Healthcare is an information business with expanding use of information and communication technologies (ICTs). Current ICT tools are immature, but a brighter future looms. We examine 7 areas of ICT ...in healthcare: electronic health records (EHRs), health information exchange (HIE), patient portals, telemedicine, social media, mobile devices and wearable sensors and monitors, and privacy and security. In each of these areas, we examine the current status and future promise, highlighting how each might reach its promise. Steps to better EHRs include a universal programming interface, universal patient identifiers, improved documentation and improved data analysis. HIEs require federal subsidies for sustainability and support from EHR vendors, targeting seamless sharing of EHR data. Patient portals must bring patients into the EHR with better design and training, greater provider engagement and leveraging HIEs. Telemedicine needs sustainable payment models, clear rules of engagement, quality measures and monitoring. Social media needs consensus on rules of engagement for providers, better data mining tools and approaches to counter disinformation. Mobile and wearable devices benefit from a universal programming interface, improved infrastructure, more rigorous research and integration with EHRs and HIEs. Laws for privacy and security need updating to match current technologies, and data stewards should share information on breaches and standardize best practices. ICT tools are evolving quickly in healthcare and require a rational and well-funded national agenda for development, use and assessment.
In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand--there may be a ...lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services.
Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open Data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya.
Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives.
This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible.
A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.
•Open-source global goods can be adapted to meet needs during a disaster response.•Crisis situations can lead to innovative solutions.•Lessons from adapting OpenMRS for COVID-19 can be leveraged for ...future responses.
As the coronavirus pandemic progressed through the United States, Indianapolis Emergency Medical Services (IEMS) identified a gap between the health system capacity and the projected need to support an overwhelmed health care system. In addressing emergencies or special cases, each medical institution in a metropolitan area typically has a siloed process for capturing emergency patient records. These approaches vary in technical capabilities and may include use of an electronic medical record system (EMR) or a hybrid paper/EMR process. Given the projected volume of patients for the COVID-19 pandemic and the proposed multi-institutional team approach needed in case of significant provider illness, IEMS sought a simple, efficient, consolidated EMR solution to support planning for the potential capacity gap. IEMS approached Regenstrief Institute (RI), an established partner with experience in supporting OpenMRS, a global good EMR platform that had been deployed in multiple settings globally.
The purpose of this project was to determine if OpenMRS, a global good, could be used to quickly stand up a system that would meet the needs for health emergency data collection and reporting.
The team used an “all hands on deck” approach, bringing together technical and subject matter experts, and a human-centered and iterative process to ensure the system met the key needs of IEMS. The OpenMRS Reference Application was adapted to the specific need and deployed as Docker containers to servers within the Indiana Health Information Exchange.
In less than two weeks, the Regenstrief team was able to install, configure and set up a working version of OpenMRS to support the desired electronic record requirements for the IEMS disaster field clinics. Using a human-centered approach, the RI team developed, tested, and released a user-friendly, installation-ready solution complete with an end user manual and a base support plan. IEMS and RI are sharing this approach to demonstrate how a global good can quickly generate a solution for COVID-19 and other disaster responses.
Open source global goods can rapidly be adapted to meet local needs in an emergency. OpenMRS can be adapted to meet the needs of basic emergency medical services registration, triage, and basic data collection.
Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with ...computer-generated reminders could improve clinicians' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.
A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.
Changes in order rates for overdue CD4 tests were compared between and within the two clinics.
The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR = 1.80, CI 1.34 to 2.42, p < 0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR = 2.32, CI 1.67 to 3.22, p < 0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p = 0.51). Limitations Evaluation was conducted at two clinics in a single institution.
Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.
The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic ...logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the "digital divide." Financial and technical sustainability by Kenyans will be key to its future use and development.
The developing world faces a series of health crises including HIV/AIDS and tuberculosis that threaten the lives of millions of people. Lack of infrastructure and trained, experienced staff are ...considered important barriers to scaling up treatment for these diseases. In this paper we explain why information systems are important in many healthcare projects in the developing world. We discuss pilot projects demonstrating that such systems are possible and can expand to manage hundreds of thousands of patients. We also pass on the most important practical lessons in design and implementation from our experience in doing this work. Finally, we discuss the importance of collaboration between projects in the development of electronic medical record systems rather than reinventing systems in isolation, and the use of open standards and open source software.
The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to ...existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain.
We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers.
Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations.
Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.
Despite unprecedented spending, US maternal outcomes have worsened drastically over the past decade. In comparison, maternal outcomes of many Low and Middle-Income Countries (LMIC) have improved. ...Lessons learnt by their success may be applicable to the US. We performed a literature review to identify innovations that had met with success across LMIC, and should be considered for adoption in the US. mHealth and patient facing alerts, Telehealth, patient controlled health records, inclusion of patient relationship data in health information systems and positioning empowered community health workers as catalysts of maternal care delivery were identified as innovations worthy of further evaluation. These innovations were categorized into several themes; knowledge, technology, patient/community empowerment, coordination and process change. Tools that place informed and empowered patients and community members at the center of maternal care has greatly improved maternal outcomes, and are suitable to be considered for the US healthcare system.
Abstract
Objectives
The Chronic Pain Treatment Tracker (Tx Tracker) is a prototype decision support tool to aid primary care clinicians when caring for patients with chronic noncancer pain. This ...study evaluated clinicians' perceived utility of Tx Tracker in meeting information needs and identifying treatment options, and preferences for visual design.
Methods
We conducted 12 semi-structured interviews with primary care clinicians from four health systems in Indiana. The interviews were conducted in two waves, with prototype and interview guide revisions after the first six interviews. The interviews included exploration of Tx Tracker using a think-aloud approach and a clinical scenario. Clinicians were presented with a patient scenario and asked to use Tx Tracker to make a treatment recommendation. Last, participants answered several evaluation questions. Detailed field notes were collected, coded, and thematically analyzed by four analysts.
Results
We identified several themes: the need for clinicians to be presented with a comprehensive patient history, the usefulness of Tx Tracker in patient discussions about treatment planning, potential usefulness of Tx Tracker for patients with high uncertainty or risk, potential usefulness of Tx Tracker in aggregating scattered information, variability in expectations about workflows, skepticism about underlying electronic health record data quality, interest in using Tx Tracker to annotate or update information, interest in using Tx Tracker to translate information to clinical action, desire for interface with visual cues for risks, warnings, or treatment options, and desire for interactive functionality.
Conclusion
Tools like Tx Tracker, by aggregating key information about past, current, and potential future treatments, may help clinicians collaborate with their patients in choosing the best pain treatments. Still, the use and usefulness of Tx Tracker likely relies on continued improvement of its functionality, accurate and complete underlying data, and tailored integration with varying workflows, care team roles, and user preferences.
Abstract
Objective
To evaluate primary care provider (PCP) experiences using a clinical decision support (CDS) tool over 16 months following a user-centered design process and implementation.
...Materials and Methods
We conducted a qualitative evaluation of the Chronic Pain OneSheet (OneSheet), a chronic pain CDS tool. OneSheet provides pain- and opioid-related risks, benefits, and treatment information for patients with chronic pain to PCPs. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems.
Results
PCPs stated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs used OneSheet for distinct subgroups of patients with chronic pain, including patients prescribed opioids, with poorly controlled pain, or new to a provider or clinic. PCPs reported variable workflow integration and selective use of certain OneSheet features driven by their preferences and patient population. PCPs recommended broadening OneSheet access to clinical staff and patients for data entry to address clinician time constraints.
Discussion
Differences in patient subpopulations and workflow preferences had an outsized effect on CDS tool use even when the CDS contained the right information identified in a user-centered design process.
Conclusions
To increase adoption and use, CDS design and implementation processes may benefit from increased tailoring that accommodates variation and dynamics among patients, visits, and providers.
Lay Summary
We evaluated primary care providers’ (PCP) experiences with a clinical decision support (CDS) tool called the Chronic Pain OneSheet (OneSheet), designed to assist with the management of patients with chronic pain. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems. PCPs indicated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs reported using OneSheet for specific patient subgroups, such as those prescribed opioids, with poorly controlled pain or new to a provider or clinic. However, OneSheet utilization varied depending on PCPs’ workflow preferences and patient population. To address PCPs’ time constraints, they recommended expanding OneSheet access to clinical staff and patients for data entry. Our findings highlight the importance of tailoring CDS tools to accommodate differences in patient characteristics, visits, and PCPs’ workflow preferences. In conclusion, this study suggests that personalized CDS tools like OneSheet can enhance chronic pain management in primary care settings. By incorporating individualized elements and considering variations among patients, visits, and providers, these tools can better support PCPs in making informed decisions for effective chronic pain management.
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