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Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals.

ABSTRACT: BACKGROUND:One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally enabled care pathway for patients with acute kidney injury (AKI) at a tertiary referral hospital in the United Kingdom. A dedicated clinical response team-comprising existing nephrology and patient-at-risk and resuscitation teams-received AKI alerts in real time via Streams, a mobile app. Here, we present a qualitative evaluation of the experiences of users and other health care professionals whose work was affected by the implementation of the care pathway. OBJECTIVE:The aim of this study was to qualitatively evaluate the impact of mobile results viewing and automated alerting as part of a digitally enabled care pathway on the working practices of users and their interprofessional relationships. METHODS:A total of 19 semistructured interviews were conducted with members of the AKI response team and clinicians with whom they interacted across the hospital. Interviews were analyzed using inductive and deductive thematic analysis. RESULTS:The digitally enabled care pathway improved access to patient information and expedited early specialist care. Opportunities were identified for more constructive planning of end-of-life care due to the earlier detection and alerting of deterioration. However, the shift toward early detection also highlighted resource constraints and some clinical uncertainty about the value of intervening at this stage. The real-time availability of information altered communication flows within and between clinical teams and across professional groups. CONCLUSIONS:Digital technologies allow early detection of adverse events and of patients at risk of deterioration, with the potential to improve outcomes. They may also increase the efficiency of health care professionals' working practices. However, when planning and implementing digital information innovations in health care, the following factors should also be considered: the provision of clinical training to effectively manage early detection, resources to cope with additional workload, support to manage perceived information overload, and the optimization of algorithms to minimize unnecessary alerts.

SUBMITTER: Connell A

PROVIDER: S-EPMC6693304 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals.

Connell Alistair A Black Georgia G Montgomery Hugh H Martin Peter P Nightingale Claire C King Dominic D Karthikesalingam Alan A Hughes Cían C Back Trevor T Ayoub Kareem K Suleyman Mustafa M Jones Gareth G Cross Jennifer J Stanley Sarah S Emerson Mary M Merrick Charles C Rees Geraint G Laing Christopher C Raine Rosalind R

Journal of medical Internet research 20190715 7

<h4>Background</h4>One reason for the introduction of digital technologies into health care has been to try to improve safety and patient outcomes by providing real-time access to patient data and enhancing communication among health care professionals. However, the adoption of such technologies into clinical pathways has been less examined, and the impacts on users and the broader health system are poorly understood. We sought to address this by studying the impacts of introducing a digitally e ...[more]

PMID: 31368443

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Project description:BackgroundThe development of acute kidney injury (AKI) in hospitalized patients is associated with adverse outcomes and increased health care costs. Simple automated e-alerts indicating its presence do not appear to improve outcomes, perhaps because of a lack of explicitly defined integration with a clinical response.ObjectiveWe sought to test this hypothesis by evaluating the impact of a digitally enabled intervention on clinical outcomes and health care costs associated with AKI in hospitalized patients.MethodsWe developed a care pathway comprising automated AKI detection, mobile clinician notification, in-app triage, and a protocolized specialist clinical response. We evaluated its impact by comparing data from pre- and postimplementation phases (May 2016 to January 2017 and May to September 2017, respectively) at the intervention site and another site not receiving the intervention. Clinical outcomes were analyzed using segmented regression analysis. The primary outcome was recovery of renal function to ?120% of baseline by hospital discharge. Secondary clinical outcomes were mortality within 30 days of alert, progression of AKI stage, transfer to renal/intensive care units, hospital re-admission within 30 days of discharge, dependence on renal replacement therapy 30 days after discharge, and hospital-wide cardiac arrest rate. Time taken for specialist review of AKI alerts was measured. Impact on health care costs as defined by Patient-Level Information and Costing System data was evaluated using difference-in-differences (DID) analysis.ResultsThe median time to AKI alert review by a specialist was 14.0 min (interquartile range 1.0-60.0 min). There was no impact on the primary outcome (estimated odds ratio [OR] 1.00, 95% CI 0.58-1.71; P=.99). Although the hospital-wide cardiac arrest rate fell significantly at the intervention site (OR 0.55, 95% CI 0.38-0.76; P<.001), DID analysis with the comparator site was not significant (OR 1.13, 95% CI 0.63-1.99; P=.69). There was no impact on other secondary clinical outcomes. Mean health care costs per patient were reduced by £2123 (95% CI -£4024 to -£222; P=.03), not including costs of providing the technology.ConclusionsThe digitally enabled clinical intervention to detect and treat AKI in hospitalized patients reduced health care costs and possibly reduced cardiac arrest rates. Its impact on other clinical outcomes and identification of the active components of the pathway requires clarification through evaluation across multiple sites.

Project description:BACKGROUND:Implementing digital technology in home care services challenges care arrangements built on face-to-face encounters. Digital welfare technology has been suggested as a solution to increasing demands on health care services from an ageing population. Medication delivery is a major task for home care services, and digital medication devices could lessen the need for resources. But technology has scripts based on how designers picture its use, and these might not fit with users' needs and practices. New technology must go through processes of domestication among its users. In the present study, we investigate how health professionals experienced the implementation of a digital medication dispenser into home care services in Norway. METHODS:This was a qualitative interview study with 26 health professionals from home care services in five municipalities. RESULTS:All five municipalities had implemented a digital medication dispenser in home care services. Prior to the introduction of the dispenser, medication practices had been based on home visits. The safety of medication practices was the main concern of health professionals who had to negotiate the technological script in order to make it work in a new care arrangement. Rationalities of effectiveness collided with rationalities of care, symbolized by warm hands. Professionals who had been used to working independently became dependent on technical support. Being unfamiliar with the new medication arrangement led to resistance towards the digital dispenser, but more direct experiences changed the focus from technology to new care arrangements. Negotiating practical and organizational arrangements led health professionals to trust the digital medication dispenser to contribute to safe and good care for service users. CONCLUSIONS:Implementing digital technology in home care services must be informed by previous practices in the field, especially when it concerns safety for patients. Through processes of domestication, health professionals negotiate technological scripts to make them fit professional ideals and practices. Policymakers and managers must address questions of care arrangements and individualized adaptions to patients' needs in order to receive support from health professionals when implementing digital technology in home care services.

Project description:BackgroundThe number of remote video consultations between doctors and patients has increased during the last few years and especially during the COVID-19 pandemic. The health care service is faced with rising rates of chronic illness and many patients who are more confident in self-management of their illnesses. In addition, there is an improved long-term outlook for serious conditions, such as cancer, that might require flexibility in everyday life.ObjectiveThis study aimed to investigate how medical doctors in the outpatient clinic use and experience the use of video consultations with hematological patients, with a focus on relational and organizational aspects.MethodsThe study was designed as an explorative and qualitative study. Data were collected via participant observations and focus group interviews with medical doctors.ResultsThe study identified possibilities and barriers in relation to adapting to the alternative way of meeting patients in the clinical setting. One of the main findings in this study is that the medical doctors were afraid that they missed important observations, as they were not able to perform a physical examination, if needed. They also emphasized that handshake and eye contact were important in order to get an overall impression of the patient's situation. It also became clear that the medical doctors used body language a lot more during video consultation compared with consultation in a physical setting. The medical doctors found the contact with the patients via the screen to be good, and the fact that the technology was working well made them feel comfortable with the video consultation.ConclusionsIn this study, we found that the medical doctors were able to maintain good contact with the patients despite the screen and were able to assess the patients in a satisfying manner. However, there were still uncertainties among some doctors about the fact that they could not examine the patients physically. New knowledge about how to use gestures and body language during video consultation was obtained.

Project description:BackgroundHealth policy in many countries directs treatment to the lowest effective care level and encourages collaboration between primary and specialist mental health care. A number of models for collaborative care have been developed, and patient benefits are being reported. Less is known about what enables and prevents implementation and sustainability of such models regarding the actions and attitudes of stakeholders on the ground. This article reports from a qualitative sub-study of a cluster-RCT testing a model for collaborative care in Oslo, Norway. The model involved the placement of psychologists and psychiatrists from a community mental health centre in each intervention GP practice. GPs could seek their input or advice when needed and refer patients to them for assessment (including assessment of the need for external services) or treatment.MethodsWe conducted in-depth qualitative interviews with GPs (n = 7), CMHC specialists (n = 6) and patients (n = 11) in the intervention arm. Sample specific topic guides were used to investigate the experience of enablers and barriers to the collaborative care model. Data were subject to stepwise deductive-inductive thematic analysis.ResultsParticipants reported positive experiences of how the model improved accessibility. First, co-location made GPs and CMHC specialists accessible to each other and facilitated detailed, patient-centred case collaboration and learning through complementary skills. The threshold for patients' access to specialist care was lowered, treatment could commence early, and throughput increased. Treatment episodes were brief (usually 5-10 sessions) and this was too brief according to some patients. Second, having experienced mental health specialists in the team and on the front line enabled early assessment of symptoms and of the type of treatment and service that patients required and were entitled to, and who could be treated at the GP practice. This improved both care pathways and referral practices. Barriers revolved around the organisation of care. Logistical issues could be tricky but were worked out. The biggest obstacle was the funding of health care at a structural level, which led to economic losses for both the GP practices and the CMHC, making the model unsustainable.ConclusionsParticipants identified a range of benefits of collaborative care for both patients and services. However, the funding system in effect penalises collaborative work. It is difficult to see how policy aiming for successful, sustainable collaboration can be achieved without governments changing funding structures.Trial registrationClinicalTrials.gov identifier: NCT03624829.

Project description:BackgroundChronic pain constitutes a significant burden for the individuals affected, and is a frequent reason why patients seek health care services. While in-person psychosocial interventions can be of support to people living with chronic pain, such interventions are not always accessible. eHealth interventions may provide greater accessibility, but the evidence and use of digital self-management solutions for chronic pain are still limited and the lack of health care provider input in the development process of such solutions a concern. Therefore, the aim of the current study was to investigate health care providers' experiences of treating patients with chronic pain, their attitudes towards, and use of, digital solutions in pain management, and their suggestions for content and design elements for a potential digital pain self-management intervention.MethodsTwelve health care providers representing a variety of health care disciplines participated in semi-structured interviews. The interviews were analyzed using thematic analysis.ResultsThe material was analyzed into three main themes: [1] Patients with chronic pain and their current use of the health care services, [2] Health care providers' own motivation and impression of patient prerequisites for use of digital self-management interventions, and [3] Suggestions for content and design elements in a digital self-management intervention for people living with chronic pain. The challenges faced by patients living with chronic pain were described as numerous. Despite interest and positive attitudes, few of the health care providers had used or recommended eHealth solutions to their patients. A range of potential content and functionality elements were identified, including aspects of motivation and engagement and providers also emphasized the importance of easy access and positive, personal content to support existing treatment.ConclusionsThis study offers insights into health care providers' considerations for the potential of digital self-management interventions supporting patients living with chronic pain. Findings indicate the need for change and a more comprehensive treatment approach to pain management. eHealth solutions may contribute to such change, and providers pointed to a need for health care provider involvement, timely support and follow-up as important factors for integrating digital pain self-management interventions into clinical care.Trial registrationClinicalTrials.gov : NCT03705104.

Dataset Information

Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals.

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Implementation of a Digitally Enabled Care Pathway (Part 2): Qualitative Analysis of Experiences of Health Care Professionals.

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