applications.

A variety of telehealth applications have been implemented throughout the industrialized world. Given that telehealth has yet to become routine in the practices of physicians, the impact of such applications on health care management remains difficult to identify. Only by becoming integrated into the 'normal practice' of clinicians can telehealth facilitate smooth communications in health care delivery processes. In this paper we demonstrate the importance of developing a 'theory of use', describing how clinicians are expected to use teleconsultation in their daily activities. By employing Giddens' Structuration Theory, we can develop a clear vision of the utilization of telehealth, and a better framework with which to assess its added value for health care delivery. We illustrate this claim by referring to our research on the Quebec Inter-Regional Telemedicine Network. In this study we compare the 'theory of use' behind the telemedicine network with the perceptions of physicians regarding their needs in terms of communications and access to expert advice. The breach between the theory and the perceptions of physicians may help to explain how the utilization of telehealth could be enhanced, and how new and sustainable routines for its integration into the health care system might be created.

The computer-based patient record challenges towards timeless and spaceless medical practice.

Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project ($50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

A review of organizational performance assessment in health care.

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

The computer based patient record: a strategic issue in process innovation.

Reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project ($45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Family physicians' involvement in two hospitals. Two different models of inpatient care.

OBJECTIVE: To describe the roles of family physicians in two hospitals with different models of inpatient care. DESIGN: Cross-sectional descriptive study of a random sample of 11528 patients admitted to two hospitals between 1985 and 1988. SETTING: Two acute-care community hospitals in suburban Montreal, Que. SUBJECTS: Family physicians providing inpatient care at the two hospitals. MAIN OUTCOME MEASURE: How often family physicians were attending physicians (attending responsibility); what percentage of patients were visited by at least one family physician (case load); and what percentage of bedside visits were made by family physicians (workload). RESULTS: In one hospital, where family physicians were actively promoted as primary care providers, they were frequently attending physicians, had heavier case loads, and made more patient visits. Also, they collaborated more often with specialists. In the other hospital, family physicians tended to care for specific populations of patients. CONCLUSION: When hospitals promote different organizational models of medical care, family physicians' roles are affected.

The diluting effect of medical work groups on feedback efficacy in changing physician's practice.

Feedback intervention has been advocated as a successful method to modify the way that physicians practice medicine. However, most studies concerned with modifying physician profiles have focused on interns and residents. The results presented here concern regular staff and therefore provide a better basis for generalization. Over a 2.5-year period, we analyzed the use of clinical resources by physicians practicing in four medical specialties in two hospitals. Hierarchical multiple regression models were used to control case mix in order to identify the specific effects attributable to feedback. The information failed to modify the physicians' practice profiles. Our results suggest that this failure is related to the organization of inpatient medical practice as a group effort. This mode of practice has a negative effect on feedback efficacy. First, it weakens one of the main feedback mechanisms, that is personal identification with the data. Second, it probably generates mutual adjustment among physicians, thus eliminating practice variations at the source.

Using the handicap code of the ICIDH for classifying patients by intensity of nursing care requirements.

An 11-class patient classification system (PCS) has been built on a recode of two dimensions of the handicap code of the ICIDH: physical independence and mobility handicaps. The proposed system, called MAC XI, explains 78% of the variance of nursing care hours required by nursing-home residents and extended-care hospital patients. This percentage of variation is higher than the one explained by traditional dependency grids such as the Exton-Smith, Murphy, Kuntzmann and SMAF. MAC XI, based on two dimensions of the handicap code, is thus a powerful tool for predicting intensity of nursing care for staffing and budgeting purposes in long-term care institutions.