Factors affecting the use of nursing information systems in Taiwan

AIM: This paper reports a study to test a proposed model of factors (demographic variables, computer experience and perceived technology characteristics) influencing the efficient use of a computerized nursing care planning system by hospital clinical nurses. BACKGROUND: Although nursing information systems have been used in health care institutions, little research has explored the efficiency of computer use in nurses' daily practice. METHOD: A secondary data analysis was applied to focus on clinical nurses' daily computer use. The original data were collected from a medical centre in Taiwan to establish the reliability and validity of a scale to evaluate computerized nursing care plan systems. RESULTS: Younger nurses with more education, less computer knowledge and less usage pressure, and who perceived that they had less usage benefit, more education training and usability regarding system use, spent less time on the computerized nursing care plan. CONCLUSION: The results can be used for further organization of education programmes and as a reference for training strategies. Further examination and analysis of item content are suggested.     

Staff perceptions implementing interprofessional team-based behavioural healthcare

The US Veterans Health Administration (VHA) in 2013 mandated a nationwide implementation of interprofessional team-based care in the general mental health setting and officially endorsed the collaborative care model in 2015 to guide the coordinated and anticipatory care to be delivered by these teams. Front-line clinic staff are major stakeholders whose practices are most directly affected by this implementation and may or may not view teams as useful or feasible for their practice. Our objective was to examine their perspectives on delivering team-to-patient care in order to understand what system-level efforts can best support the transition to such care from the more conventional provider-to-patient care. We conducted 14 semi-structured interviews with staff from general mental health clinics across three different VHA medical facilities. The interview questions focused on asking how care is organised and delivered at their clinic, their experiences in collaborating with other staff, and how the clinic handles changes. Four recurrent themes were identified: navigating workplace supervision, organisation, and role structures; continuing professional growth and relationships; delivering patient-focused care through education and connection to resources; and utilising information technology for communication and panel-based management. Quality improvement efforts were rarely discussed during the interviews. Our results indicate that staff’s endorsement of the implementation of interprofessional care teams in general mental health settings may be strengthened through associated efforts targeted at enhancing their experiences aligned to these emergent themes.     

Nursing standards to support the electronic health record

Quality and low cost health care that is free of medical mistakes requires continuity of person-centric healthcare information across the life span and healthcare settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive Order called for a National Health Information Network and the widespread adoption of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to support nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development.     

Capturing Information Needs of Care Providers to Support Knowledge Sharing and Distributed Decision Making

Background

This paper reports on work carried out to elicit information needs at a trans-disciplinary, nurse-managed health care clinic that serves a medically disadvantaged urban population. The trans-disciplinary model provides a “one-stop shop” for patients who can receive a wide range of services beyond traditional primary care. However, this model of health care presents knowledge sharing challenges because little is known about how data collected from the non-traditional services can be integrated into the traditional electronic medical record (EMR) and shared with other care providers. There is also little known about how health information technology (HIT) can be used to support the workflow in such a practice.

Objectives

The objective of this case study was to identify the information needs of care providers in order to inform the design of HIT to support knowledge sharing and distributed decision making.

Methods

A participatory design approach is presented as a successful technique to specify requirements for HIT applications that can support a trans-disciplinary model of care.

Results

Using this design approach, the researchers identified the information needs of care providers working at the clinic and suggested HIT improvements to integrate non-traditional information into the EMR. These modifications allow knowledge sharing among care providers and support better health decisions.

Conclusions

We have identified information needs of care providers as they are relevant to the design of health information systems. As new technology is designed and integrated into various workflows it is clear that understanding information needs is crucial to acceptance of that technology.     

Rising to the challenge of home health care

The managed care concept has had a major impact on most health care delivery systems (from the hospital to home) and the professional practice of the people within those systems. It is important that all types of providers who are involved in an individual's care have a basic understanding of the challenges they each face. Sharing information may contribute to a more efficient transfer of the client's care from one provider to another and improve continuity of care and cost containment. This article presents some of the challenges that the Visiting Nurse Association of Chicago (VNAC), a home care provider, has faced as a participant in managed care.     

Principles for Real-World Implementation of Bedside Predictive Analytics Monitoring

A new development in the practice of medicine is Artificial Intelligence-based predictive analytics that forewarn clinicians of future deterioration of their patients. This proactive opportunity, though, is different from the reactive stance that clinicians traditionally take. Implementing these tools requires new ideas about how to educate clinician users to facilitate trust and adoption and to promote sustained use. Our real-world hospital experience implementing a predictive analytics monitoring system that uses electronic health record and continuous monitoring data has taught us principles that we believe to be applicable to the implementation of other such analytics systems within the health care environment. These principles are mentioned below:• To promote trust, the science must be understandable.• To enhance uptake, the workflow should not be impacted greatly.• To maximize buy-in, engagement at all levels is important.• To ensure relevance, the education must be tailored to the clinical role and hospital culture.• To lead to clinical action, the information must integrate into clinical care.• To promote sustainability, there should be periodic support interactions after formal implementation.     

Measuring outcomes in primary care practice

Systematic attention to outcomes is becoming a requirement of primary care practice. Outcomes of interest include improvement in health (medical outcomes), patient satisfaction with the health care experience (service outcomes), and curtailing of expenditures (cost outcomes). Primary care providers who monitor outcomes in their practice have many advantages: They have the opportunity to evaluate themselves before others evaluate them; they may alter or improve their system of care; and they can provide data on their effectiveness. This article discusses how primary care providers can measure outcomes at the practice level and the inherent values in this practice.     

Mental health consumers' with medical co‐morbidity experience of the transition through tertiary medical services to primary care

Medical comorbidity in people with long‐term mental illness is common and often undetected; however, these consumers frequently experience problems accessing and receiving appropriate treatment in public health‐care services. The aim of the present study was to understand the lived experience of mental health consumers with medical comorbidity and their carers transitioning through tertiary medical to primary care services. An interpretative, phenomenological analysis approach was used, and semistructured, video‐recorded, qualitative interviews were used with 12 consumers and four primary caregivers. Four main themes and related subthemes were abstracted from the data, highlighting consumer's and carers’ experience of transition through tertiary medical to primary care services: (i) accessing tertiary services is difficult and time consuming; (ii) contrasting experiences of clinician engagement and support; (iii) lack of continuity between tertiary medical and primary care services; and (iv) Mental Health Hospital Admission Reduction Programme (MH HARP) clinicians facilitating transition. Our findings have implications for organisational change, expanding the role of MH HARP clinicians (whose primary role is to provide consumers with intensive support and care coordination to prevent avoidable tertiary medical hospital use), and the employment of consumer and carer consultants in tertiary medical settings, especially emergency departments.     

Factors influencing nurses' attitudes towards the use of computerized health information systems in Kuwaiti hospitals

Title. Factors influencing nurses’ attitudes towards the use of computerized health information systems in Kuwaiti hospitals Aim. This paper reports a survey of nurses’ attitudes towards computerized health information systems, the characteristics that influence these attitudes and the level of nurses’ skills in computer use. Background. The use of such systems in developed countries and in some developing countries has already become a reality. However, nurses as a group of care providers have been found to resist computerization, seeing computerized health information systems as dehumanizing, confusing and uncaring. Nurses with more computer experience tend to have more positive views; education and training positively influence attitudes; and younger and less experienced nurses may have more positive attitudes. Methods. A structured questionnaire was used to measure the attitudes of nurses working in Kuwait towards computerization. A random sample of 574 nurses working in Ministry of Health hospitals were sent a questionnaire, and 530 replies were received (response rate 92·3%). The data were collected from November 2002 to January 2003. Findings. Respondents generally had positive attitudes toward computerized health information systems. Analysis of variance revealed statistically significant differences in attitudes in relation to nationality, level of education, previous experience in computer use, and computer skills (P < 0·05). Multiple regression analysis showed that gender, nationality, education levels, and duration of computer use were statistically significant predictors of attitudes toward computerized health information systems (P < 0·05). Conclusion. With adequate computerized health information system training, the implementation of computerized health information systems could be effective for nurses in providing quality health care, as found in other studies.     

A physicians' agenda for partnering with employers and insurers: fresh ideas

We report the results of the second phase of a multiphase qualitative investigation of the ways physicians, employers, and insurers can work together more effectively to provide better ambulatory care to employees and their dependents. This article focuses on ways physicians can develop more useful relationships among these groups. We used a grounded theory approach to conduct 71 interviews from August 12, 2004, to December 27, 2005, with 25 practicing physicians in large and small groups, urban and rural areas, private and academic settings, and primary care and specialty practices; 33 hospital administrators, medical association executives, health insurance medical officers, and health policy analysts; and 13 senior executives of large and small companies. The study identifies 2 approaches to the structuring of ambulatory care that can lead to improved health care outcomes and value. In the first approach, direct contracting between physicians and employers transfers tasks previously performed by insurers to employers or other intermediaries who may be able to provide better service or lower cost. In the second approach, insurer-mediated relationships between physicians and employers are restructured, particularly in ways that improve information flow. Such relationships may strengthen physicians' ability to provide quality services while enabling patients to make more informed decisions about physician selection, treatments, and spending. We believe that broader use of these approaches may improve the quality and efficiency of ambulatory care for the large proportion of the population that has work-related health insurance. Although the findings are promising, our intent is not to claim broad external validity but rather to encourage greater experience with these approaches and more formal studies of their effectiveness.     

The use of expert systems for improving test use and enhancing the accuracy of diagnosis

The experience with BloodLink and LAS provides strong evidence that electronic knowledge support has a significant and lasting effect on laboratory test ordering by physicians. Compliance with CPG is also improved despite the ability of the guideline process to keep up to date. As discussed previously, the limitations to the application of protocols and CPG can be eliminated by electronic knowledge support. Indeed, this technology may be considered the future salvation of evidence-based medicine. It is also apparent that using the expert system to provide interpretations of the results ensures optimal use of the tests. The ability to reduce costs by 20% using stringent use control measures is meaningless if by misunderstanding, all of the potential information is not understood. In the future, as computer connectivity becomes pervasive within the practice of medicine, systems, such as BloodLink and LAS, will be used routinely for many aspects of care. Molecular genetic testing and proteomics will become a major component of routine medical practice. The complexity of what to order, the implications of performing the tests, on whom to do them, and what the vast array of data mean, will demand the use of CARTKS. It is becoming increasingly popular for patients to obtain their own results and to manage their own medical record. In some jurisdictions patients may order their own tests. We will undoubtedly see the development of knowledge support tools that are designed for patient use. The CARTKS provided by computer systems is the most powerful approach to use control and it has the additional benefit of doing so while enhancing medical care.     

Second victim phenomenon: Is ‘just culture’ a reality? An integrative review

BackgroundDespite rigorous and multiple attempts to establish a culture of patient safety and a goal to decrease incidence of patient deaths in the health care, estimations of preventable mortality due to medical errors varied widely from 44,000 to 250,000 in hospital settings. This magnitude of medical errors establishes patient safety as being at the forefront of public concerns, healthcare practice and research. In addition to the potential negative impact on patients and the healthcare system, medical errors evoke intense psychological responses in health care providers' responses that threaten their personal and professional selves, and their ability to deliver high quality patient care. Studies show half of all hospital providers will suffer from second victim phenomena at least once in their careers. Health care institutions have begun a paradigm shift from blame to fairness, referred to as ‘just culture’. ‘Just culture’ better ensures that a balanced, responsible approach for both providers who err and healthcare organizations in which they practice, and shifts the focus to designing improved systems in the workplace.ObjectivesThe aim of this review was to identify: how medical errors affect health care professionals, as second victims; and how health care organizations can make ‘just culture’ a reality.DesignAn integrative review was performed using a methodical three-step search on the concept of second victims' perceptions and responses, as well as ‘just culture’ of health care institutions.ResultsA total of 42 research studies were identified involving health care professionals: 10 qualitative studies; eight mixed-method studies; and 24 quantitative studies. Second victims' perceptions of the current ‘just culture’ included: 1) fear of repercussions of reporting medical errors as a barrier; 2) supportive safety leadership is central to reducing fear of error reporting; 3) improved education on adverse event reporting, developing positive feedback when adverse events are reported, and the development of non-punitive error guidelines for health care professionals are needed; and 4) the need for development of standard operating procedures for health care facility peer-support teams.ConclusionsSecond victims' perceptions of organizational and peer support are a part of ‘just culture’. Enhanced support for second victims may improve the quality of health care, strengthen the emotional support of the health care professionals, and build relationships between health care institutions and staff. Although some programs are in place in health care institutions to support ‘just culture’ and second victims, more comprehensive programs are needed.     

Electronic medical record in the intensive care unit.

The EMR in the ICU has the utility of providing the necessary information to make sound clinical decisions for critically ill patients. For it to be optimized, the EMR must be more than just what is being replicated in the written record or merely a documentation tool; it must add value that supports and enhances clinical decision support. The EMR is too expensive a tool just to be a computer designed to ease documentation and retrieve data faster. Gardner and Huff have suggested that the EMR must answer three questions: Why, What, and So What. The "Why" is relatively easy to answer, but the "What" data to use so that the information is meaningful to a provider and the "So What" are more difficult to answer. Provided one can qualitatively assess "What" information is important for a health care provider, then "So What" becomes an important objective in the empirical quantification of the benefits that the EMR provides. It is clear that to analyze some of the outcomes that health care delivery provides, one needs some mechanism to automate the information at the point of care, particularly now that the regulatory agencies are requiring it. Given the fact that there is no single integrated computerized patient record, this becomes the daunting task for the next century. Making it easier for health care providers to interact with the system and providing them with instantaneous feedback that changes their medical decision so they can deliver better care (clinical pathways, clinical practice guidelines) will be the task required of the next generation of CISs.     

Clinical decision support systems for patient safety: a focus group needs assessment with Korean ICU nurses

An ICU is known as a data-rich environment, and information technology can improve the quality of care by utilizing stored clinical data and providing decision support effectively and in a timely manner to clinicians. The necessity of clinical decision support systems is emphasized now more than ever because patient safety and nursing-sensitive outcomes in the clinical setting have become a critical issue. The purpose of this study was to explore nursing-sensitive outcomes issues related to patient safety in critical care and to understand the types and contents of clinical decision support systems that nurses desire in a clinical practice setting. Focus group interviews were conducted with 37 nurses who worked in one university hospital system in Korea. Our findings are summarized into threats to patient safety, nursing-sensitive outcomes, and the types and contents of clinical decision support systems, which are categorized into the following groups: (1) reminders, notification, alert, and warning systems; (2) point-of-care guidelines; and (3) references for information/guidelines. Nurses consistently stated that clinical decision support systems can help improve nursing outcomes by applying standardized nursing care. Our study is expected to provide a practical suggestion for developing and designing a new clinical decision support system or for refining an existing one.     

基于主成分分析法的天津市某三级甲等医院CCU患者满意度分析

目的：采用主成分分析法分析影响住院患者满意度的主要因素指标权重,为进一步提高医疗护理服务质量,提升患者就医感受提供理论依据。方法：采用自行设计的住院患者满意度调查问卷,对天津市某三级甲等医院CCU的100名住院患者进行调查。指标权重采用主成分分析,各指标评价采用象限图法。结果：指标权重分析结果显示,对患者满意度影响较大的指标分别为医院提供的心理辅导、家属的关心、健康教育、医生沟通能力、病房探视制度、就医费用、病房软件环境（隔音、温湿度、气味等）、医院提供的饮食。象限图显示非常重要但是满意度相对不高的指标依次为医院提供的饮食、医院提供的心理辅导、就医费用、病房软件环境、病房探视制度、健康教育。结论：医院应优先改进医院提供的饮食、心理辅导、就医费用、病房软件环境、病房探视制度及健康教育这6个方面,以提高医疗护理服务质量,提升患者就医感受。     

Collaborating with medicine? Perceptions of Australian naturopaths on integrating within the conventional medical system

Complementary and alternative medicine (CAM) is an increasingly prevalent part of contemporary health care. Whilst there have been some attempts to understand the dynamics of CAM integration in the health care system from the perspective of conventional care providers and patients, little research has examined the view of CAM practitioners. This study aims to identify the experiences of integration within a conventional healthcare system as perceived by naturopaths. Qualitative semi-structured interviews were conducted using a purposeful sample of 20 practising naturopaths in South East Queensland, Australia to discuss their experiences and perceptions of integrating with conventional medical providers. Analysis of the interviews revealed five broad challenges for the integration of CAM according to naturopaths: competing paradigms between CAM and conventional medicine; co-option of CAM by conventional medical practitioners; the preservation of separate CAM and conventional medical worlds by patients and providers due to lack of formalised relations; negative feedback and biases created through selective or limited experience or information with CAM; and indifferent, reactive and one-sided interaction between CAM and conventional medical providers. Naturopaths support the integration of health services and attempt to provide safe and appropriate care to their patients through collaborative approaches to practice. The challenges identified by naturopaths associated with integration of CAM with conventional providers may impact the quality of care of patients who choose to integrate CAM and conventional approaches to health. Given the significant role of naturopaths in contemporary health-care systems, these challenges require further research and policy attention.     

Laboratory computers: tools for increased productivity

Revolutionary changes in the computer industry brought about in part by the introduction of personal computers are now reaching into clinical laboratories everywhere. Although the true justification for any computer tool may be an intangible one such as improvement in service, such tools can typically be cost justified by increases in productivity alone. A broad spectrum of applications software useful in the medical laboratory is now available in any scale required to meet the needs of any size of laboratory. Perhaps one of the most dramatic changes in this field in the last several years has been the introduction of small-scale integrated laboratory systems that are true small-scale laboratory information systems. As a result, smaller laboratories can now acquire laboratory information systems appropriately scaled to their workload for a fraction of the cost of the large systems. These small laboratory information systems are typically more easily cost justified than larger ones. Achieving productivity gains using computer tools in the laboratory is a management-intensive process requiring careful analysis and thorough planning. Laboratory managers who eschew computer tools are now an anachronism; extinction of this species is imminent.     

Where's the Beef? The Promise and the Reality of Clinical Documentation

Physician-generated emergency department clinical documentation (information obtained from clinician observations and summarized decision processes inclusive of all manner of electronic systems capturing, storing, and presenting clinical documentation) serves four purposes: recording of medical care and communication among providers; payment for hospital and physician; legal defense from medical negligence allegations; and symptom/disease surveillance, public health, and research functions. In the consensus development process described by Handler, these objectives were balanced with the consideration of efficiency, often evaluated as physician time and clinical documentation system costs, in recording the information necessary for their accomplishment. The consensus panel session participants and authors recommend that 1) clinical documentation be electronically retrievable; 2) selection and implementation be evidence-based and grounded on valid metrics (research is needed to identify these metrics); 3) the user interface be crafted to promote clinical excellence through high-quality information collection and efficient charting techniques; 4) the priorities for integration of clinical information be standardized and implemented within enterprises and across health and information systems; 5) systems use accepted standards for bidirectional, real-time clinical data exchange, without limiting the location or number of simultaneous users; 6) systems fully utilize existing electronic sources of specific patient information and general medical knowledge; 7) systems automatically and reliably capture appropriate data that support electronic billing for emergency department services; and 8) systems promote bedside documentation and mobile access.