The role of ethics in information technology decisions: a case-based approach to biomedical informatics education

The purpose of this paper is to propose a case-based approach to instruction regarding ethical issues raised by the use of information technology (IT) in healthcare. These issues are rarely addressed in graduate degree and continuing professional education programs in health informatics. There are important reasons why ethical issues need to be addressed in informatics training. Ethical issues raised by the introduction of information technology affect practice and are ubiquitous. These issues are frequently among the most challenging to young practitioners who are ill prepared to deal with them in practice. First, the paper provides an overview of methods of moral reasoning that can be used to identify and analyze ethical problems in health informatics. Second, we provide a framework for defining cases that involve ethical issues and outline major issues raised by the use of information technology. Specific cases are used as examples of new dilemmas that are posed by the introduction of information technology in healthcare. These cases are used to illustrate how ethics can be integrated with the other elements of informatics training. The cases discussed here reflect day-to-day situations that arise in health settings that require decisions. Third, an approach that can be used to teach ethics in health informatics programs is outlined and illustrated.     

Using conceptual work products of health care to design health IT

This paper introduces a new, model-based design method for interactive health information technology (IT) systems. This method extends workflow models with models of conceptual work products. When the health care work being modeled is substantially cognitive, tacit, and complex in nature, graphical workflow models can become too complex to be useful to designers. Conceptual models complement and simplify workflows by providing an explicit specification for the information product they must produce. We illustrate how conceptual work products can be modeled using standard software modeling language, which allows them to provide fundamental requirements for what the workflow must accomplish and the information that a new system should provide. Developers can use these specifications to envision how health IT could enable an effective cognitive strategy as a workflow with precise information requirements. We illustrate the new method with a study conducted in an outpatient multiple sclerosis (MS) clinic. This study shows specifically how the different phases of the method can be carried out, how the method allows for iteration across phases, and how the method generated a health IT design for case management of MS that is efficient and easy to use.     

Transitioning from a computerized provider order entry and paper documentation system to an electronic health record: Expectations and experiences of hospital staff

ObjectivesTo examine healthcare worker's perceptions, expectations, and experiences regarding how work processes, patient-related safety, and care were affected when a quaternary care center transitioned from one computerized provider order entry (CPOE) system to a full electronic health record (EHR).MethodsThe I-SEE survey was administered prior to and 1-year after transition in systems. The construct validity and reliability of the survey was assessed within the current population and also compared to previously published results. Pre- and 1-year post-implementation scale means were compared within and across time periods.ResultsThe majority of respondents were nurses and personnel working in the acute care setting. Because a confirmatory factor analysis indicated a lack of fit of our data to the I-SEE survey's 5-factor structure, we conducted an exploratory factor analysis that resulted in a 7-factor structure which showed better reliability and validity. Mean scores for each factor indicated that attitudes and expectations were mostly positive and score trends over time were positive or neutral. Nurses generally had less positive attitudes about the transition than non-nursing respondents, although the difference diminished after implementation.ConclusionsFindings demonstrate that the majority of responding staff were generally positive about transitioning from CPOE system to a full electronic health record (EHR) and understood the goals of doing so, with overall improved ratings over time. In addition, the I-SEE survey, when modified based on our population, was useful for assessing patient care and safety related expectations and experiences during the transition from one CPOE system to an EHR.     

Health informatics and the delivery of care to older people

In the light of an aging society, effective delivery of healthcare will be more dependent on different technological solutions supporting the decentralisation of healthcare, higher patient involvement and increased societal demands. The aim of this article is therefore, to describe the role of health informatics in the care of elderly people and to give an overview of the state of the art in this field. Based on a review of the existing scientific literature, 29 review articles from the last 15 years and 119 original articles from the last 5 years were selected and further analysed. Results show that review articles cover the fields of information technology in the home environment, integrated health information systems, public health systems, consumer health informatics and non-technology oriented topics such as nutrition, physical behaviour, medication and the aging process in general. Articles presenting original data can be divided into 5 major clusters: information systems and decision support, consumer health informatics, emerging technologies, home telehealth, and informatics methods. Results show that health informatics in elderly care is an expanding field of interest but we still do lack knowledge about the elderly person's needs of technology and how it should best be designed. Surprisingly, few studies cover gender differences related to technology use. Further cross-disciplinary research is needed that relates informatics and technology to different stages of the aging process and that evaluates the effects of technical solutions.     

Visions and strategies to improve evaluation of health information systems. Reflections and lessons based on the HIS-EVAL workshop in Innsbruck

BACKGROUND: Health care is entering the Information Society. It is evident that the use of modern information and communication technology offers tremendous opportunities to improve health care. However, there are also hazards associated with information technology in health care. Evaluation is a means to assess the quality, value, effects and impacts of information technology and applications in the health care environment, to improve health information applications and to enable the emergence of an evidence-based health informatics profession and practice. OBJECTIVE: In order to identify and address the frequent problems of getting evaluation understood and recognised, to promote transdisciplinary exchange within evaluation research, and to promote European cooperation, the Exploratory Workshop on "New Approaches to the Systematic Evaluation of Health Information Systems" (HIS-EVAL) was organized by the University for Health Sciences, Medical Informatics and Technology (UMIT), Innsbruck, Austria, in April 2003 with sponsorship from the European Science Foundation (ESF). Methods: The overall program was structured in three main parts: (a). discussion of problems and barriers to evaluation; (b). defining our visions and strategies with regard to evaluation of health information systems; and (c). organizing short-term and long-term activities to reach those visions and strategies. RESULTS: The workshop participants agreed on the Declaration of Innsbruck (see ), comprising four observations and 12 recommendations with regard to evaluation of health information systems. Future activities comprise European networking as well as the development of guidelines and standards for evaluation studies. CONCLUSION: The HIS-EVAL workshop was intended to be the starting point for setting up a network of European scientists working on evaluation of health information systems, to obtain synergy effects by combining the research traditions from different evaluation fields, leading to a new dimension and collaboration on further research on information systems' evaluation.     

Development and classification of a robust inventory of near real-time outcome measurements for assessing information technology interventions in health care

ObjectiveTo develop and classify an inventory of near real-time outcome measures for assessing information technology (IT) interventions in health care and assess their relevance as perceived by experts in the field.Materials and methodsTo verify the robustness and coverage of a previously published inventory of measures and taxonomy, we conducted semi-structured interviews with clinical and administrative leaders from a large care delivery system to collect suggestions of outcome measures that can be calculated with data available in electronic format for near real-time monitoring of EHR implementations. We combined these measures with the most commonly reported in the literature. We then conducted two online surveys with subject-matter experts to collect their perceptions of the relevance of the measures, and identify other potentially relevant measures.ResultsWith input from experienced health care leaders and informaticists, we developed an inventory of 102 outcome measures. These measures were classified into a taxonomy of commonly used measures around the categories of quality, productivity, and safety. Safety measures were rated as most relevant by subject-matter experts, especially those measuring medication processes. Clinician satisfaction and measures assessing mean time to complete tasks and time spent on electronic documentation were also rated as highly relevant.DiscussionBy expanding the coverage of our previously published inventory and taxonomy, we expect to help providers, health IT vendors and researchers to more effectively and consistently monitor the impact of EHR implementations in near real-time, and report more standardized outcomes in future studies. We identified several measures not commonly assessed by previous studies of IT implementations, especially those of safety and productivity, which deserve more attention from the broader informatics community.ConclusionOur inventory of measures and taxonomy will help researchers identify gaps in their measurement approaches and report more standardized measurements of IT interventions that could be shared among researchers, hopefully facilitating comparison across future studies and increasing our understanding of the impact of IT interventions in health care.     

The geographic distribution of cardiovascular health in the stroke prevention in healthcare delivery environments (SPHERE) study

BackgroundCommunity-level factors have been clearly linked to health outcomes, but are challenging to incorporate into medical practice. Increasing use of electronic health records (EHRs) makes patient-level data available for researchers in a systematic and accessible way, but these data remain siloed from community-level data relevant to health.PurposeThis study sought to link community and EHR data from an older female patient cohort participating in an ongoing intervention at the Ohio State University Wexner Medical Center to associate community-level data with patient-level cardiovascular health (CVH) as well as to assess the utility of this EHR integration methodology.Materials and methodsCVH was characterized among patients using available EHR data collected May through July of 2013. EHR data for 153 patients were linked to United States census-tract level data to explore feasibility and insights gained from combining these disparate data sources. Analyses were conducted in 2014.ResultsUsing the linked data, weekly per capita expenditure on fruits and vegetables was found to be significantly associated with CVH at the p < 0.05 level and three other community-level attributes (median income, average household size, and unemployment rate) were associated with CVH at the p < 0.10 level.ConclusionsThis work paves the way for future integration of community and EHR-based data into patient care as a novel methodology to gain insight into multi-level factors that affect CVH and other health outcomes. Further, our findings demonstrate the specific architectural and functional challenges associated with integrating decision support technologies and geographic information to support tailored and patient-centered decision making therein.     

Evaluation of a proximity card authentication system for health care settings

BackgroundMultiple users access computer workstations in busy clinical settings, requiring many logins throughout the day as users switch from one computer to another. This can lead to workflow inefficiencies as well as security concerns resulting from users sharing login sessions to save time. Proximity cards and readers have the potential to improve efficiency and security by allowing users to access clinical workstations simply by bringing the card near the reader, without the need for manual entry of a username and password.ObjectivesTo assess the perceived impact of proximity cards and readers for rapid user authentication to clinical workstations in the setting of an existing electronic health record with single sign-on software already installed.MethodsQuestionnaires were administered to clinical faculty and staff five months before and three months after the installation of proximity card readers in an inpatient birthing center and an outpatient obstetrics clinic. Open-ended feedback was also collected and qualitatively analyzed.ResultsThere were 71 and 33 responses to the pre- and post-implementation surveys, respectively. There was a significant increase in the perceived speed of login with the proximity cards, and a significant decrease in the self-reported occurrence of shared login sessions between users. Feedback regarding the system was mostly positive, although several caveats were noted, including minimal benefit when used with an obstetric application that did not support single sign-on.ConclusionsProximity cards and readers, along with single sign-on software, have the potential to enhance workflow efficiency by allowing for faster login times and diminish security concerns by reducing shared logins on clinical workstations. The positive feedback was used by our health system leadership to support the expanded implementation of the proximity card readers throughout the clinical setting.     

Clinical information technology in hospitals: a comparison between the state of Iowa and two provinces in Canada

Despite the growing interest in adopting information technology (IT) in healthcare, the degree of technology sophistication varies among healthcare organizations. Changes in the health care sector and continuous pressure to improve the quality of care have driven the evolution of IT in hospitals. This paper provides an overview of clinical IT sophistication in a sample of U.S. hospitals, and compares clinical IT capacities in this sample with a sample of Canadian hospitals. The instrument used for the comparison measures three clinical dimensions of IT sophistication: functional sophistication, technological sophistication and integration level. Clinical areas that were considered include patient management, patient care activities and clinical support activities. The comparison between hospitals in Iowa and Canada shows differences in clinical IT sophistication between the two settings. Hospitals in Iowa appear to have more technologies but fewer computerized processes and integration of patient management activities. Technological sophistication however, was low in both samples. Our findings confirm the construct validity of the measurement instrument and show initial evidence of its generalizability. More initiatives using the instrument would lead to enhancement in IT assessment tools that can be used for evaluation of IT in relation to patient management and quality outcomes.     

Development of a cognitive framework of patient record summary review in the formative phase of user-centered design

Excellent usability characteristics allow electronic health record (EHR) systems to more effectively support clinicians providing care and contribute to better quality and safety. The Office of the National Coordinator for Health IT (ONC) therefore requires all vendors to follow a User-Centered Design (UCD) process to increase the usability of their products in order to meet certification criteria for the Safety-Enhanced Design part of the Meaningful Use (stage 2) EHR incentive program. This report describes the initial stage of a UCD process in which foundational design concepts were formulated. We designed a functional prototype of an EHR module intended to help clinicians to efficiently complete a summary review of an electronic patient record before an ambulatory visit. Cognitively-based studies were performed and the results used to develop a cognitive framework that subsequently guided design of a prototype. Results showed that clinicians categorized and reasoned with patient data in distinct patterns; they preferred to review relevant history in the assessment and plan section of the most recent note, to search for changes in health and for new episodes of care since the last visit and to look up current-day data such as vital signs. These basic concepts were represented in the design, for instance, by screen division into vertical thirds that had historical content to the left and most recent data to the right. Other characteristics such as visual association of contextual information or direct, one-click access to the assessment and plan section of visit notes were directly informed by our findings and refined in a series of UCD-specific iterative testing. Understanding of tasks and cognitive demands early in the UCD process was critically important for developing a tool optimized for reasoning and workflow preferences of clinicians.     

Comparison of Electronic Health Record System Functionalities to support the patient recruitment process in clinical trials

ObjectivesReusing data from electronic health records for clinical and translational research and especially for patient recruitment has been tackled in a broader manner since about a decade. Most projects found in the literature however focus on standalone systems and proprietary implementations at one particular institution often for only one singular trial and no generic evaluation of EHR systems for their applicability to support the patient recruitment process does yet exist. Thus we sought to assess whether the current generation of EHR systems in Germany provides modules/tools, which can readily be applied for IT-supported patient recruitment scenarios.MethodsWe first analysed the EHR portfolio implemented at German University Hospitals and then selected 5 sites with five different EHR implementations covering all major commercial systems applied in German University Hospitals. Further, major functionalities required for patient recruitment support have been defined and the five sample EHRs and their standard tools have been compared to the major functionalities.ResultsIn our analysis of the site's hospital information system environments (with four commercial EHR systems and one self-developed system) we found that – even though no dedicated module for patient recruitment has been provided – most EHR products comprise generic tools such as workflow engines, querying capabilities, report generators and direct SQL-based database access which can be applied as query modules, screening lists and notification components for patient recruitment support. A major limitation of all current EHR products however is that they provide no dedicated data structures and functionalities for implementing and maintaining a local trial registry.ConclusionsAt the five sites with standard EHR tools the typical functionalities of the patient recruitment process could be mostly implemented. However, no EHR component is yet directly dedicated to support research requirements such as patient recruitment. We recommend for future developments that EHR customers and vendors focus much more on the provision of dedicated patient recruitment modules.     

Use of health information technology (HIT) to improve statin adherence and low-density lipoprotein cholesterol goal attainment in high-risk patients: Proceedings from a workshop

The workshop discussions focused on how low-density lipoprotein cholesterol (LDL-C) goal attainment can be enhanced with the use of health information technology (HIT) in different clinical settings. A gap is acknowledged in LDL-C goal attainment, but because of the passage of the American Recovery & Reinvestment Act and the Health Information Technology for Economic and Clinical Health Acts there is now reason for optimism that this gap can be narrowed. For HIT to be effectively used to achieve treatment goals, it must be implemented in a setting in which the health care team is fully committed to achieving these goals. Implementation of HIT alone has not resulted in reducing the gap. It is critical to build an effective management strategy into the HIT platform without increasing the overall work/time burden on staff. By enhancing communication between the health care team and the patient, more timely adjustments to treatment plans can be made with greater opportunity for LDL-C goal attainment and improved efficiency in the long run. Patients would be encouraged to take a more active role. Support tools are available. The National Lipid Association has developed a toolkit designed to improve patient compliance and could be modified for use in an HIT system. The importance of a collaborative approach between nongovernmental organizations such as the National Lipid Association, National Quality Forum, HIT partners, and other members of the health care industry offers the best opportunity for long-term success and the real possibility that such efforts could be applied to other chronic conditions, for example, diabetes and hypertension.     

Developing a standard for de-identifying electronic patient records written in Swedish: Precision, recall and F-measure in a manual and computerized annotation trial

Background

Electronic patient records (EPRs) contain a large amount of information written in free text. This information is considered very valuable for research but is also very sensitive since the free text parts may contain information that could reveal the identity of a patient. Therefore, methods for de-identifying EPRs are needed. The work presented here aims to perform a manual and automatic Protected Health Information (PHI)-annotation trial for EPRs written in Swedish.

Methods

This study consists of two main parts: the initial creation of a manually PHI-annotated gold standard, and the porting and evaluation of an existing de-identification software written for American English to Swedish in a preliminary automatic de-identification trial. Results are measured with precision, recall and F-measure.

Results

This study reports fairly high Inter-Annotator Agreement (IAA) results on the manually created gold standard, especially for specific tags such as names. The average IAA over all tags was 0.65 F-measure (0.84 F-measure highest pairwise agreement). For name tags the average IAA was 0.80 F-measure (0.91 F-measure highest pairwise agreement). Porting a de-identification software written for American English to Swedish directly was unfortunately non-trivial, yielding poor results.

Conclusion

Developing gold standard sets as well as automatic systems for de-identification tasks in Swedish is feasible. However, discussions and definitions on identifiable information is needed, as well as further developments both on the tag sets and the annotation guidelines, in order to get a reliable gold standard. A completely new de-identification software needs to be developed.     

The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: A review of the literature

Purpose

The introduction of a Critical Care Information System (CCIS) into an intensive care unit (ICU) is purported to reduce the time health care providers (HCP) spend on documentation and increase the time available for direct patient care. However, there is a paucity of rigorous empirical research that has investigated these assertions. Moreover, those studies that have sought to elucidate the relationship between the introduction of a CCIS and the time spent by staff on in/direct patient care activities have published contradictory findings. The objective of this literature review is to establish the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU.

Methods

Five electronic databases were searched including PubMed Central, EMBASE, CINAHL, IEEE Xplore, and the Cochrane Database of Systematic Reviews. Reference lists of all published papers were hand searched, and citations reviewed to identify extra papers. We included studies that were empirical articles, published in English, and provided original data on the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU.

Results

In total, 12 articles met the inclusion criteria. Workflow analysis (66%) and time-and-motion analysis (25%) were the most common forms of data collection. Three (25%) studies found an increase in time spent charting, five (42%) found no difference, and four (33%) studies reported a decrease. Results on the impact of a CCIS on direct patient care were similarly inconclusive.

Conclusions

Due to the discrepant findings and several key methodological issues, the impact of a CCIS on time spent charting and in direct patient care remains unclear. This review highlights the need for an increase in rigorous empirical research in this area and provides recommendations for the design and implementation of future studies.     

User-designed information tools to support communication and care coordination in a trauma hospital

BackgroundIn response to inherent inadequacies in health information technologies, clinicians create their own tools for managing their information needs. Little is known about these clinician-designed information tools. With greater appreciation for why clinicians resort to these tools, health information technology designers can develop systems that better meet clinicians’ needs and that can also support clinicians in design and use of their own information tools.ObjectiveTo describe the design characteristics and use of a clinician-designed information tool in supporting information transfer and care coordinationDesignObservations, semi-structured interviews, and photographing were used to collect data. Participants were six nurse coordinators in a high-volume trauma hospital. Content analysis was carried out and interactions with information tools were analyzed.ResultsNurse coordinators used a paper-based information tool (a nurse coordinator’s clipboard) that consisted of the compilation of essential data from disparate information sources. The tool was assembled twice daily through (1) selecting and formatting key data from multiple information systems (such as the unit census and the EHR), (2) data reduction (e.g., by cutting and whitening out non-essential items from the print-outs of computerized information systems), (3) bundling (e.g., organizing pieces of information and taping them to each other), and (4) annotating (e.g., through the use of colored highlighters and shorthand symbols). It took nurse coordinators an average of 41 min to assemble the clipboard. The design goals articulated by nurse coordinators to fit the tool into their tasks included (1) making information compatible with the mobile nature of their work, (2) enabling rapid information access and note-taking under time pressure, and (3) supporting rapid information processing and attention management through the effective use of layout design, shorthand symbols, and color-coding.ConclusionsClinicians design their own information tools based on the existing health information technologies to meet their information needs. The characteristics of these clinician-designed tools provide insights into the “realities” of how clinicians work with health information technologies. The findings suggest an often overlooked role for health information technologies: facilitating user creation of information tools that will best meet their needs.     

Development of an instrument for measuring clinicians' power perceptions in the workplace

We report on the development of an instrument to measure clinicians’ perceptions of their personal power in the workplace in relation to resistance to computerized physician order entry (CPOE). The instrument is based on French and Raven’s six bases of social power and uses a semantic differential methodology. A measurement study was conducted to determine the reliability and validity of the survey. The survey was administered online and distributed via a URL by email to 19 physicians, nurses, and health unit coordinators from a university hospital. Acceptable reliability was achieved by removing or moving some semantic differential word pairs used to represent the six power bases (alpha range from 0.76 to 0.89). The Semantic Differential Power Perception (SDPP) survey validity was tested against an already validated instrument and found to be acceptable (correlation range from 0.51 to 0.81). The SDPP survey instrument was determined to be both reliable and valid.     

Characteristics of health IT outage and suggested risk management strategies: An analysis of historical incident reports in China

BackgroundThe healthcare industry has become increasingly dependent on using information technology (IT) to manage its daily operations. Unexpected downtime of health IT systems could therefore wreak havoc and result in catastrophic consequences. Little is known, however, regarding the nature of failures of health IT.ObjectiveTo analyze historical health IT outage incidents as a means to better understand health IT vulnerabilities and inform more effective prevention and emergency response strategies.MethodsWe studied news articles and incident reports publicly available on the internet describing health IT outage events that occurred in China. The data were qualitatively analyzed using a deductive grounded theory approach based on a synthesized IT risk model developed in the domain of information systems.ResultsA total of 116 distinct health IT incidents were identified. A majority of them (69.8%) occurred in the morning; over 50% caused disruptions to the patient registration and payment collection functions of the affected healthcare facilities. The outpatient practices in tertiary hospitals seem to be particularly vulnerable to IT failures. Software defects and overcapacity issues, followed by malfunctioning hardware, were among the principal causes.ConclusionsUnexpected health IT downtime occurs more and more often with the widespread adoption of electronic systems in healthcare. Risk identification and risk assessments are essential steps to developing preventive measures. Equally important is institutionalization of contingency plans as our data show that not all failures of health IT can be predicted and thus effectively prevented. The results of this study also suggest significant future work is needed to systematize the reporting of health IT outage incidents in order to promote transparency and accountability.     

Use of the internet to communicate with health care providers in the United States: estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS)

Background

Despite substantial evidence that the public wants access to Internet-based communication with health care providers, online patient-provider communication remains relatively uncommon, and few studies have examined sociodemographic and health-related factors associated with the use of online communication with health care providers at a population level.

Objective

The aim of the study was to use nationally representative data to report on the prevalence of and changes in use of online patient-provider communication in 2003 and 2005 and to describe sociodemographic and health-related factors associated with its use.

Methods

Data for this study are from two iterations of the Health Information National Trends Survey (HINTS 2003, HINTS 2005). In both years, respondents were asked whether they had ever used email or the Internet to communicate with a doctor or a doctor’s office. Adult Internet users in 2003 (n = 3982) and 2005 (n = 3244) were included in the present study. Multivariate logistic regression analysis was conducted to identify predictors for electronic communication with health care providers.

Results

In 2003, 7% of Internet users had communicated online with an health care provider; this prevalence significantly increased to 10% in 2005. In multivariate analyses, Internet users with more years of education, who lived in a metro area, who reported poorer health status or who had a personal history of cancer were more likely to have used online patient-provider communication.

Conclusions

Despite wide diffusion of the Internet, online patient-provider communication remains uncommon but is slowly increasing. Policy-level changes are needed to maximize the availability and effectiveness of online patient-provider communication for health care consumers and health care providers. Internet access remains a significant barrier to online patient-provider communication.