Development and Psychometric Evaluation of the Impact of Health Information Technology (I-HIT) Scale

Objective

The use of health information technology (HIT) for the support of communication processes and data and information access in acute care settings is a relatively new phenomenon. A means of evaluating the impact of HIT in hospital settings is needed. The purpose of this research was to design and psychometrically evaluate the Impact of Health Information Technology scale (I-HIT). I-HIT was designed to measure the perception of nurses regarding the ways in which HIT influences interdisciplinary communication and workflow patterns and nurses’ satisfaction with HIT applications and tools.

Design

Content for a 43-item tool was derived from the literature, and supported theoretically by the Coiera model and by nurse informaticists. Internal consistency reliability analysis using Cronbach’s alpha was conducted on the 43-item scale to initiate the item reduction process. Items with an item total correlation of less than 0.35 were removed, leaving a total of 29 items.

Measurements

Item analysis, exploratory principal component analysis and internal consistency reliability using Cronbach’s alpha were used to confirm the 29-item scale.

Results

Principal components analysis with Varimax rotation produced a four-factor solution that explained 58.5% of total variance (general advantages, information tools to support information needs, information tools to support communication needs, and workflow implications). Internal consistency of the total scale was 0.95 and ranged from 0.80-0.89 for four subscales.

Conclusion

I-HIT demonstrated psychometric adequacy and is recommended to measure the impact of HIT on nursing practice in acute care settings.     

Targeted screening for pediatric conditions with the CHICA system

Objective

The Child Health Improvement through Computer Automation (CHICA) system is a decision-support and electronic-medical-record system for pediatric health maintenance and disease management. The purpose of this study was to explore CHICA''s ability to screen patients for disorders that have validated screening criteria—specifically tuberculosis (TB) and iron-deficiency anemia.

Design

Children between 0 and 11 years were randomized by the CHICA system. In the intervention group, parents were asked about TB and iron-deficiency risk, and physicians received a tailored prompt. In the control group, no screens were performed, and the physician received a generic prompt about these disorders.

Results

1123 participants were randomized to the control group and 1116 participants to the intervention group. Significantly more people reported positive risk factors for iron-deficiency anemia in the intervention group (17.5% vs 3.1%, OR 6.6, 95% CI 4.5 to 9.5). In general, far fewer parents reported risk factors for TB than for iron-deficiency anemia. Again, there were significantly higher detection rates of positive risk factors in the intervention group (1.8% vs 0.8%, OR 2.3, 95% CI 1.0 to 5.0).

Limitations

It is possible that there may be more positive screens without improving outcomes. However, the guidelines are based on studies that have evaluated the questions the authors used as sensitive and specific, and there is no reason to believe that parents misunderstood them.

Conclusions

Many screening tests are risk-based, not universal, leaving physicians to determine who should have a further workup. This can be a time-consuming process. The authors demonstrated that the CHICA system performs well in assessing risk automatically for TB and iron-deficiency anemia.     

Using statistical text classification to identify health information technology incidents

Objective

To examine the feasibility of using statistical text classification to automatically identify health information technology (HIT) incidents in the USA Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.

Design

We used a subset of 570 272 incidents including 1534 HIT incidents reported to MAUDE between 1 January 2008 and 1 July 2010. Text classifiers using regularized logistic regression were evaluated with both ‘balanced’ (50% HIT) and ‘stratified’ (0.297% HIT) datasets for training, validation, and testing. Dataset preparation, feature extraction, feature selection, cross-validation, classification, performance evaluation, and error analysis were performed iteratively to further improve the classifiers. Feature-selection techniques such as removing short words and stop words, stemming, lemmatization, and principal component analysis were examined.

Measurements

κ statistic, F1 score, precision and recall.

Results

Classification performance was similar on both the stratified (0.954 F1 score) and balanced (0.995 F1 score) datasets. Stemming was the most effective technique, reducing the feature set size to 79% while maintaining comparable performance. Training with balanced datasets improved recall (0.989) but reduced precision (0.165).

Conclusions

Statistical text classification appears to be a feasible method for identifying HIT reports within large databases of incidents. Automated identification should enable more HIT problems to be detected, analyzed, and addressed in a timely manner. Semi-supervised learning may be necessary when applying machine learning to big data analysis of patient safety incidents and requires further investigation.     

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

Objective

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

Materials and methods

The study uses ethnographic methods to explore the mediators'' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

Results

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

Discussion

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users'' practices and norms, credibility with users, and knowledge of the technology and users'' technical abilities. We describe three additional factors observed in this case: ‘influence on system developers,’ ‘influence on institutional authorities,’ and ‘understanding the network of organizational relationships that shape the users'' work.’

Conclusion

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.     

The impact of the heparin-induced thrombocytopenia (HIT) computerized alert on provider behaviors and patient outcomes

Objective

The aim of this study was to measure the effect of an electronic heparin-induced thrombocytopenia (HIT) alert on provider ordering behaviors and on patient outcomes.

Materials and Methods

A pop-up alert was created for providers when an individual''s platelet values had decreased by 50% or to <100 000/mm³ in the setting of recent heparin exposure. The authors retrospectively compared inpatients admitted between January 24, 2008 and August 24, 2008 to a control group admitted 1 year prior to the HIT alert. The primary outcome was a change in HIT antibody testing. Secondary outcomes included an assessment of incidence of HIT antibody positivity, percentage of patients started on a direct thrombin inhibitor (DTI), length of stay and overall mortality.

Results

There were 1006 and 1081 patients in the control and intervention groups, respectively. There was a 33% relative increase in HIT antibody test orders (p=0.01), and 33% more of these tests were ordered the first day after the criteria were met when a pop-up alert was given (p=0.03). Heparin was discontinued in 25% more patients in the alerted group (p=0.01), and more direct thrombin inhibitors were ordered for them (p=0.03). The number who tested HIT antibody-positive did not differ, however, between the two groups (p=0.99). The length of stay and mortality were similar in both groups.

Conclusions

The HIT alert significantly impacted provider behaviors. However, the alert did not result in more cases of HIT being detected or an improvement in overall mortality. Our findings do not support implementation of a computerized HIT alert.     

Psychosocial Variables of Voluntary Blood Donors at Blood Bank of a Medical College

Background

This study was undertaken to study the motivational factors leading to voluntary blood donation and understanding the psychosocial variables of blood donors.

Methods

300 blood donors were selected by systematic random sampling method.

Result

It was observed that most of the voluntary donors were males (89.3%) and belonged to age group 16-25 years (48%). Most of the donors (93.46%) had studied upto high school and above and 84.33% of the donors belonged to the middle class. 27% of the donors had donated blood previously. The common motivational factors to donate blood were for ‘a good cause'', ‘for the society’ and ‘to save a life''. 4.67% of them donated blood for self satisfaction.

Conclusion

Motivation, recruitment and retention of voluntary blood donors are important criteria to achieve safe blood donation.Key Words: Motivation, Psychosocial, Voluntary, Blood Donors     

Oral misoprostol is an effective and acceptable alternative to vaginal administration for cervical priming before first trimester pregnancy termination

Background

Cervical priming agents mainly prostaglandins in different doses and routes are used during first trimester vaccum aspiration to prevent cervical injury and shorten the abortion procedure. This study was carried out to assess women''s acceptability, the efficacy and side effects of oral versus vaginal administration of misoprostol in facilitating cervical dilatation prior to first trimester vaccum aspiration.

Methods

A randomised control study where 120 women were divided in oral (51) and vaginal (69) group. Each group received 400 mcg of misoprostol either orally or vaginally 04 h prior to first trimester pregnancy termination. Baseline cervical dilatation, women''s acceptability and side effects and complications were noted in both the groups.

Results

There was no difference between the oral and vaginal misoprostol groups with respect to mean cervical dilatation (5.53 mm vs 5.43 mm; p > 0.05). A total of 88% of women in the oral group expressed satisfaction with the route of misoprostol administration as compared to 74% in the vaginal route. The women in the vaginal group were experienced more preoperative vaginal bleeding (43% vs 25%).

Conclusion

Oral administration of misoprostol is an effective alternative to vaginal administration in preinduction cervical ripening prior to first trimester pregnancy termination.     

Genetic data and electronic health records: a discussion of ethical,logistical and technological considerations

Objective

The completion of sequencing the human genome in 2003 has spurred the production and collection of genetic data at ever increasing rates. Genetic data obtained for clinical purposes, as is true for all results of clinical tests, are expected to be included in patients’ medical records. With this explosion of information, questions of what, when, where and how to incorporate genetic data into electronic health records (EHRs) have reached a critical point. In order to answer these questions fully, this paper addresses the ethical, logistical and technological issues involved in incorporating these data into EHRs.

Materials and methods

This paper reviews journal articles, government documents and websites relevant to the ethics, genetics and informatics domains as they pertain to EHRs.

Results and discussion

The authors explore concerns and tasks facing health information technology (HIT) developers at the intersection of ethics, genetics, and technology as applied to EHR development.

Conclusions

By ensuring the efficient and effective incorporation of genetic data into EHRs, HIT developers will play a key role in facilitating the delivery of personalized medicine.     

Psychological Well-being of Medical Students

Background

Training in medicine is emotionally demanding. Psychological well being of medical students is a matter of concern. There is lack of Indian studies in this area.

Methods

A total of 105 medical student of one batch were assessed utilizing psychophysiological state inventory, Institute for personality and ability testing (IPAT) anxiety and depression scale, achievement motivation scale, scale for locus of control and 16 PF in three phases at one-year intervals.

Result

Majority of the students had average achievement, motivation and adaptability. Anxiety and depression scores fell within normal limits. In personality profile factor ‘B’, ‘M’ and ‘Q4₁’ had changed significantly. Achievement motivation showed significant decreases and CSS1 and PO1 scores showed significant increase during the years of medical education.

Conclusion

The results demonstrate that over satisfaction and relaxed attitude may have poor academic outcome.Key Words: Psychological well-being, Anxiety, Depression, Achievement motivation     

Care transitions as opportunities for clinicians to use data exchange services: how often do they occur?

Background

The electronic exchange of health information among healthcare providers has the potential to produce enormous clinical benefits and financial savings, although realizing that potential will be challenging. The American Recovery and Reinvestment Act of 2009 will reward providers for ‘meaningful use’ of electronic health records, including participation in clinical data exchange, but the best ways to do so remain uncertain.

Methods

We analyzed patient visits in one community in which a high proportion of providers were using an electronic health record and participating in data exchange. Using claims data from one large private payer for individuals under age 65 years, we computed the number of visits to a provider which involved transitions in care from other providers as a percentage of total visits. We calculated this ‘transition percentage’ for individual providers and medical groups.

Results

On average, excluding radiology and pathology, approximately 51% of visits involved care transitions between individual providers in the community and 36%–41% involved transitions between medical groups. There was substantial variation in transition percentage across medical specialties, within specialties and across medical groups. Specialists tended to have higher transition percentages and smaller ranges within specialty than primary care physicians, who ranged from 32% to 95% (including transitions involving radiology and pathology). The transition percentages of pediatric practices were similar to those of adult primary care, except that many transitions occurred among pediatric physicians within a single medical group.

Conclusions

Care transition patterns differed substantially by type of practice and should be considered in designing incentives to foster providers'' meaningful use of health data exchange services.     

Is Relevance Relevant? User Relevance Ratings May Not Predict the Impact of Internet Search on Decision Outcomes

Objective

A common measure of Internet search engine effectiveness is its ability to find documents that a user perceives as ‘relevant’. This study sought to test whether user provided relevance ratings for documents retrieved by an Internet search engine correlate with the decision outcome after use of a search engine.

Design

227 university students were asked to answer four randomly assigned consumer health questions, then to conduct an Internet search on one of two randomly assigned search engines of different performance, and to again answer the question.

Measurements

Participants were asked to provide a relevance score for each document retrieved as well as a pre and post search answer to each question.

Results

User relevance rankings had little or no predictive power. Relevance rankings were unable to predict whether the user of a search engine could correctly answer a question after search and could not differentiate between two search engines with statistically different performance in the hands of users. Only when users had strong prior knowledge of the questions, and the decision task was of low complexity, did relevance appear to have modest predictive power.

Conclusions

User provided relevance rankings taken in isolation seem to be of limited to no value when designing a search engine that will be used in a general-purpose setting. Relevance rankings may have a place in situations in which experts provide rankings, and decision tasks are of complexity commensurate with the abilities of the raters. A more natural metric of search engine performance may be a user''s ability to accurately complete a task, as this removes the inherent subjectivity of relevance rankings, and provides a direct and repeatable outcome measure which directly correlates with the performance of the search technology in the hands of users.     

Contextual Implementation Model: A Framework for Assisting Clinical Information System Implementations

Objective

This paper presents a multiple perspectives model of clinical information system implementation, the Contextual Implementation Model (CIM). Although other implementation models have been developed, few are grounded in data and others fail to take adequate account of the clinical environment and users’ requirements.

Design

The CIM arose from qualitative data collected from four clinical units in two large Australian teaching hospitals. The aim of the study was to explore physicians’ test management work practices associated with the compulsory use of a hospital-wide, mandatory computerized provider order entry (CPOE) system.¹ The dataset consisted of non-participatory observations of physicians using CPOE (n=55 sessions) and interviews with health professionals (n=28) about test management work practices. Data were analyzed by two researchers independently using an iterative grounded approach.

Results

A core underlying theme of ‘contextual differences’ emerged which explained physicians’ use of the CPOE system in the sites. The CIM focuses attention on diversity at three contextual levels: the organizational level; the clinical or departmental level, and the individual level. Within each of these levels there are dimensions for consideration (for example, organizational culture, leadership and diverse ways of working) which affect physicians’ attitudes to, and use of, CPOE.

Conclusion

The CIM provides a contextual differences perspective which can be used to facilitate the implementation of clinical information systems. Developing a clinical information system implementation model serves as a framework to guide future implementations to ensure their safe and efficient use and also improve the likelihood of uptake by physicians.     

Should female health providers be involved in medical male circumcision? Narratives of newly circumcised men in Malawi

Background

The Malawi government has endorsed voluntary medical male circumcision (VMMC) as a biomedical strategy for HIV prevention after a decade of debating its effectiveness in the local setting. The “policy” recommends that male circumcision (MC) should be clinically based, as opposed to the alternative of traditional male circumcision (TMC). Limited finances, acceptability concerns, and the health system''s limited capacity to meet demand are among the challenges threatening the mass rollout of VMMC. In terms of acceptability, the gender of clinicians conducting the operations may particularly influence health facility-based circumcision. This study explored the acceptability, by male clients, of female clinicians taking part in the circumcision procedure.

Methods

Six focus group discussions (FGDs) were conducted, with a total of 47 newly circumcised men from non-circumcising ethnic groups in Malawi participating in this study. The men had been circumcised at three health facilities in Lilongwe District in 2010. Data were audio recorded and transcribed verbatim. Data were analysed using narrative analysis.

Results

Participants in the FGDs indicated that they were not comfortable with women clinicians being part of the circumcising team. While few mentioned that they were not entirely opposed to female health providers'' participation, arguing that their involvement was similar to male clinicians'' involvement in child delivery, most of them opposed to female involvement, arguing that MC was not an illness that necessitates the involvement of clinicians regardless of their gender. Most of the participants said that it was not negotiable for females to be involved, as they could wait until an all-male clinician team could be available. Thematically, the arguments against female clinicians'' involvement include sexual undertones and the influences of traditional male circumcision practices, among others.

Conclusion

Men preferred that VMMC should be conducted by male health providers only. Traditionally, male circumcision has been a male-only affair shrouded in secrecy and rituals. Although being medical, this study strongly suggested that it may be difficult for VMMC to immediately move to a public space where female health providers can participate, even for men coming from traditionally non-circumcising backgrounds.     

Migrating existing clinical content from ICD-9 to SNOMED

Objective

To identify challenges in mapping internal International Classification of Disease, 9th edition, Clinical Modification (ICD-9-CM) encoded legacy data to Systematic Nomenclature of Medicine (SNOMED), using SNOMED-prescribed compositional approaches where appropriate, and to explore the mapping coverage provided by the US National Library of Medicine (NLM)''s SNOMED clinical core subset.

Design

This study selected ICD-CM codes that occurred at least 100 times in the organization''s problem list or diagnosis data in 2008. After eliminating codes whose exact mappings were already available in UMLS, the remainder were mapped manually with software assistance.

Results

Of the 2194 codes, 784 (35.7%) required manual mapping. 435 of these represented concept types documented in SNOMED as deprecated: these included the qualifying phrases such as ‘not elsewhere classified’. A third of the codes were composite, requiring multiple SNOMED code to map. Representing 45 composite concepts required introducing disjunction (‘or’) or set-difference (‘without’) operators, which are not currently defined in SNOMED. Only 47% of the concepts required for composition were present in the clinical core subset. Search of SNOMED for the correct concepts often required extensive application of knowledge of both English and medical synonymy.

Conclusion

Strategies to deal with legacy ICD data must address the issue of codes created by non-taxonomist users. The NLM core subset possibly needs augmentation with concepts from certain SNOMED hierarchies, notably qualifiers, body structures, substances/products and organisms. Concept-matching software needs to utilize query expansion strategies, but these may be effective in production settings only if a large but non-redundant SNOMED subset that minimizes the proportion of extensively pre-coordinated concepts is also available.     

Blue Button use by patients to access and share health record information using the Department of Veterans Affairs’ online patient portal

Objective

The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs’ (VA) personal health record portal, My HealtheVet.

Materials and methods

An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers.

Results

Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button.

Conclusions

This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.     

Health Professionals Expose TB Patients to Stigmatization in Society: Insights from Communities in an Urban District in Ghana

Objectives

To determine how the activities and attitudes of health professionals expose TB patients to stigmatization in the community.

Design

Qualitative research approach using individual interviews and focus groups

Setting

Shama Ahanta East Metropolitan district in the western region of Ghana

Participants

Members in nine communities in the district

Outcome measures

Words and statements that depict how activities and attitudes of health professionals may expose TB patients to stigmatization

Results

Five interrelated ways by which activities and attitudes of health professionals may expose TB patients to stigmatization in the community were identified in data: TB control practices; fear-based responses to TB; inappropriate health education messages; medical licensing for sellers; and prohibition of burial rites.

Conclusions

The findings may explain the diagnostic delay and low TB case detection rate in Ghana. This calls for intensification of education on TB and regular organization of refresher courses and possibly retraining of health professionals in TB control and management. When health professionals are seen to be treating TB patients as ‘normal’ individuals, it has the potential of changing the society''s perception about the disease.     

Research and applications: ICD-9 tobacco use codes are effective identifiers of smoking status

Objective

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations.

Materials and methods

Using data on cancer cases and cancer-free controls from Vanderbilt''s biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses.

Results

ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of  0.32), and there is little evidence of documentation bias. Frequency of code transitions between ‘current’ and ‘former’ tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies.

Discussion

Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records.

Conclusions

Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.     

Resolution pattern of jaundice among children presenting with severe malaria in rural South-West Nigeria

Objective

To compare the pattern of jaundice resolution among children with severe malaria treated with quinine and artemether.

Methods

Thirty two children who fulfilled the inclusion criteria were recruited for the study from two hospitals with intensive care facilities. They were divided into two groups; ‘Q’ and ‘A’, receiving quinine and artemether, respectively. Jaundice was assessed by clinical examination.

Results

Sixteen out of 32 children recruited (representing 50%) presented with jaundice on the day of recruitment. The mean age was (7.00°C2.56) years. On day 3, four patients in ‘A’ and six patients in ‘Q’ had jaundice. By day 7, no child had jaundice.

Conclusion

The study has shown that both drugs resolve jaundice although artemether relatively resolves it faster by the third day.     

Social determinants of stunting in rural area of Wardha,Central India

Background

Stunting is a consequence of long term, cumulative inadequacies of health and nutrition. Health system uses underweight for growth monitoring for its simplicity. Lately there is renewed interest in stunting and especially severe acute malnutrition. Stunting is a relatively neglected indicator. It is therefore imperative to understand the causes of stunting early in infancy and childhood, so that preventive measures can be taken. Hence, the present study was undertaken to study the social determinants of stunting in rural Wardha.

Methods

The present cross-sectional study was undertaken in three Primary Health Centres (PHCs) of Wardha district with total population of 88,187. The sample was drawn from three PHC areas by 30-cluster sampling technique. Stunting was defined using WHO Child Growth Standards for ‘height-for-age’. ‘Height-for-age’ values below 2 standard deviations were considered as stunted while below 3 standard deviations were considered ‘severe stunting’.

Result

Prevalence of stunting was observed to be 52.3% and severe stunting was 25.1%. The significant determinants of stunting were found to be age, father''s education, fathers'' occupation, low income, not receiving Vitamin-A supplement during last 6 months and having anaemia. Sex, caste, mother''s education and mothers'' occupation did not contribute significantly to the stunting.

Conclusion

Low income and related factors such as father''s education and his occupation are important determinant of the stunting. Father being the decision maker, his education is of importance. Vitamin-A supplementation and anaemia as surrogate indicators for access to health care also found out to be significant determinants of stunting.