The Impact of Digital Health on Safety and Quality of Healthcare

January2018

ImpactofDigitalHealthontheSafetyandQualityofHealthCare

ProfessorTimShaw,DrMoniqueHinesandMsCandiceKielly-CarrollfromResearchinImplementationScienceandeHealth,UniversityofSydneyhavepreparedthisreportonbehalfoftheAustralianCommissiononSafetyandQualityinHealthCare.

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ShawT,Hines,M,Kielly-Carroll,C.ImpactofDigitalHealthontheSafetyandQualityofHealthCare.Sydney:ACSQHC;2017

Disclaimer

ThecontentofthisdocumentispublishedingoodfaithbytheCommissionforinformationpurposes.Thedocumentisnotintendedtoprovideguidanceonparticularhealthcarechoices.Youshouldcontactyourhealthcareproviderforinformationoradviceonparticularhealthcarechoices.

Thisdocumentincludestheviewsorrecommendationsofitsauthorsandthirdparties.PublicationofthisdocumentbytheCommissiondoesnotnecessarilyreflecttheviewsoftheCommission,orindicateacommitmenttoaparticularcourseofaction.TheCommissiondoesnotacceptanylegalliabilityforanyinjury,lossordamageincurredbytheuseof,orrelianceon,thisdocument.

Preface

ThisprefacewaswrittenbytheAustralianCommissiononSafetyandQualityinHealthCare(theCommission)toprovidecontextandbackgroundtothereportwhichfollows,ImpactofDigitalHealthontheSafetyandQualityofHealthCare.ThemainreportwaswrittenbytheResearchinImplementationScienceandeHealth,UniversityofSydneyonbehalfoftheCommission.

Background

TheroleoftheCommissionistoleadandcoordinatenationalimprovementsinthesafetyandqualityofhealthcare.TheCommissionworksinpartnershipwiththeAustralianGovernment,stateandterritorygovernmentsandtheprivatesectortoachieveasafe,high-qualityandsustainablehealthsystem.Indoingso,theCommissionalsoworkscloselywithpatients,carers,clinicians,managers,policymakersandhealthcareorganisations.

KeyfunctionsoftheCommissionincludedevelopingnationalsafetyandqualitystandards,developingclinicalcarestandardstoimprovetheimplementationofevidence-basedhealthcare,coordinatingworkinspecificareastoimproveoutcomesforpatients,andprovidinginformation,publicationsandresourcesaboutsafetyandquality.

TheCommissionworksinfourpriorityareas:

1. Patientsafety
2. Partneringwithpatients,consumersandcommunities
3. Quality,costandvalue
4. Supportinghealthprofessionalstoprovidesafeandhigh-qualityhealthcare.

TheCommission’scombinedworkplan2017–2020specifiesdevelopmentofareportontheimpactofhealthITonthequalityofpatientcare.

Digitalinitiativesinhealthcanproducesignificantbenefitforpatientsandhealthcareproviders.Benefitscaninclude:

• Improvedoutcomes
• Reductioninunwarrantedvariation
• Reductioninpreventableharm
• Improvedappropriatenessofhealthcare
• Improvedpatientcenteredness

• Increasedopportunitiesformonitoringandqualityimprovement.

Thereportwillassistgovernmentsandhealthcareorganisationstoidentifyelementsofdigitisationinhealthcarethatbestimprovethesafetyandqualityofpatientcare.Itwillalsohelphealthcareorganisationstomonitortheirdigitalprogressagainstbest-practicetargets,andtoincreasethevaluetheyderivefromtheirdigitalactivities.

Keyfindings

Thereviewfindingsarefocusedonfivedigitalhealthinterventions:

• Electronicpatientportals
• Electronicpatientreminders(mobiletechnologies)
• Information-sharingatdischarge(electronicdischargesummaryorEDS)
• Computerisedproviderorderentry(CPOE)includingelectronicprescribing
• Clinicaldecision-supportsystems(CDSSs).

Electronicpatientportals

Electronicpatientportalsprovidepatientswithsecureaccesstotheirhealthinformation.Theyhelpconsumerstobecomeactiveparticipantsindecision-makingabouttheirhealthcare.

Findingsofthereportinclude:

• Successfulpatientportalsincludefunctionssuchassecuremessaging,patientreminders,andprescriptionrefillorders
• Electronicpatientportalsaremostsuccessfulwhenintegratedwithotherinterventionsthatsupportpatientstoactontheinformationavailableintheportal,suchasremindersandclinicaldecisionsupporttools
• Thereareconsistentdisparitiesinelectronicportaluseacrosspatientpopulations,reflectingthe‘digitaldivide’betweenpatientsfromdifferentsocioeconomicbackgrounds
• Healthprofessionalengagementinandsupportforelectronicpatientportalusemayincreaseadoptionandusebypatients
• Makingelectronicpatientportalsavailablewithinclinicalcontextsenablesgreateraccessandprovidesopportunitiesforhealthprofessionalstodemonstrateapplicationofportalfunctionsinsupportoftreatmentplans.

Electronicpatientreminders(mobiletechnologies)

Men,andpeopleunder40yearsofageandfromlowsocioeconomicbackgrounds,areathigherriskofnon-attendanceatscheduledappointmentsandpoorcompliancewithmedicationregimens.

Findingsofthereportinclude:

• Theuseofmobiletechnologiesmaybeeffectiveindeliveringreminderstoalargeproportionofthepatientpopulationgroup;however,theappropriatenessofmobiletechnologiesisunknownforsomegroups,suchasolderpatientsandpatientswhodonotspeakorreadEnglish
• Appropriatetiminganddeliveryofremindersmayavoidreminderfatigueandsupportsuccessfuladoptionofpatientmessaginginterventions
• Bidirectionalmessagingmaypromotesuccessfuloutcomesbygeneratingpersonalisedcommunicationbetweenhealthcareprofessionalsandpatients;however,thismayalsoimpactonclinicalworkflow.

Information-sharingatdischarge(electronicdischargesummary)

Timelysharingofhigh-qualityinformationattransitionsincare,suchasdischargefromhospital,iscriticaltocontinuityofcareandpromotionofpatientsafety.

Findingsofthereportinclude:

• Electronicdischargesummaries(EDSs)maypromotetimelinessofpreparationandtransmissionofpatientinformationtoprimarycareproviders
• EDSsmaybemoresuccessfulwhenauto-populatedandauto-sentwithinformationfromahospital’sEMR,whendeliveredviasecureemail,andwhenintegratedwithreminderstohealthprofessionalstocompletetheEDS
• HealthprofessionalsappeartoneedtrainingandsupporttofacilitatesuccessfulgenerationanduseoftheEDS.

Computerisedproviderorderentry

Findingsofthereportinclude:

• Computerisedproviderorderentry(CPOE),includingelectronicprescribing,appearstobemostsuccessfulwhenimplementedinconjunctionwithadditionalsoftwarecomponents,particularlyCDSSs
• CombiningCPOEwithtargetededucationmodulesandperformancefeedbackmayfurtherenhanceCPOEutilisationandadherencetomedicationguidelines
• InteroperabilityofCPOEwithexistingelectronicsystemsappearstoimprovethesuccessofCPOEadoptionandusability

• TailoringCPOEsystemstothelocalhealthcaresettingincreasesitsappropriateness.

Theliteratureshowedelectronicprescribinghasproducedimprovementsinorganisationalefficiencyandthesafetyofprescribing.1

Clinicaldecision-supportsystems

Clinicaldecision-supportsystems(CDSSs)matchpatient-specificcharacteristicstoadatabase,andcreatepersonalisedpredictionsforassessingdiseasestatus,diagnosis,appropriatetreatmentoptionsandotherclinicaldecisions.CDSSscanalsogeneratepatient-specificremindersoralerts,whendeviationfromrecommendedcareisdetected.

Findingsofthereportinclude:

• CDSSsappearstobemostsuccessfulwhenimplementedincombinationwithadditionalsoftwarecomponents
• InteroperabilityofCDSSswithexistingelectronicsystemsmayimprovethesuccessofitsadoptionandusability

• CDSSsthattargetsdecisionsupportaccordingtoalocalminimumsetofindicatorsappeartohavegreateruptakeandimpactonqualityofcare.

TheliteraturehasshownCDSSshavehadapositiveimpactonpatientsafety–forexample,intheareasofaccessibility,clinicaljudgement,dataintegrative,guidelinesadherence,indicatedcare,organisationalefficiency,patientoutcomes,resourceutilisationandsafetyprescribing.[1]

Conclusion

Introducingdigitalhealthinitiativesintohealthcareorganisationscanproducesignificantbenefitstopatientsandhealthcareproviders.Improvementstoquality,safetyandefficiencyofpatientcareareachievableviadigitalinterventions.Theliteratureindicatesthatacombinationofdigitalinterventionsmayyieldgreaterbenefit.However,thesuccessesoftheseinterventionsaredependentonensuringarigorousimplementationprocess.

Thereislimitedpublishedevidenceregardingapproachestomeasuringdigitalhealth.Thevariationamongimplementeddigitalhealthinterventionslimitscomparativedataandknowledge-sharing.Measurementsaretypicallyfocusedonstructural,process,oroutcomemetrics.Thereareexemplarmeasurementframeworksavailable.Customisationofsuchframeworks,however,willelicitspecificdatarelatedtotheintervention,whichwillenablegreaterattribution.

Nextsteps

TheCommissionwillcontinuetoworkwithstatesandterritories,theAustralianDigitalHealthAgency,andotherhealthcareproviderstoidentifybest-valueapproachestohealthITinitiativeswhichoptimisepatientsafetyandthequalityofcare.

Contents

Preface

Background

Keyfindings

Acronyms and abbreviations

1.Summary

1.1Changingthehealthcontextanditseffectonprogramevaluation

1.2Literatureandfindings

2.Introduction

2.1Contextandbackground

2.2Aimsandscope

3.Method

3.1Definitionofreviewscope

3.2Literaturereview

3.3Informantinterviews

4.Findings

4.1Literaturereviewfindings

4.1.1Electronicpatientportals

4.1.2Patient remindersusing mobile technologies

4.1.3Information sharing on discharge

4.1.4Computerised providerorder entry

4.1.5Clinical decision-supportsystems

4.1.6Greyliterature

4.2Informantinterviewfindings

4.2.1Electronicpatientportals

4.2.2Patient remindersusing mobile technologies

4.2.3Information sharing on discharge

4.2.4Computerised providerorder entry

4.2.5Clinical decision supportsystems

5.Criticalsuccess factors common acrossdigitalhealth interventions

5.1Positiveorganisationalleadership,governance,cultureandresourcing

5.2Iterative,continuousimprovementapproaches

5.2.1Incorporatediverseperspectivesinconsultation

5.2.2Using datatoimprovesafetyand quality

5.3Attentiontoworkflow

5.4Multifaceteddigitalhealthstrategies

6.Existing approaches tomeasuring digitalhealth

6.1Structuralmeasurement

6.2Processmeasurement

6.3Outcomemeasurement

6.4Examplemeasurementmodels

6.4.1NHSDigital MaturityIndex

6.4.2World Health Organization’s Monitoring and Evaluating DigitalHealthInterventions

6.4.3National QualityForumHealth Information TechnologyMeasurementFramework

AppendixAGlossary

Appendix BSearch strategy

Appendix CInterviewscript

References

Tables

Table 1:Summaryofthe mainfindings andcriticalsuccessfactors

Table 2:The NHS Digital MaturityIndex

Table 3:Linkingstagesof interventionmaturitywithmeasurementandobjectives

Table 4:NationalQualityForumHealthInformationTechnologyMeasurementFramework

Acronymsandabbreviations

ADEadversedrugevent

CDSSclinicaldecisionsupportsystem

CPOEcomputerisedproviderorderentry

EDemergencydepartment

EDSelectronicdischargesummary

EHRelectronichealthcarerecord

HIThealthinformationtechnology

ICTinformationandcommunicationstechnology

ICUintensivecareunit

ITinformationtechnology

UKUnitedKingdom

USUnitedStates

1.Summary

TheUniversityofSydneywascontractedtodevelopareportontheeffectsoffivedigitalhealthinterventionsonpatientsafetyandqualityofcare:

• Electronicpatientportals
• Electronicpatientreminders(mobiletechnologies)
• Information-sharingondischarge(electronicdischargesummary)
• Computerisedproviderorderentry

• Clinicaldecisionsupportsystems.

Thereportusedtwoapproaches:1)asynthesisofsystematicreviews;and2)interviewswithinformantsfromAustralia,theUnitedStatesandtheUnitedKingdom.

Thereportisintendedtoprovidearesourcefororganisationsandindividualsto:

• Identifyelementsofdigitalhealththatbestimprovesafetyandquality

• Explainexistingapproachestoself-assess,monitorandbenchmarkbest-practicedigitalhealth.

Thisreportincludesareviewoftheliterature,mainfindings,existingapproachestomeasurementandaglossaryofterms.

1.1Changingthehealthcontextanditseffectonprogramevaluation

Theliteratureandinformantinterviewsprovidedinsightinto:

• Thecurrentstateandfuturedirectionofdigitalhealthinterventions
• Theeffectofdigitalhealthinterventionsonpatientsafetyandqualityofcare

• Prioritiesforfuturedevelopmentofthedigitalhealthlandscape.

Theseinsightsneedtobeconsideredinthecontextofthebroaderandrapidlyevolvinginformationandcommunicationtechnology(ICT)environment.Substantialinvestmentshavebeenmadegloballyindigitalhealth.However,healthlagsbehindmanyotherindustrieswhenitcomestointroducingandusingcloud-basedsolutions,machinelearning,cognitivecomputingandmobiletechnologies.

Inaddition,globally,healthsystemsarechallengedbytheinteroperabilityofhealthICTinfrastructureandtheirintegrationacrosshealthserviceorganisations.Therefore,thereareconsiderablechallengesinthetransferandaccessofreliabledatainrealtime.

Itwasapparentthatleadinghealthserviceorganisationswithinnovativedigitalhealthsystemsareemployingacombinationoftechnologieswithinlargerintegratedsolutions.Thisfurthercomplicatestheinterpretationof,andabilitytoattribute,successtosingledigitalhealthinterventiontypes.

1.2Literatureandfindings

Fourmainfindingscanbedrawnfromthisstudy:

• Theevidencesuggeststhatthefivedigitalhealthinterventionsreviewedinthisreportcanimprovequalityofcare,patientsafetyandpatientoutcomes
• Themostconvincingevidencerelatestoestablishedsystemssuchascomputerisedproviderorderentrysystems;thereislessevidencesurroundingnewersystemssuchaspatientportals
• Thereisevidencethatthefeatureddigitalinterventionscouldnegativelyaffectpractice,userexperienceandoutcomesifnotdesignedorimplementedappropriately

• Itisclearfromtheliteratureandinformantinterviewsthatthemannerinwhichsystemsaredevelopedandimplementeddeterminesanynegativeorpositiveeffectsofdigitalhealthinterventionsonpatientsafetyandqualityofcare.

ThefindingsandcriticalsuccessfactorsforthefivedigitalhealthinterventionsaresummarisedinTable1.

Table1:Summaryofthemainfindingsandcriticalsuccessfactors

Digitalhealthintervention / Mainfindingsandcriticalsuccessfactors
Information-sharingondischarge /

• Electronicdischargesummaries(EDSs)maypromotefasterpreparationandtransmissionofpatientinformationtoprimarycareclinicians
• EDSsmaybemoresuccessfulwhenauto-populatedwithinformationfromahospital’selectronichealthrecord(EHR),whendeliveredthroughsecureemail,andwhenintegratedwithreminderstoclinicianstocompletetheEDS
• CliniciansappeartoneedtrainingandsupportsotheycansuccessfullyuseEDSs

Electronicpatientportals /

• Successful patient portalsappear toincludefunctionssuch assecuremessaging, remindersandprescriptionrefill orders
• Electronicpatientportalsappear tobemostsuccessfulwhen integrated with otherinterventionsthat supportconsumers to act ontheinformation available in the portal,such asremindersand clinical decision-support tools
• There are consistent disparitiesin electronicportal useacrossconsumer populations, reflecting the ‘digital divide’betweenconsumers fromdifferent socioeconomicbackgrounds
• Clinicianengagement in, and supportfor, electronicpatientportalusemayincrease adoption andusebyconsumers

Patientremindersusingmobiletechnologies /

• Theuseofmobiletechnologiesmaybeeffectiveindeliveringreminderstoalargeproportionofconsumers;however,theappropriatenessofmobiletechnologiesisunknownforsomegroups,suchasolderconsumers,andculturallyandlinguisticallydiverseconsumers
• Appropriatetiminganddeliveryofremindersmayavoidreminderfatigueandsupportsuccessfuladoptionofpatientmessaginginterventions
• Two-waymessagingmaypromotesuccessfuloutcomesbygeneratingpersonalisedcommunicationbetweencliniciansandconsumers;however,thismayalsoaffectclinicalworkflow

Computerised providerorder entry (CPOE) /

• CPOE appearsto bemostsuccessful when implementedwith extra software components, especially CDSSs
• Interoperability ofCPOEwith existingelectronicsystemsappearsto improve thesuccessofCPOE adoption andusability
• TailoringaCPOE system tothe health serviceorganisationincreasesitsappropriateness

Clinicaldecision-supportsystems(CDSSs) /

• CDSSsappear to bemostsuccessful when implementedin combination with extrasoftware components
• Interoperability ofaCDSS with existingelectronicsystemsmayimprove thesuccessofits adoption andusability
• CDSSsthat target decision supportaccording toa localminimum set ofindicatorsappear to have better uptakeandeffect onquality ofcare.

Theliteraturereviewshowedmixedresultsabouttheeffectofelectronicpatientportalsonencouragingconsumerstoengagewithclinicians.1Similarly,mobiletextmessageremindershavescantevidenceregardingpatientcompliancewithmedicationregimens.2Acombinationofdigitalhealthinterventions,suchasCPOEandCDSSs,haveshownmorepositiveeffectsonpatientsafetycomparedwithstandaloneinterventions.3-6

Thesuccessfulimplementationofthedigitalhealthinterventionsislinkedtothoroughconsultationamongmanydifferentclinicians.Thealignmentofdigitalinterventionswithworkflowisattributedtouseracceptance,adoptionandpositiveoutcomes.7-12Digitalinterventionshavealsodemonstratedapositiveeffectonclinician–consumercommunication.3,13,14Electronicpatientportalshavedemonstratedanimprovementinconsumersatisfactionduetotheconvenienceofprescriptionrefillordering,sharingpersonalhealthinformationandhavingeasyaccesstoinformation.15

Asdigitalhealthtechnologiesareevolvingrapidly,thereismuchtobelearnedabouthowdigitalhealthinterventionsshouldbemosteffectivelydesigned,implementedandused.Futureresearchshouldconsider:

• Standardisationofdigitalhealthmeasurementstrategies,toenablemeaningfulcomparisonsbetweendifferentdigitalhealthinterventions
• Definitionsandmeasurementofmainoutcomes,includingpatienthealthoutcomes
• Benefitsrealisationthroughrichcasestudies;thesewhichbestprovidetheinformationneededbyimplementerstosupportdecision-makingaboutdigitalhealthinterventions

• Capitalisingonexisting,unpublisheddataondigitalhealthevaluationsbysupportingorganisationstosharetheirfindings,thusdrivinginnovationandprogressindigitalhealthimplementation.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

2.Introduction

Informationandcommunicationtechnology(ICT)isabroadtermthatcoversanyproductorprogramthatstores,retrieves,manipulates,transmitsorreceivesdigitalinformation.TheapplicationofICTinhealthcareisknownashealthinformationtechnology(HIT).HITreferstodifferentproducts,technologiesandservicesthathelpuserstocollect,shareandusehealthinformationfordifferentpurposes.TheimplementationofHITwillbereferredtoasdigitalhealthinterventionsthroughoutthisreportforclarityandconsistency.

2.1Contextandbackground

TheAustralianCommissiononSafetyandQualityinHealthCare(theCommission)promotesandsupportsthesafeandeffectiveimplementationofHITinAustralia.UsingHITcanimprovethequality,safetyandefficiencyofhealthcare.However,thepracticalimplementationofHITinacomplexanddynamichealthcareenvironmentcanbechallenging.TheCommissionhasproduceddifferentresourcestohelphealthserviceorganisationsandclinicianswithbest-practiceimplementation.

Thisprojectaimstoidentifyelementsofdigitisationinhealthcarethatbestimprovethesafetyandqualityofpatientcare,todrivesafeandeffectiveuseofnationaldigitalhealthinfrastructureintothefuture.Thisincludesidentifyingexistingapproachestoself-assess,monitorandbenchmarkuptakeofrecommendeddigitalhealthinterventions.TheCommission’srollingthree-yearworkplanfeaturesthisprojectunderdeliverablesfor2017–18.

2.2Aimsandscope

TheResearchinImplementationScienceandeHealthgroup,theUniversityofSydney,wasengagedbytheCommissionto:

• Conductaliteraturereviewandanalysisofanygreyliteratureaboutdigitalhealthinterventionsthathaveimprovedpatientsafetyandqualityofcare,andidentifiedapproachestobenchmarkuptakeofdigitalhealth
• Conductfiveinformantinterviewstodocumentexperiencesofdigitaltransformationnotcapturedinpublishedliterature

• Consolidate(anddevelop,ifappropriate)definitionstosupporttheunderstandingofdigitalhealthterminologyattheCommission.

Thereportsynthesisesthisinformationandoutlinesseveralfindings.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

3.Method

Theprojectmethodwasunderpinnedbytheimportanceofarigorousevidencebase,andaconsultativeapproachconsistingofaliteraturereviewandinformantinterviews.

3.1Definitionofreviewscope

Thefivedigitalhealthinterventionsthatareexploredinthisreport,andwerenominatedbytheAustralianCommissiononSafetyandQualityinHealthCare,are:

• Electronicpatientportals
• Electronicpatientreminders(mobiletechnologies)
• Informationsharingondischarge(electronicdischargesummaries)
• Computerisedproviderorderentry

• Clinicaldecision-supportsystems.

Computerisedproviderorderentry(CPOE)isthemostcommonlyusedtermintheliteraturetorepresentelectronicorderentry.InsomeAustralianstatesandterritories,‘electronicmedicationmanagement’and‘orderentry’arethepreferredterms.CPOEreplacestraditionalpapertoolsandrequiresclinicianstodirectlyplaceordersformedicines,testsorstudiesintoanelectronicsystem, whichtransmitstheorderdirectlytotherecipientresponsibleforimplementingtheorder.16

Digitalhealthcareterms,relevanttothesearchstrategy,wereconsideredandcompiledasaglossaryinthisreport(AppendixA).

3.2Literaturereview

BasedonthefivefocusareasinSection3.1,ascopingreviewwasconductedtoaddressthefollowingresearchquestions:

• Whatistheimpactof<insertdigitalhealthtype>onthesafetyandqualityofhealthcare?

• Whatfactorscontributetosuccessful<digitalhealthtype>implementation?

Searchmethodsincluded:

• Systematicdatabasesearches
• Handsearchesoftargetjournals
• Snowballingandcitationtracking
• Targetedreviewofwebsitesofkeyorganisationsassociatedwithsafetyandqualityinhealthcare

• Websearchesforrelevantgreyliterature.

Thesearchincorporatedresultsofsystematicreviewspublishedinafive-yearperiod,from2012to2017.

Publicationsdatedpre-2012wereincludedonlyifconsideredtobeseminalworkorofsignificantimpact.ThesearchstrategywasdevelopedincollaborationwithanacademiclibrarianfromtheFacultyofHealthSciences,UniversityofSydney(AppendixB).

3.3Informantinterviews

Interviewswithkeyinformantsservedasthe‘livedexperiences’oforganisationsandindividualsactivelyengagedinthedevelopment,implementationandreviewofdigitalhealthinterventions.Theinformantinterviewscapturedexperientialevidencenotpublishedorreportedintheliterature.Inparticular,informantinterviewswereusedtogatherinformationaboutthepracticalitiesofdigitalhealthelementsthatcontributetopositivesafetyandqualityoutcomes.Thiswasconsideredanimportantprojectcomponent,giventhepracticalnatureoftheprojectoutputs.

Eachinterviewwasguidedbyapre-approvedinterviewscript(AppendixC)andapprovedbytheUniversityofSydneyEthicsCommittee.Interviewsweretranscribedverbatim,andtworeviewersthematicallyanalysedthemforemergingandfinalthemes.Duringtheanalysis,casestudyexamplesandillustrativequoteswerehighlightedandgroupedbythemes.Theseexamplesandquotesarepresentedthroughoutthisreporttocomplementthemainfindingsfromtheliteraturereview.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

4.Findings

Thischapterdescribesthemainfindingsfromtheliteraturereviewandtheinformantinterviews.

4.1Literaturereviewfindings

Theliteraturesearchesretrievedmorethan500results.Afterremovingduplicatereportsandreviewingtheabstracts,84systematicreviewswereselectedforfulltextreview.MostofthepublicationswerefromtheUnitedStates(US),Canada,theUnitedKingdom(UK),AustraliaandEurope.Resultswerelargelyassociatedwithhospital-relatedandprimarycaredigitalhealthinterventions.Systematicreviewsonvariousclinicaltopicswerenotedintheliterature,includingintheclinicalareasofdiabetes,cardiology,cancercareandmentalhealth.

Althoughthedigitalhealthliteraturebaseisexpandingrapidly,therehasnotbeenacommensurateincreaseintheunderstandingoftheeffectsofdigitalhealth,orhowdigitalhealthcanbeusedtoimprovehealthandhealthcare.Moststudieswereoflowtomoderatequalityduetoconsiderableheterogeneityoftechnologydesign,implementationsandcontext.Mostresultsofthisreviewarerelatedtoprocessoutcomes,withfarfewerresultsabouttheclinicaloutcomesforpatientsafetyandquality.Itisacknowledgedthatitischallengingtoattributepatientoutcomestoasingledigitalhealthintervention.Furtherdetailsoftheliteraturereviewresultshavebeenanalysedandsynthesisedintorelevantsectionsthroughoutthisreport.

Consistentuseofstandardisedterminologiesindigitalhealthisoftenlimitedduetothecomplexityandvariabilityofhealthserviceorganisations.Adesktopscanwasdonetohelpunderstandcurrentpatternsofterminologyuse.Aglossaryoftermswasassembledtoinformrelevantsearchstrategiesandtovalidatetheconsistentuseofdigitalhealthterminology(AppendixA).

4.1.1Electronicpatientportals

Thisliteraturesearchidentified10systematicreviewsabouthowelectronicpatientportalimplementationaffectspatientsafetyandqualityofhealthcare.Mostofthesystematicreviews1,3,13-15,17,18hadallpatientsubgroupsandtypesofhealthserviceorganisationsintheirinclusioncriteria.Onefocusedonelectronicportalsforpeoplewithdiabetes19,andanotherfocusedonelectronicportalsforpaediatricpatients.20

4.1.2Patientremindersusingmobiletechnologies

Theliteraturesearchidentified21systematicreviewsabouttheeffectsofpatientremindersusingmobiletechnologies.2,4,21-39Thesereviewslookedatdifferentsafetyandqualityoutcomes,including:

• Medicationadherence
• Appointmentattendance
• Preventivehealthcareandscreening
• Self-managementoflong-termillnesses

• Treatmentcomplianceinmentalhealth.

4.1.3Informationsharingondischarge

Thisliteraturesearchidentifiedthreesystematicreviewsabouttheeffectsofelectronicdischargesummaries(EDSs)onsafety,andthatweretransmittedfromahospitaltoprimarycareproviders.40-42NoneofthesystematicreviewsfocusedsolelyonEDSs;rather,theauthorsinvestigateddifferentinterventionstoimprovepatientdischarge.Findingsweresupplementedbyreviewingthestudiesincludedineachsystematicreviewandpublishedaftertheyear2000.Thus,atotalofninestudieswerereviewed43-51,whichexploreddifferentEDSsystemsandprocesses.Althoughthesestudieswereallpublishedwithinthepast

11years,theEDSsystemsevaluatedincludedsomethatreliedonoutdatedtechnologies.Forinstance,inmostofthestudies,EDSsweregeneratedusingelectronictemplates,thentransmittedtoprimarycareprovidersusingconventionalmail45,50,51,orelectronicorconventionalfax.46,48Incontrast,email43orsecuremessaging44wasusedtotransmitEDSsinonlytwooftheincludedstudies.

4.1.4Computerisedproviderorderentry

Theliteraturesearchidentified21systematicreviewsabouthowcomputerisedproviderorderentry(CPOE)affectsthesafetyandqualityofhealthcare.Mostofthesystematicreviewslookedatthehospitalsetting,andincluded:

• All patient subgroups for inpatients and outpatients16,52-57
• Intensive care units (ICUs)5,58,59
• Emergency departments (EDs)6,60
• Acute care61

• Transplant centres.62

Onesystematicreviewlookedatprimarycare63andtheremainderdidnotspecifyasettingorpatientsubgroup.13,64-68SevenofthesystematicreviewsfocusedonCPOE,whereastherestfocusedoninvestigatingdifferentdigitalhealthinterventionstoimprovepatientsafetyandquality,whichincludedCPOE.CPOEwasoftenstudiedincombinationwithcliniciandecision-supportsystems(CDSSs).Overall,assessmentofCPOEmostlyusedprocessmeasuresratherthanclinicaloutcomemeasures.6,54

4.1.5Clinicaldecision-supportsystems

Theliteraturesearchidentified29systematicreviewsabouthowCDSSsaffectthesafetyandqualityofhealthcare.Eightsystematicreviewsfocusedonprimarycare8,9,69-74,twoonEDs60,75,twoondiabetescare10,76andtwoonacutekidneyinjury.77,78Beyondthesestudies,otherpatientgroupsandhealthcaresettingsincludedICUs79,transfusionpractice11,mentalhealth80,paediatrics81,acutecare82,cardiovascularmanagement83,HIVcare84andancillarydepartments.85Theremainingstudiesdidnotspecifyasetting.12,86,87MostsystematicreviewsfocusedontheimplementationofCDSSasastandaloneproduct,whereastheremainderfocusedoninvestigatingdifferentinterventionstoimprovepatientsafetyandquality,whichincludedCDSSs.AswithCPOE,CDSSresearchstudiesprocessmeasuresratherthanclinicaloutcomemeasures.83

4.1.6Greyliterature

Anumberofhighlyinformativeandactionableresourceswereidentifiedinthegreyliteraturereview,includingdetailedreportsfromkeyinternationalorganisationsforsafetyandquality.TheNationalHealthServiceintheUKprovidesaguidetodigitalhealthassessmentandmappingofdigitalroadmaps.88,89Similarly,theNationalQualityForumintheUSprovidesaHITMeasurementFramework.90TheWorldHealthOrganizationhasasociotechnicalmodelformeasuringdigitalhealthinterventionsatmultiplepointsthroughoutthedigitalinterventionlifecycle.91TheUS-basedAgencyforHealthcareResearchandQuality’sHealthInformationTechnologyunitdescribenationaldigitalhealthimplementationintheguideHealthIT-EnabledQualityMeasurement:Perspectives,pathways,andpracticalguidance.92Recently,StandardsAustraliaproducedtheDigitalHospitalHandbook,whichinformsthedesignandimplementationofdigitalhospitals.93

4.2Informantinterviewfindings

Interviewswithfivekeyinformantswereconducted.Keyinformantsareconsideredtobeinternationalleadersindigitalhealth,andarebasedindifferenthealthcare,academic,governmentandpeakbodyorganisationsinAustralia,theUSandtheUK.Thesekeyinformantshavebroadexperienceinthedesign,implementationandevaluationofdigitalhealthinterventionsatlocal,regionalornationallevels.Specifically,keyinformantsdrewontheirdirectexperiencewithelectronichealthrecords,CPOEorelectronicmedicationmanagement,CDSSs,digitalinformatics,andelectronicpatientportals.Keyinformantsalsoincludedindividualswhohaveheldrolesinnationalpeakbodies,governmentalstatutoryauthoritiesandnationalagenciessupportingdigitalhealthsystemsandstrategies,standardsdevelopment,andbenchmarking.

Toprotectindividualidentities,specificdetailsonemployerorganisationshavenotbeenincluded,norhasanyinformationofasensitivenaturedescribedbykeyinformants.

However,duetothenatureofthisstudy,itispossiblethatindividualkeyinformantsmaybeidentifiablefromtheinformationprovidedinthisreport.AstatementthatacknowledgesthiswasprovidedintheParticipantInformationSheet.

4.2.1Electronicpatientportals

Theincreasinguseofelectronicpatientportalsinhealthreflectsagrowingmovementtowardsperson-centredcare.Electronicpatientportalshelpconsumerstobecomeactiveparticipantsindecision-makingabouttheirhealthcare.90Healthserviceorganisationsareincreasinglybeingrequiredtoprovideperson-centredcare,andsupportconsumerstoshareindecision-makingandbecomeactiveparticipantsintheirowncare.94

Drivers of uptake: increasingpatient engagement

Themaindrivingforcebehindourimplementationofpatientportalswasregulation:TheAffordableCareAct,Obamacare.Wehadtocommunicatewithourpatients …Itwaspartofthiswholephilosophyofpatientandfamilyengagement.

ElectronicpatientportalshavebeendefinedbytheUnitedStatesGovernmentas‘asecureonlinewebsitethatgivespatientsconvenient24-houraccesstopersonalhealthinformationfromanywherewithaninternetconnection’.95Moreoften,patientportalsaretetheredtohealthserviceorganisations’EHRs.Alternatively,electronicpatientportalsmaystandalone,asisthecasewithAustralia’sMyHealthRecordsystem,apersonallycontrolledhealthcarerecord.Onekeyinformantdescribedtheadvantageofpersonallycontrolledhealthcarerecordsintermsofempoweringconsumerstobeinvolvedintheirownhealthcare.

Personallycontrolled health information

Ithinkthekeythingisthatthefactthatitprovidespeoplewithaccessto,andcontrolof,theirownpersonalhealthinformationlikethey'veneverhadbefore…Itwillbelikethewaywecan'timaginewhatwedidbeforewehadamobilephone25,35yearsago.Itwillbeabitofagamechangerbecausethewaypeoplehavetheirownknowledgeofwhat'shappenedintheirhealthcarewillbesogreatlyenhanced.They'llbeabletoengage,andbemuchbetteractivatedintermsoftheirconnectionstotheirtreatmentplansandtheirowndecision-makingabilitiesaswell.Havingaccessto theirownpersonalhealthinformationwillactuallytransformthewaypeopleinteractwiththeir healthcareproviders.

Electronicpatientportalsmayencompassdifferentfunctions,includingtheabilityforconsumersto:

• Viewanddownloaddischargesummariesandpersonalhealthinformation
• Scheduleappointments
• Exchangesecuremessageswithclinicians

• Requestprescriptionrefills.

Incertaincontexts,accesstoanelectronicpatientportaliscombinedwithotherservices,suchascasemanagementandtelehealth,aspartofalargerpatientmanagementsystem.

Electronicpatientportalsseemtohavethepotentialtoenabletheconvergenceoftechnologiesintosophisticated,integratedsolutions.Keyinformantshighlightedthisasanelementthatmaysupportpositivesafetyandqualityoutcomesinthefuture.

TheMyHealth Record system: a basis for converging technologies

[The]My HealthRecord[system]isgoingtobethebasis,weenvisage,thatalotofthird-partyapplicationswillsitontopof,anddrawinformationfrom.Thelong-termvisionisthatyouwon'tbelookingatthisthroughourconsumerportalorourproviderportalatall.Itisaseriesofpipeswherealloftheinformationwillflowtoacentralpoint,andthenthird-partyapplicationsand vendorsoftwaresystemscansitontopofthesystemandpullouttherelevantstuff,andpresentittopeopleinawaythat'sdigestibleandeasytouse,andlookslikeyouriPhonestuffthatyou'reusedto.

Theliteraturehasidentifiedfourwaysthatelectronicpatientportalsmaysupportimprovedoutcomes14:

• Providingconsumerswithsecureaccesstotheirpersonalhealthinformationengagesthemindecision-makingandmotivatesthemtofollowtreatmentregimes,resultinginimprovedhealthoutcomes
• Patientportalfunctions,suchasremindersanddecisionsupporttools,mayempowerconsumerstoactontheinformationpresented,thusimprovingadherencetotreatmentplans
• Patientportalsenablecommunicationbetweenconsumersandclinicians,enablingdevelopmentofstrongclinician–consumerrelationships,translatingintoimprovedcontinuityofcare,consumersatisfactionandclinicaloutcomes

• Electronic portals may provide consumers with convenient access to the services, resources and information they require, resulting in improved consumer satisfaction.14

Theevidenceiscurrentlyinsufficienttoidentifyanyeffectsofelectronicportalsonpatientoutcomes.Somestudiessuggestedthatelectronicportalusemayleadtoimprovedpatientsafetyandqualityofcare.However,theseeffectswereneitherconsistentnorstrongacrossallstudies.13,20Forinstance,inKruseetal.’sreview13,only10outofthe27includedarticlesreportedpositivepatientoutcomesassociatedwithportaluse.Conversely,negativeoutcomesarerarelyreported.13,14Nevertheless,thereareexamplesofindividualstudiesinwhichpatientportalusewasassociatedwithpositiveoutcomesacrossdifferentchronicdiseases,suchasdiabetes,hypertensionanddepression.1,13,15,20Improvedmedicationadherence1,13,14,17andincreaseduseofpreventivemedicineandscreening1,13havealsobeenassociatedwithportaluse.However,thesepositivefindingswerenotuniformandwerenotsupportedacrossawiderbodyofliterature.

Similarly,itwassuggestedthatelectronicportalusemayhelptosupportconsumerengagement,consumerempowermentindecision-making13,15,17andimprovedself-management.13However,conflictingresultsarereportedacrosstheliterature.Theavailableevidenceislimitedduetoweakstudydesignsandsmallnumbersofstudiesreportingdatafortheseoutcomes.Ammenwerthetal.17concludedthat‘better-informedpatientsarenotnecessarilyhealthierpatients’(p.10).Thismaybebecauseprovidinghealthinformationviaanelectronicportalisonlyoneofmanyfactorsthatsupportqualityhealthcare.Pairingelectronicpatientportalswithotherhealthservices,suchascasemanagement15,orwithotherdigitalhealthinterventions,suchaspatientreminders,decisionsupporttoolsandsecuremessaging17,wasfoundtobemoreeffective.Acombinedapproachbettersupportedandguidedpatientstousetheinformationinelectronicportals.17

Consumersatisfactionwithelectronicportalsisgenerallyhigh,especiallywhenportalsfeaturesecuremessagingfunctionsthatenablecommunicationwithclinicians.13,14Overall,consumersfoundinformationinportalsusefulandvaluable15,feltitimprovedcommunicationwiththeirclinicians13andincreasedtheirprominenceinperson-centredcare.1,13Consumersalsofavouredportalfunctionsthatofferconvenience,suchasprescriptionrefillordering,accesstomedicalrecordsandtheabilitytosharetheserecordswithothers.3Cliniciansappeartohavemorenegativeattitudesaboutelectronicportalsthantheirpatients.Cliniciansarereportedtobeconcernedaboutconsumers’reactionstoreadingtheirclinicalnotes;liability,potentialprivacyandsecurityissues3,15;theaccuracyofconsumer-entereddata;andtheeffectontheclinician–consumerrelationship.3However,theseconcernsappeartoresolveovertimeandwithmoreexperienceinusingtheportals.96

Keyinformantcommentsreflectedthepublishedevidenceabouttheeffectsofportaluseonconsumersatisfactionandclinicaloutcomes.Althoughthekeyinformantswereunsureaboutassociatedhealthoutcomes,onekeyinformantreportedhighelectronicpatientportalregistrationratesandanupwardstrendinportalvisitsintheircancercentre,indicatinghighconsumersatisfaction.Thiskeyinformantbelievedthatthemainoutcomeofinteresttargetedbyportalswasthatofconsumerengagement.

Electronic portals and patient engagement

It’smoreaboutthequalityandtheengagementwiththecareteam,emailingandgettingmedicationlistsfromprimarycare.Wecanaddsomething.

Ithasbeenhypothesisedthatelectronicpatientportalsmaysupportimprovedqualityofcarebyreducingunnecessaryhealthcareuseandallowingclinicianstofocusonpatientswithhigherneeds.Therearemixedresultsintheliteraturefortheeffectofelectronicpatientportaluseonhealthcareuse.Somestudieshavedemonstratedanassociationbetweenelectronicportaluseandlowerratesofin-personspecialistvisits,visitstotheemergencydepartmentandtelephoneconversationswithclinicians.3,13-15,17,20Theseresourcesavingsarenotconsistentacrossthestudies.Incontrast,somestudieshavefoundportalstobeassociatedwithincreasedconsumercommunicationwithclinicians,viasecuremessaging,telephonecontactandrequestsforextendedconsultations.13Insomestudies,electronicpatientportalusehasbeenassociatedwithimprovementsincontinuityofhealthcare13,suchasdecreasednon-attendance3,13and,whenpairedwithpatientappointmentreminders,increasedattendanceatclinicappointments.3However,theseobservationsarenotconsistent.Overall,itisunlikelythatelectronicpatientportalswillhavesubstantialeffectsonhealthcareuse.15Electronicpatientportalsappeartocomplement,ratherthansubstitutefor,existinghealthservices.14

Electronicpatientportalresearchhasfocusedonexploringthedifferencesinportaluseacrossconsumerpopulations.Promotionanduseofelectronicpatientportalsbycliniciansappeartohaveastronginfluenceonpatients’ownsustaineduseofelectronicportals.3,19Inaddition,consumers’interestin,andabilitytouse,portalsareheavilyinfluencedbypersonalfactors,withsocioeconomicdisparitiesinportaluseconsistentlyidentified.14Consumersfromculturallyandlinguisticallydiversebackgrounds,andthosewithlowereducationandincomelevelstendtouseportalslessoften.3,15,19,20Incontrast,patients(andtheircarers)withchronichealthconditionsandpatientswithcomorbiditiestendtouseportalsmore.3,19,20Younger,well-educatedconsumersandthosewithhighercomputerliteracyarealsomorepositiveaboutusingelectronicportals.1,3,13,15,19Theapparent‘digitaldivide’betweensocioeconomicgroups–intermsofhavingaccesstotheinternetandhomecomputers–mayfurtherpreventdisadvantagedgroupsfromhavingequalaccesstoportals.1,19

Similarobservationsabouttheinfluenceofpersonalfactors,suchastheimpactofchronicdiseaseandageonportaluse,werevoicedbyonekeyinformant.

Disparities in patientportal use

Weknowwe'vegotavery highregistrationrate.Maybeit'stheoncologypatientsthatwanttobeinformed.They'rehungryforknowledge.They'reevenencouragedtoregisterbeforetheirfirstvisitandcompleteaveryextensive,onlinepersonalhealthassessmentbeforethefirstvisit.

I'mchallengedlookingattheageofpeoplewalkingthroughourcorridors.We'resurroundedbymanyelderlypatients.Youknow,thebulkofourinsurancecarrierisMedicare,peopleover65.Ijustwonderhowmuchtheywoulduseit.

Further,healthliteracyandnumeracyappeartoexertastronginfluenceonconsumers’useofelectronicpatientportals.3,13,20Whenusinganelectronicportal,consumersaresupportedinaccuratelyenteringtheirdata,understandingmedicalterminology,interpretingtestresultsandactingoninformation.Suchdisparitiesinhealthliteracyandnumeracymaypartiallyexplaindifferencesinuseindifferentsociodemographicgroups.Attentiontohealthliteracyandnumeracyappearstobeanessentialelementofportaldesign,whichisnecessarytosupportpositivepatientoutcomes.Otherwise,consumersmaybeunabletouseportalstotheirfullextentwithoutthehelpofclinicians,andconsumersareatriskofenteringincorrectdataormisinterpretingtheavailableinformation.13

Mainfindingsandcriticalsuccessfactors:

• Successfulpatientportalsappeartoincludefunctionssuchassecuremessaging,patientremindersandprescriptionrefillorders
• Electronicpatientportalsappeartobemostsuccessfulwhenintegratedwithotherinterventionsthatsupportpatientstoactontheinformationavailableintheportal,suchasremindersandclinicaldecisionsupporttools
• Electronicportaluseisconsistentlydifferentacrossconsumerpopulations,reflectingthedigitaldividebetweenconsumerfromdifferentsocioeconomicbackgrounds
• Ifcliniciansareengagedin,andsupport,electronicpatientportals,thenconsumersmayusetheseportalsaswell

• Makingelectronicpatientportalsavailablewithintheclinicalcontextallowsclinicianstohavebetteraccesstothem,andprovidesmoreopportunitiesforclinicianstousetheseportalswhendesigningtreatmentplans.

4.2.2Patientremindersusingmobiletechnologies

Non-attendanceatscheduledappointmentsisabarriertopatientsreceivingtimelyevidence-basedhealthcare.Itisalsoamajorsourceoflostresourcesandunderuseofcliniciantime.26Consumersespeciallyatriskofnon-attendanceincludethosethataremen,agedunder40yearsandfromlowsocioeconomicbackgrounds.36Similarly,medicationnon-adherenceisawell-documentedhealthcareissuestronglyassociatedwithpoorpatientoutcomesandincreasedcoststothehealthcaresystem.32Ithasbeenhypothesisedthatpatientremindersmayimproveattendance,reducedelaysindiagnosisandtreatment,andultimatelyimprovepatientoutcomes.26Giventhewidespreaduseandacceptanceofmobiletechnologiesacrossdifferentsocioeconomicandculturalgroups29,suchtechnologiesmayalsopotentiallysupportconsumerbehaviourchange.Examplesincludeincreasingpatientadherencetomedicationregimesbyremindingthemofwhentotakemedicines,andthroughprovisionofeducationalandmotivationalhealthinformation.Mobiletextmessaginginterventionshavetypicallyincludedone-waymessages,fromclinicianstoconsumers.Othersaretwoway,allowingconsumerstoconfirmreceiptofthemessage,orindicatewhethertheyhavetakentheirmedicineorareabletoattendtheirupcomingappointment.

Theliteraturegenerallyconcludesthatelectronicremindersviamobiletextmessagesaresimpleandpotentiallyeffectivewaysofsupportingmedicationadherenceacrossdifferentchronicdiseaseconditions29,35,37,includingasthma37,38,diabetes27,28,HIV2,25,infantandmaternalhealth33,andcancer.22However,notallsystematicreviewsdemonstratedaconsistentlypositiveimpact.DeJonghetal.23foundmixedresultsfortheimpactoftextmessagesonpatientself-managementofchronicconditionssuchasasthma,hypertensionanddiabetes.Zapataetal.4andSmithetal.34foundinconsistentfindingsfororalcontraceptiveuse.Kauppietal.30concludedthatevidenceformedicationadherenceinpeoplewithmentalillnesswasinconclusive.Similarly,electronicpatientreminderswereassociatedwithimprovementsinmedicationadherenceinonlythreeofninestudiesincludedinthereviewconductedbyMistryetal.31Themagnitudeofpositivebenefit,althoughstatisticallysignificant,appearstobesmallandmaynotnecessarilyresultinimprovementsinmedicationadherence.37

Overall,theevidenceshowingthatmobiletextmessagesimprovemedicationadherenceispromising,butweak.32Further,fewstudieshavedocumentedapositiveeffectofpatientremindersformedicationadherenceonclinicaloutcomesorqualityoflife.23,38Finitsisetal.25foundthatpeoplewithHIVwhoreceivedtextmessagestosupportmedicationadherencedemonstratedimprovedbiologicaloutcomes,suchasdecreasedviralloadandincreasedCD4+count.

Certainfeaturesofpatientremindersappeartoaffectmedicationadherencedifferently.Forexample,Waldetal.39foundthatone-waytextmessaginginterventionshadlittlepositiveeffectonmedicationadherence.Thiswascomparedwithtwo-waytextmessaging,whichwasassociatedwithsignificantimprovements.Patientswere20%morelikelytoadheretomedicationregimeswhentwo-waymessagingsystemswereused.Similarly,Finitsisetal.25reportedthattwo-waymessagingsystemsproducedsignificantlygreatereffectsonmedicationadherencethanone-waymessagingsystems.One-waymessagingplatformscanonlysupportadherenceinpatientswhounintentionallyforgettotaketheirmedicine.37However,two-waymessagingmaybeespeciallyimportantwhensupportingadherenceinpatientswhointentionallydecidenottotaketheirmedicine,forexample,duetoconcernsaboutrisksassociatedwithdosage.39Two-waymessagingmayprovidebettersupportthanoneway,asitmayimproveconsumerengagement,givingcliniciansanopportunitytoinvestigatereasonsfornon-adherence,andtoaddressconcernsandprovideextrasupport.

Keyinformantcommentssupportedtheviewaboutthesuperiorityoftwo-waymessagingfunctionoftheorganisation’spatientportal,butalsohighlightedthesubsequenteffectsonworkload.

Success in two-waymessaging

Wherewe'venotseentheoptimalsuccessfrommyperspectiveisthebidirectionalexchangeofpatientinformation.WithintheCerner'ssystem,there'sMessageCentre,whichislikeaninboxandthere'sabell-shapedcurveofhowwellthat'sbeingusedacrossourorganisation.Youdon'twantbusyconsultantsgettingablizzardofemailsfrompatients,butthere'sacapabilitytocreateapoolwiththeMessageCentre,soyoucanhaveanursedothefilter,forwardthecriticalemailstothemedicalstafftothengetaresponse.

Thedesignandcontentoftextmessagesthemselvesmayaffectmedicationadherence.Textmessagesthatareengaging,motivating,non-automatedorpersonalisedmaybemoreeffectiveforadherence.Basic,standardisedmessageswithrepetitivecontentmaybeassociatedwithlittleornoeffectonadherence.25,31-33,37Usingremindersystemstoprovidefeedbacktoconsumersabouttheirownadherenceratesmayalsoincreasemedicationadherance.97

Asisthecaseforpatientreminderstopromotemedicationadherence,thelimitedevidencesuggeststhatmobilephoneremindersmaybeeffectiveatimprovingattendanceatscheduledhealthcareappointments21,26,29,33,36,andinincreasingre-attendanceandretestingforHIVorsexuallytransmittedinfections.24Patientremindersmayincreaseimmunisationratesinchildrenandscreeningratesfordifferentconditions,althoughtheevidenceisinconsistentandoflowcertainty.33Studieshavefoundmobiletextmessagestobemoreeffectivethannoremindersorpostalreminders.21,26Mobilephonemessagingremindershavealsobeenfoundtobeaseffectiveas26,ormoreeffectivethan36,telephonecallreminders.Otherstudieshaveconcludedthatthereiscurrentlyinsufficientevidencetosupportoneformofpatientremindersoveranother24,includingforpeoplewithmentalillness.30

Aswithmedicationadherence,thereislittlepublishedresearchonwhetherimprovedattendanceatappointmentstranslatesintoimprovedpatienthealthoutcomes.26Similarly,safetyconsiderations,suchasriskstoconsumers’privacy,havereceivedlittleattentionintheliterature.Researchintotheeffectofremindersonhealthoutcomesiscriticallyneeded,tounderstandthedegreetowhichthisinterventionhasaffectedpatientsafetyandquality.

Itiscurrentlyunclearwhatthebesttiming,rateanddegreeofpersonalisationofmobilephoneremindersare.21Holcomb28concludedthatweeklytextmessagesbestsupportedpositiveclinicaloutcomesforpatientswithdiabetes.Similarly,Finitsisetal.25reportedthatpatientremindersdeliveredlessoftenthandailyandthatmirroredtheindividual’smedicationscheduleweremoreeffectiveatsupportingadherenceforHIV.Morefrequentremindersmayleadtomessagefatigueandtopatientsnotrespondingtoreminders.Poormanetal.33recommendedthat,iftextmessagesareused,theircontentandtimingshouldbevariedtominimisereminderfatigueandpromotepatients’responsetoalerts.Moreresearchaboutmessagecontent,timingandfrequencymayhelptodefinehowtextmessagingcanincreasepositiveoutcomes,andinformsuccessfulimplementationofmessaginginterventions.23

Mainfindingsandcriticalsuccessfactors:

• Mobiletechnologiesmaybeeffectiveindeliveringreminderstoalargeproportionofthepatientpopulationgroup;however,theappropriatenessofmobiletechnologiesisunknownforsomegroups,suchasolderpatientsandpatientswhodonotspeakorreadEnglish
• Appropriatetiminganddeliveryofremindersmayavoidreminderfatigueandsupportsuccessfuladoptionofpatientmessaginginterventions

• Two-waymessagingmaypromotesuccessfuloutcomesbygeneratingpersonalisedcommunicationbetweencliniciansandconsumers;however,thismayalsoaffectclinicalworkflow.

4.2.3Informationsharingondischarge

Timelysharingofhigh-qualityinformationattransitionsincareisrecognisedascriticaltocontinuityofcareandpromotionofpatientsafety.Anexampleofatransitionofcareisbetweenacuteandprimarycarecliniciansatpatientdischargefromhospital.However,inhealthsystemswhenprimaryandacutecareisprovidedbyseparateservices,thetransmissionofdischargesummariesisoftendelayedbetweenbothgroupsofclinicians.Also,thequalityofinformationcontainedinconventionaldischargesummariesmaybesuboptimal.Informationaboutpendingtestresults,dischargeplanningandmedicationchanges41maybeleftout,whichcouldjeopardisepatientsafetyandqualityofcare.40EDSsaimtoconsidersuchchallengesbyimprovingprocessesrelatedtothegenerationof dischargesummariesandtheirtransmissiontoprimarycareclinicians.OnekeyinformantreinforcedtheideathattheseamlesstransferofinformationacrossafragmentedhealthsystemisoneofthemajoropportunitiesfordigitalhealthintheAustraliancontext.

Digital health as an aid for information transfer

Digitalhealthistheonlywaytogetsafelyfromoneplacetoanother,interms ofinformationflowingseamlesslyfrompoint-to-pointwithinthefragmentedhealthsystemthatwehave,inawaythatalldifferentprovidersinthesystemarelookingatthesamepieceofinformationatthesametime…Theadvantageofdigitalhealth,particularlyfromaclinicalsafetyperspective,isthewayitcanprovideclinicianswithinformationimmediatelywhentheyneedtomakeadecision.Sothatavoidsthedelaythatcancauseerrorsinclinicalcare,becausewearelookingforpiecesofinformationthataremissing,orwedon'thaveaccesstoit.Weknowthatmanycliniciansspendalotoftimelookingforinformationthattheyneverfind.Thathasanimpact,obviously,onthewayyoumakeasensibledecision.

EDSsappeartobeapromisinginterventionforpromotingpatientsafetyandqualityofcare;however,high-qualityevidencefortheiruseislimited.EDSscanpromotetimelinessofpreparationandtransmissionofpatientinformationtoprimarycareclinicians.40-42Timelinessmaybesupportedbyspecificautomatedsystemfeatures,suchas:

• PopulationofEDSswithinformationfromthehospital’sEHRsystem
• ReminderstocompletetheEDS
• ElectronicdeliveryofEDSsviasecureemailorfax

• Electronic notification for primary care clinicians about when EDSs are available on shared EHRs.41,46

FindingsaremixedabouthowEDSsaffectthequalityofinformationprovided,includingthecompletenessandaccuracyoftheinformation.OfthefivestudiesincludedinareviewbyKatteletal.41,onlytwofoundthequalityofEDSstobesignificantlybettertoconventionaldischargesummaries.NoevidenceinthisreviewsuggeststhatEDSshadadetrimentaleffectoninformationquality.41However,thereviewbyUnnewehretal.42foundasignificantreductioninqualityofpatientinformationinEDSsintwostudies.49,50ThisworseninginqualitymaybeduetotimeconstraintsplacedonfinishingEDSs,wordlimitsinsetfieldsofEDStemplates,alackoftrainingandeducationonEDSs,andpoorintegrationintoroutineworkflow.AlthoughlegibilityappearstobesupportedbyEDSs,Reinkeetal.47reportedthatreadabilitymayalsobecompromisedwhencliniciansentercommentsdirectlyfromprogressnotes.Thus,unintendedconsequencesofEDSmayincludethepropagationofinaccurateorout-of-contextinformation,potentiallyhavinganegativeeffectonpatientsafetyandqualityofcare.90

TheevidenceabouttheeffectofEDSonpatientoutcomesisverylimited.Oftheincludedstudies,onlytwoinvestigatedadverseoutcomesornearmissesduetoproblematictransferofpatientinformation.45,46BothfoundnostatisticaldifferenceinthesepatientoutcomesforEDSscomparedwithconventionaldischargesummaries.OnestudyintheKatteletal.41reviewfoundthatconsumersviewedtheuseofEDSsasasignofimproveddischargepreparedness.

Mainfindingsandcriticalsuccessfactors:

• EDSsmayhelpthepreparationandtransmissionofpatientinformationtoprimarycarecliniciansontime
• EDSsmaybemoresuccessfulwhen

auto-populatedwithinformationfromahospital’sEHR

deliveredviasecureemail

theyusereminderstoclinicianstocompletetheEDS

• CliniciansappeartoneedtrainingandsupporttoenablesuccessfuluseoftheEDS.

4.2.4Computerisedproviderorderentry

Medicationerrorsarecommonandapreventablecauseofpatientharm.13,63,69Theageingpopulation,increasingcomplexityofmedicalpractice,andpatientswithmultiplecomorbiditiescanallcontributetomedicationerrors.57,63Medicationerrorsarereportedtooccurinupto11%ofallprescriptionsandareestimatedtocause2–3%ofallhospitaladmissionsinAustralia.85,98Theburdenofmedicationerrorsandconsequentadversedrugevents(ADEs)havebeenshowntohavelargeeffectsonpatientsafetyandqualityofcare.52Recentresearchhasdemonstratedthattechnologycanbeusedtodecreasetheincidenceofmedicationerrors.CPOEisoneofthemostwidelypromotedapplicationstohelpclinicianscreateandmanagemedicalorders.13,58,63CPOEreplacestraditionalpapertools,andcanimprovecommunicationandprovidearobustaudittrail.53,67

Large-scaleinvestmentin,andimplementationof,CPOEhasbeenjustifiedonthebasisthatitcanreduceunwarrantedvariationinthequalityofhealthcare.60,67However,despitethepotentialbenefits,CPOEsystemshavenotyetbeenwidelyadoptedbyhealthserviceorganisationsinAustralia.13Thismaybepartiallyattributedtohighinitialandongoingcosts,butorganisationsarealsounsureabouthowmuchCPOEcancontributetobetterhealthcare.

TheevidenceunderpinningtheeffectsofCPOEonmostsafetyandqualityoutcomesremainsuncertain.13,60CPOEappearstohavealimitedeffectonhospitalmortalityandlengthofstay.60However,theresultsofsomepre-postdesignstudies,randomisedcontroltrialsandtimeseriesstudiessuggestedthatCPOEsystemshaveapositiveeffectonmedicationerrorsandADEs.CPOEinhospitalsettingswasassociatedwithreducednumbersofmedicationerrorsandADEsinmorethan50%ofstudies.64Also,theautomateddosecalculationfeatureofCPOEsystemswasassociatedwitha37–80%reductioninmedicationerror.64

TheimplementationofCPOEinhospitalstosupporttheappropriateuseofantibioticshasbeenreportedtoleadtoseveralbenefits,whichinclude:

• Reducedmedicationerrors
• Increasedde-escalation(commencementoftreatmentofapresumedinfectionwithbroad-spectrumantibioticsandnarrowingdrugspectrumbasedonculturesensitivities)
• Improvedsensitivity
• Increaseddetectionofinfection

• Improvements in the timely discontinuation of medicines.54

CPOEinemergencydepartments(EDs)hasbeenreportedtoleadtoa54%decreaseinmedicationerrorsandADEs.However,inthereviewbyKeasberryetal.,theriskofnewmedicationerrorsdoubledintwooutof16(12.5%)studies.60CPOEsystemsinpaediatricintensivecareunits(ICUs)havebeenreportedtoleadtoreducedmedicationerrors,suchasprescriptionsthataremiscalculated,incompleteorillegible,orexceedmaximumconcentration.5Similarly,anothersystematicreviewreportedan85%reductioninmedicationerrorsinICUs,whichwaslargelyattributedtoimprovedlegibilityofprescriptions.58

Despitesomepositivereports,moststudiesreportedmixedresultsandsomeinstancesofunintendedadverseconsequencesfollowingCPOEimplementation.Adverseconsequencesincludeincreasedmedicationerrorsindifferenthealthserviceorganisations.6,53,54,56,57,60,64,65Forexample,inasystematicreviewofCPOEinadultICUsettings,reducedmedicationerrorsweredemonstratedinthreeoutoffivestudies,butincreasedmedicationerrorswerereportedintheremainingtwostudies.59However,thesedifferencesmaybeattributedtothespecificsofaparticularintervention,context,consumerdemographicsandimplementation.ItmaynotmeanthatCPOEisapoordigitalhealthintervention.

Asidefromminimisingmedicationerrors,CPOEappearstohaveapositiveinfluenceonclinicians’behaviours;theymaybetteradheretoguidelinesandusebest-practicecare.However,asformedicationerrors,thecurrentevidenceforclinicians’behaviourisuncertainandcontainsmixedresults.Forexample,inthereviewofhospitalCPOEsystemsbyPageetal.61:

• 53%ofincludedstudiesreportedasignificantbeneficialeffectonclinicians’behaviour
• 34%reportednosignificanteffect

• 6%reportedasignificantdetrimentaleffect.

AsystematicreviewonCPOEinEDsreportedimprovementsinclinicians’adherencetoguidelines,moreappropriatemedicationordersandincreasedvaccinationrates.6TwosystematicreviewsfoundthatCPOEimprovedlaboratoryturnaroundtimes.60,62Anotherreviewshowed54:

• Lesstimetothefirstdoseofantibiotics
• Improvedantibioticselection
• Optimiseddosing
• Improvedadherencetoguidelines

• Fewerantibioticsprescribedoverall.

OnestudyfoundthatCPOEimprovedmedicationverificationtimes;however,thiswasnotassociatedwithareductionintimebetweenthemedicationorderandadministration.66

AlthoughCPOEhasreducedmedicationerrorsandADEsinsomeinstances,evidenceindicatesthatCPOEmaybemoresuccessfulwhenconfiguredwithintegratedclinicaldecisionsupportsystems(CDSSs).5,52,54,60,66ThissuggeststhatCPOEfunctionscanbeimprovedwhenothersoftwarecomponentsandspecialty-specificextensionsareintegrated.16,52,99CPOEconfiguredwithCDSSprovidesclinicianswithtimelyaccesstopatientinformationandelectronicdecisionsupporttoimproveclinicaldecision-makingandtheprovisionofqualityclinicalcare.ThecombinationofCPOEandCDSSisgenerallyassociatedwithagreaterreductioninmedicationerrorscomparedwithCPOEsystemswithoutextrasoftwarecomponents.5,6,13,52Maniasetal.5reportedthatsevenofeightstudiesincludedintheirreviewshowedsignificantreductionsinmedicationerrorrateswhenCPOEwascombinedwithclinicaldecisionsupport.Inaddition,CDSSsincorporatedintoCPOEwereassociatedwithimprovedguidelinecomplianceregardingmedicationreconciliationforinpatientproviders.6

DespitemixedreportsontheeffectivenessofCPOE,thefactorsassociatedwithitssuccessfulimplementationhavenotbeenwellexplored.13,56EachCPOEsystemcanvaryconsiderablyintermsoffunctionality,interoperability,costandinvolvementofstakeholdersinitsimplementation.54,63CPOEimplementationisahighlycomplexsociotechnicalintervention,successesandfailuresmaybeattributabletointerventiondesign,uniquefeaturesofthecontextandspecificimplementationfactors.56Asaresult,unintendedadverseconsequencesreportedintheliteraturemaybedifficulttoanticipateinothercontexts.54Manyofthesystematicreviewsidentifiedthatunintendedadverseconsequenceswereduetotechnicalfunctionalityandhumanfactors.Forinstance,onesystematicreviewidentifiedthatsociotechnicalfactorswerenotconsideredduringCPOEdesign,whichcontributedtonewtechnology–inducederrorsasaresultofcomputerscreendisplay,dropdownmenus,auto-population,wording,defaultsettingsandnon-intuitiveorderingwhenthesystemwasimplemented.53ThisriskhighlightstheneedfortailoredCPOEsystemsappropriatetothehealthserviceorganisation.56

DespitevariabilityinCPOEsystemsacrosssettings,CPOEalertsareconsistentlyreportedtohaveapotentiallydetrimentaleffectonworkflow,andconstituteamajorbarriertosuccessfulimplementation.5,16,53,54,57,59,61,63,64,66,67,100,101Alertfatigueleadstohighratesofalertoverride,andisawell-recognisedresultoffrequentorirrelevantalerts,andinterruptionstoworkflow.5,16,59,60Ithasbeensuggestedthat49–96%ofmedicationalertshavebeenoverriddenasaresultofalertfatigue.60Alertfatiguehasbeenlinkedtocliniciansoverridingcriticalsafetyalertsandwarningsofseriousdrug–druginteractions16,67,90,whichisamajorrisktopatientsafety.

TailoredCPOEalertshavebeenproposedasastrategytodealwithalertfatigue.Forinstance,tailoredCPOEalertshavebeenreportedtobeusefulwhenprescribingunfamiliarmedicinesortochangethewayinwhichpatientsaremonitored.64SometailoredCPOEalertsusehistoricaldatatoimprovethesensitivityandspecificityofthealerts,therebydecreasingthefrequencyofirrelevantalerts.Creationofcontext-specificalertsusingpatient-specificinformationmayimproveacceptanceofCPOE,reducealertfatigue61,66and,asaresult,promotepatientsafety.

Mainfindingsandcriticalsuccessfactors:

• CPOEappearstobemostsuccessfulwhenimplementedinconjunctionwithextrasoftwarecomponents,especiallyCDSSs
• InteroperabilityofCPOEwithexistingelectronicsystemsappearstoimprovethesuccessofCPOEadoptionandusability

• TailoringCPOEsystemstothehealthserviceorganisationincreasestheirappropriateness.

4.2.5Clinicaldecisionsupportsystems

Numerousclinicalguidelinesexist,butstudieshaveshownalargediscrepancyintheapplicationofbest-practiceevidenceintocare,resultinginsubstantialriskstopatientsafety.11,12,80,102-104Also,thereisoftenagapintherequiredclinicaltrainingandknowledgeforspecialisedclinicalareasandrarediseasetypes.71TheincreasinguseofEHRsystemsoffersnewopportunitiestointegratepolicy,best-practiceguidelinesandsurveillance.12,83,103CurrentresearchhighlightsthepotentialofCDSSstohelpwiththesechallengesencounteredinclinicalpractice.71,85,102CDSSsareinformationtechnologiesthatuserule-basedalgorithmstomatchpatient-specificcharacteristicstoadatabase.8,11,71,80,85,105Case-basedreasoningfunctionalitycreatespersonalisedpredictionsforassessingdiseasestatus,diagnosis,appropriatetreatmentoptionsandotherclinicaldecisions.9,11,83,85,103,105Inaddition,CDSSscangeneratepatient-specificremindersoralertswhendeviationfromrecommendedcareisdetected.8,10,71Thesesystemshavebeenwidelypromotedasapromisingapproachtoimprovingpatientsafetyandquality,yetadoptionratesarerelativelylowandfailureratesofimplementationarehigh.10,11,72,78,85,102Theliteraturesuggeststhatthelimitationsaremostlyduetotheimplementation’ssociotechnicalcomplexity.106

MostsystematicreviewsconcludedthatCDSSimplementationisassociatedwithimprovementsintheappropriatenessofcare,including:

• Betteradherencetoguidelinesanduseofpreventivecare
• Improvedclinician–consumercommunication
• FasterandmoreaccurateaccesstoEHRdata
• Fewermedicationerrors
• Lessunnecessarydiagnostictesting

• Improved decision-making quality.8-11,60,81,83,85,102

However,theactualeffectonpatientoutcomeswasalmostunanimouslyunclear.8,11,77,78,81Forinstance,onesystematicreviewofCDSSsindiabetescareshowedweaktomodestassociationswithimprovedpatientoutcomessuchasbetterglucose,lipidandHbA1ccontrol.However,adherencetoguidelines,processindicatorsandthequalityofdocumentationledtosignificantimprovementsincare.10Likewise,inasystematicreviewofantimicrobialprescribingbyBaysarietal.,CDSSswereassociatedwithimprovedprescribingappropriatenessinsixofeightstudies.12CDSSswerealsoreportedtoreducethenumberofpharmacyinterventionsandtheuseofbroad-spectrumantimicrobials.12However,therewereuncleareffectsofCDSSsonlengthofstay,adversedrugeventsandsurvivalrates.12Similarly,CDSSswereshowntomodifytest-orderingbehaviourin75%ofthestudies,yetonly20%ofthestudiesshowedaneffectonpatientoutcomes.85

OnlyafewsystematicreviewsprovidedevidenceforapositiveeffectofCDSSsonspecificpatientoutcomes.Specifically,CDSSsinambulatorydiabetesmanagementwerefoundtobeassociatedwithimprovementsinprocessesofcarein55%ofincludedstudiesandpatientoutcomesin63%ofthestudies.105Inaddition,CDSSimplementationindepressionmanagementwasreportedtoincreaseadherencetoguidelines,andwasassociatedwithimprovedscreening,diagnosis,referralandtreatment.80Thestudyalsoreportedreductionsindepressivesymptomsandanincreaseinreportedqualityoflife.80Incardiovascularcare,CDSSswerefoundtobeassociatedwithmoderateimprovementsinsecondarypreventionmeasuresandslightreductionsinthenumberofcardiovascularreadmissions.83Thisreviewalsofoundasignificantreductioninacutemyocardialinfarctioninpeoplewithcoronaryarterydisease,butnosignificantresultsfortheongoingmanagementofbloodpressure.

EHRs,registriesandotherlargedatasetscouldimprovedecisionsupportinthefuture.Theseanalyticaltoolscouldextractrelevantinformationandprovideinsightsthatclinicianscanusetomakeevidence-supporteddecisions.Earlyresearchsuggeststhattheseresourceshaveclinicalvalue.107Inaddition,informationabouthowothercliniciansinthesamespecialtymanagesimilarclinicalcasescanbeincludedinfutureCDSSs.ThisCDSSfunctionalityallowsindividualclinicianstolearnfromtheevolvingexperienceofcolleaguesaswellasfromthescientificliterature,whichmayultimatelyimprovethesafetyandqualityofcare.71However,digitalhealthinterventionsarelimitedbytheamountandqualityofdata,andthelevelofcommitmenttochange.

AlertfatigueisanotablefactorinfluencingtheeffectofbothCPOEandCDSSs.Alertsareintendedtopromptappropriatecareandmitigaterisk.However,theexcessiveuseofalertsisreportedtobethemostcommonbarriertoaseamlessworkflow.5,16,53,54,57,59,61,63,64,66,67,100,101Alertfatigueandhighratesofalertoverridearewell-recognisedconsequencesoffrequentandirrelevantalerts.5,16,59,60Thispresentssafetyconcernswhencriticalsafetyalertsareoverridden.16,67Alert-overrideratesarealsoaffectedbyhowspecificordetailedtheinformationis.Forexample,clinicianswereoftenoverwhelmedbythecomplexityofinformationinCDSSalertsandwerethenmorelikelytodisregardthealert.60,69,71,85

Healthserviceorganisationsmaybenefitfrommonitoringmechanismstomanagealertfatigue.Althoughthereareamplevendor-suppliedalerts,theliteraturerecommendsthatorganisationscarefullyreviewtheinclusionofinterruptivealertsandimplementaminimumsetoftargetedalerts.5,60,61,66,69,71,85ThisparticularapproachwasdescribedbyonekeyinformantasasuccessfulwaytouseCDSSs.

Managing excessive alerts

Oneparticulardrugknowledgebasewasappallinglyinsensitive.Wewerehaving1,600alertsfireamonth,ouroverrideweightandnotchangingwasabove90%.It'sfiringbeforeyouorderit.It'sfiringfartoofrequently.Youjustgothroughitandignoreit.Alertfatigueiswhatyou'vegot.

I'dlearnedabouttwopharmacologistswhowrotethebibleondruginteractionchecking.Theycreatedaprocessofwheretheywentinandaddressedonlycriticalalertsandturnedeverythingelseoff.We wentfrom1,600andwegotitdowntojust320.Andthatwasahugewin.Themedicalstafflovedit.Theylookedatitandwerejustblowingthroughit.

Mainfindingsandcriticalsuccessfactors:

• CDSSsappeartobethemostsuccessfulwhenimplementedincombinationwithextrasoftwarecomponents
• InteroperabilityofCDSSswithexistingelectronicsystemsmayimprovethesuccessoftheiradoptionandusability
• CDSSsthattargetdecisionsupportaccordingtoalocalminimumsetofindicatorsappeartohavegreateruptakeandeffectonqualityofcare.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

5.Criticalsuccessfactorscommonacrossdigitalhealthinterventions

Elementsofdigitalhealththatbestsupportsafetyandquality,fromboththereviewedliteratureandkeyinformantinterviews,werecommonacrossdigitalhealthinterventionsandnotspecifictoanyindividualinitiative.Thekeyinformantsfocusedonelementsofimplementationastheprincipalsuccessfactor,whenconsideringoptimisingtheoutcomesofdigitalhealthinterventions.Thereviewedliteraturealsohighlightedimplementationprocessesashavingacentralroleininfluencingoutcomes.90Infact,differencesinimplementationprocessesareattributedtodiverseoutcomesacrosssimilardigitalhealthinterventionsimplementedindifferentsettings.54,63Giventhatdigitalhealthisahighlycomplexsociotechnicalintervention,itisnotsurprisingthatimplementationisacriticalelementforsupportingpositivepatientoutcomes.Yusofetal.108proposedasociotechnicalframeworktoevaluatetheimpactofdigitalhealthinterventionsthroughtheconceptoffitbetweenhuman,organisationandtechnology.72,108Accordingtothismodel,successandfailureofadigitalhealthinterventionmaybeattributedtotechnologydesign,aswellastocomplexinterplaybetweenuniquefeaturesoftheenvironmentalcontextinwhichtheinterventionisimplemented.10,12,53,54Thekeyinformantsalsosupportedsociotechnicalapproachestounderstandingimplementationofdigitalhealthinterventions.

Sociotechnical approaches to change

Ithinkfirstofallthatchangehastobesociotechnical.Inotherwords,youcannotsimplytakeatechnologyandthinkthatthattechnologyisgoingtodetermineanimprovementinqualityorsafety.Thechangeisthechangeinservices,thechangeinorganisationalculture,thechangeinthewaythingsaredone,thechangeinsystemsandprocesses,plusthechangeinthetechnology.

Keyinformantswereemphaticthatimplementationofdigitalhealthinterventionsisahighlycomplexphenomenon.Healthserviceorganisationsfacechallengeswhenselectingwhichdigitalhealthinterventiontouse,andwhenaligningthemultiplelevelsofcomplexitythatcomewithusingdigitalsystems.109Attributingimprovementsinhealthcaretodigitalhealthinterventionsisoftendifficult,duetotheircomplexsociotechnicalfactorsandcontextoftheorganisation.90Thisargumentwasechoedbyonekeyinformantwho,whenaskedwhetheradigitalhealthinterventionimprovedsafetyandqualityoutcomes,commentedthattherewasnostraightforwardanswer.

Dodigital health interventions improve safetyand qualityoutcomes?

Ithinkthat'swaytoosimplisticaquestionforaverycomplexprogramofwork…Ifyoutrytooversimplifythesecomplexprojects,youarenotgoingtogettothebottomofit.Diditimprovequalityorsafety?Ofcourseitimprovedsomeaspectsofquality,ofcourseitimprovedsomeaspectsofsafety,butontheotherhandtherewerebothanticipatedandunanticipatedconsequencesandtheyplayedoutdifferently indifferentcircumstances.That'sasgoodasit'severgoingtoget.Thereisnosimple,straightforwardanswer.

Implementationprocessesandenvironmentalcontextsaregenerallypoorlydescribedintheresearchliterature.13,56Thismakesitdifficulttomakeconclusivestatementsaboutthefactorsthatmakedigitalhealthinterventionssuccessful,andleavespolicymakersandclinicianswithpoorempiricalresearchtoinformimplementation.15Thefollowingsectionsofthisreportwillexplorespecificsuccessfactorsrelatedtoimplementationthatsupportpositivesafetyandqualityoutcomes,whichareextractedfromtheliteratureanddrawnfromananalysisofkeyinformantinterviews.

5.1Positiveorganisationalleadership,governance,cultureandresourcing

Althoughunder-representedinthedigitalhealthliterature,organisationalfactorshaveastrongbearingonthesuccessofdigitalhealthinterventions.72,110Theavailableevidenceemphasisestheimportanceofleadership,governanceandapositiveorganisationalculturetowardsinnovation.110Twokeyinformantsfocusedonthecriticalimportanceoforganisationalleadershipindisplayingcommitmentto,andbeliefin,theneedfordigitalhealthimplementation.Leadersneedtosupportthenecessaryinvestmentinimplementation.

Theneed for strong leadership

Whoeveristhebosshastobereallycommitted,soitdoesn'tmatterwhetherthat'stheministerorthesecretaryofthedepartment,theCEOofthehospital.Whoeveristherealbossoftheprojecthastobecompletelycommittedandbeinvolved.Otherwise,it'sdeadmeat.

Italmostseemssurprisingtomehowmuchofaconversationthereistobehadinsomeplaces[withinthesector]aboutwhythisneedstohappen.In everyotherplaceI'veworked[outsidethehealthcaresector],it'sjustacceptedthatyou'renotgoingtobeasgoodasyou'resupposedtobe,ascapable,asefficient,ascompetitive,ifyou'renotdigitisingthewayyouwork.Soitneedssupportattheorganisation’s toplevelanddrivetochangethewaytheywork,tofocusitonsafetyandtherightreasons,andtoreallybackthatchangeandinvestinit.Thatleadsthecommitmenttodoingitandbeingcrucial,andremainscrucialtoseeingitthrough.

Appropriategovernancesystemsandprocessesmustbeinplace–attheorganisationandprogramlevels–toensuresuccessfuloutcomes.93Despitetheconsiderableinvestmentinpeopleandtimeinvolved,keyinformantsbelievedthatstrongprogramgovernancewasessentialandshouldnotbecompromised.

Theneed for good governance

You’vegottomakesureyou'vesetupallthegovernanceandcommitteesthatyouneed.Youcan'tskimponprojectboards,steeringcommitteesandreferencegroups.Youcan'tskimponhowhighthosecommitteesandlevelsofgovernanceare.It'sgoingtobethemostexpensivethingyoudootherthanbuildahospitalitselfbutit'sfarmorecomplexthanbuildingahospitalitselfbecauseyouhaven'tdoneitasoften.Thegovernancehastoreportthroughtotheboardandtheboardshouldbeinterestedinwhetherit's goingwellornotgoingwell.Youcan'tgo,‘we'llgetaway withnothavingsomeelementsofgoodprojectgovernancebecausewefeellikewecandoitcheaperorfasterwithoutalltherightstructureandpeople’.It'sjustnotsomethingyoucanskimpthistime.

Strongleadershipandgovernanceshouldbeevidencedbymanagementthathasaclearunderstandingoftheanticipatedbeneficialoutcomesofthedigitalhealthintervention.Inaddition,objectivesshouldbecloselyalignedwiththehealthserviceorganisation’sexistinggoalsandstrategicpriorities.110Onekeyinformantexplainedthatcarefullyarticulatedobjectivesofadigitalhealthinterventionhelptoshapeimplementationplansthatmeettheseobjectives.Thisinturnincreasesthelikelihoodthatpositivegainsarerealised.

Strongleadershipmustalsobedemonstratedbyappropriateinvestmentin,andresourcingof,implementation.Thisincludesallocationoffundsforboththenecessarytechnicalandhumanresources.93Keyinformantshighlightedtheneedfordedicatedimplementationtime,ratherthanexpectingtaskstobeabsorbedintoexistingroles.Onekeyinformantcalledforappointmentofa‘chiefarchitect’roletooverseeimplementation.Anotherkeyinformanthighlightedthatbudgetsmayneedtoincludeallocatedfundstobackfillpositionswhileworkforcemembersattendtrainingtosupportadoption.

5.2Iterative,continuousimprovementapproaches

Implementationofdigitalhealthinterventionsisbestsupportedbyiterativeapproaches,whichallowhealthserviceorganisationstomakeprogressiveadjustmentstodigitalhealthtechnologiesandprocesses.90,93Continuousimprovementapproachestherebyimprovethefitbetweenthetechnology,humanandorganisationalcontexts110,andmaximisethepotentialfordigitalhealthinterventionstoachieveimprovedpatientsafetyandqualitycare.Organisationsneedtoestablishlearningmechanismsthatfeedbackinformationtoimprovefuturedigitalhealthiterations.111Thisknowledgehelpsdecision-makersunderstandtheuniquecharacteristicsofthecontextandhowtheseaffectimplementation,andinformimplementationstrategiestailoredtothelocalsetting.Theliteratureandthekeyinformantsidentifieddifferentstrategiestoinformlearningcycles.

5.2.1Incorporatediverseperspectivesinconsultation

Animportantsuccessfactorwasbeingabletoharnessthecollectivewisdomandexperienceofstakeholdersinthedesign,implementationandproblem-solvingofdigitalhealthinterventions.93,110Theliteratureemphasisestheneedtoconsultdifferentstakeholdergroups,includingconsumers,clinicians,informationtechnology(IT)professionalsandmanagement.Thisconsultativeapproachensuresthatinterventionsrepresentagoodfitwithendusersandtheorganisationalcontext,andinformspatientsafetyandworkflowissues.90,110Engagementandcommunicationstrategiesmayneedtobetailoredtostakeholdergroupstomaximisetheirinvolvementinlearningandeducation.93Tobemosteffectiveinsupportingpositiveoutcomes,suchengagementshouldstartearlyandbesustainedovertime.93,110Consultationfacilitatesdialogueandtrustacrossstakeholdergroupswhomayotherwisehavediverseperspectivesaboutdigitalhealthanduseuniqueterminologytodescribedigitalhealthinterventions.Consultationthusprovidesanessentialfoundationforsuccessfulimplementation.110

Facilitating dialogue around digital technologies

Ifyougetpeoplefromdifferentworlds–theclinicians,thepolicymakers,thetechnicalpeople,thecommercialpeople–inthesameroomonaregularbasis,itwillbevery,veryawkwardinitially.

Nobodywillwanttotalkto anybody else,butasthey gettoknoweachother,astheydeveloptrust,astheybegintounderstandwheretheotherstakeholdersarecomingfrom,youeventuallygettoastagewhereyou'remakingprogress…Anynewtechnologyneedstobetalkedaboutinanorganisationandacrossorganisations.YouneedtohavewhatImightcalltownmeetings,getpeopleinaroom,getthemtovoicetheirconcerns,getthemtotryitout,getthepeoplewhoareenthusiasticaboutthetechnologytotalktothepeoplewhoarelessenthusiastic,butalsotoheartheconcernsofpeoplewhoareworriedaboutthetechnologybecausetheymayberight,andaddressthem.Allthatsoftstuff,thedialogue,thenegotiation,isabsolutelykeytothesuccessofthetechnologyproject…Infact,Ithinkit'smoreimportantthanallofthehardstuffthatpeoplearealwaysmeasuring.

Widestakeholderengagementalsoprovidesanopportunitytogainadeepunderstandingoftheuniqueneeds,concernsandviewpointsofusers.Thesefactorsareconsideredtobeessentialtopromoteuseracceptanceofdigitalinterventions.Failuretoadequatelyconsideruserperspectivesthroughstakeholderconsultationandco-designprocessesmayleadto:

• Negativeoriginalexperienceswithadigitalhealthintervention
• Suboptimalacceptanceanduptake

• Abandonment of the digital program.19,90

Ultimately,thesecouldleadtoafailuretoachieveimprovementsinsafetyandquality.

Acceptanceisdirectlycorrelatedwiththedegreetowhichdigitalinterventionsareperceivedtoalignwiththespecificneedsandprioritiesofcliniciansandconsumers.3Theeaseofuseoftechnologyhasastronginfluenceontheperceivedvalueofdigitalhealthinterventions.90Ifcliniciansuseadigitalhealthinterventiontopromotepatientsafetyandqualityofcare,theymustseeanadvantageforusingthatintervention.15Forexample,theconceptofrelativeadvantagemayexplainwhypeoplewithchronicconditions,orwithintensiveorlong-termtreatmentregimens,appearmoreinclinedtouseelectronicportals.Conversely,ifconsumersdonotbelievethatportalfunctionsareuseful,theymaybealreadysatisfiedwiththeirclinician–consumerrelationships,or,iftheyarenotveryill,theymaybelesslikelytoseetheextrabenefitinusingaportal.15,19

Stakeholderengagementprovidesanopportunitytoidentifyuserneedsandconcerns,andtotailorresponsestotheseovertime.90Forexample,onekeyinformantcommentedonhowconsultationwithcliniciansenabledoneorganisationtodealwithconcernsabouttheappropriatetimingofreleasingpotentiallysensitiveinformation.

Timing of releasing information to patients

Whatwasabigissuewaswhendoyoureleaseinformationtothepatientsandhowmuchdoyourelease?Someprettylife-changingresultscomethroughandIthinkthat'swhere,ifthere'sgooduseoftheportalandapatientseesthat,theyneedacommunicationavenuewithoutgettingaclinicappointment,andtohaveanelectronicdialogue.Somesitesareactuallypayingforemailandvirtualconsults.

Medicalstaffwereconcernedthattheyshouldbemadeawareofresultsaheadofthepatient.Webuiltinfivedaysatthisorganisation.Butovertime,weshrunkthatdownandweexpandedwhatwewerereleasing.SoIthinkaspeoplegetmoreconfidenceineducatingtheirpatients,they'veshrunkthereleasetimeandexpandedwhattheyarewillingtopublishoutonthepatientportal.

Likewise,stakeholderengagementmayhelptoensureagoodfitbetweenusers,andthedesignandusabilityofdigitalhealthtechnologies.Differentusergroupsmaynotinteractwithtechnologieswiththesameeaseorlevelofproficiencyasothergroups.Theappropriatetechnologydeliveryplatformsneedtobematchedtothetargetpatient.Userinterfacesthatareconfusingortime-consumingmayleadtoerrorsindataentry,andretrievalandworkarounds,potentiallyintroducingnewrisks.90Forinstance,giventhatmobiletechnologiesareprevalentacrossallpopulations,patientremindersdeliveredviatextmessagingappeartobeaneffectivemethodofreachingunderservedordifficult-to-reachpopulations.33Thesuitabilityoftextmessageremindersforculturallyandlinguisticallydiversecommunities,orforolderpeople,requiresfurtherinvestigation.21Off-the-shelftechnologiesmayneedtobepersonalisedandtailoredtospecificuserneedswithincertainsettings.90OnekeyinformantdescribedhowengagementwithclinicianshashelpedtoidentifycriticalusabilityissueswiththeproviderportaloftheMyHealthRecordsystem.Userfeedbackhasinformedadjustmentstotheportaldesign,toincreasethefunctionalityandtherealisationofsafetyandqualityoutcomes.AstheMyHealthRecordsystemisaccessedbycliniciansthroughthird-partysoftware,acloserelationshipwiththesevendorsisessentialtothedevelopmentofaninteroperablesystemthatmeetsuserneeds.

Usabilityand theMyHealth Record system

Theissueisthatwiththosethird-partyvendors,it'smoreintheircontrolwhatthecliniciangetstoseeandhowthesystemlookstothem.Theproviderportal,unfortunately,isveryunder-utilisedbytheclinicalcommunitybecauseoftheseotherlevelsofsecurityinplace,whichhavepreventedthemfromeasilyaccessingit…Sowe'reworkingreallyhardwiththosethird-partyvendorstotryanddrivethewaytheyimprovetheviewoftheMyHealthRecordsystemthroughtheirsystembecausethat'swhattheimpressionthatcliniciansouttherehaveofthesystem,becausethat'salltheyget.Theotherthingwe'reexploringiswaystoeasilyallowclinicianstohaveaccessdirectlytotheproviderportals.

Theliteratureandkeyinformantinterviewsidentifiedthespecificstakeholdergroupsthatshouldbeconsultedaspartofimplementationofdigitalhealthinterventions.Clinicalleadershipofdigitalprogramswasemphasisedtoensurethatclinical–nottechnological–perspectivesdrivesolutions,whichmayhelptopromoteoptimisationofdigitalinterventions.93Onekeyinformantemphasisedclinicianinvolvementintheimplementationofelectronicmedicationmanagementsystems.

Drawing on clinical expertise to find solutions

There'snopointjustwhackingintheelectronicmedicationmanagementsystemandhopingitwillmagicallyworkeverythingoutwithoutofficialintelligence.You'veactuallygottoputsmartdoctorsandnursesandclinicalpharmacologistsaroundthetableandsay,‘Whichalerts?Weknowthere'salertfatigueifweputtoomanyon,sowhichalertsarewegoingtoleaveon?’

Localclinicalchampionscanactivelypromotedigitalinterventions,informingdecision-makingandstrategyplanning,andactasabridgebetweenITprofessionals,cliniciansandseniormanagement.110,111Thus,clinicianchampionscanstronglyinfluencethesuccessofanintervention.Clinicalleadershipmayhelptoensurethatpatientsafetyandqualityoutcomesareachieved,whilesupportingacceptabilityofdigitalinterventionstoclinicalusers.Forexample,onekeyinformantemphasisedtheemergingandpivotalroleofinformationofficersinmedicine,nursingorpharmacytoenablesuccessfulimplementationandbridgethegapbetweencliniciansandtechnologyprofessionals.AnotherkeyinformantrecommendedthathealthITarchitectsbehiredasawaytoincorporatehealthandITperspectivesinimplementationplans,andtosupportclearcommunicationandasharedunderstandingacrosssectors.

Combining health and information technologyperspectives

YouhireahealthITarchitect.Youdon'thireageneralistITarchitect.They'restillstrugglingtounderstandwhydoctorsarefussyhalfwaythroughtheprogram–‘Whyarethedoctorssodifficulttoworkwith?’–whereasagoodhealthITarchitectspeaksthesamelanguageandunderstandswhatthedoctorsandthenurses aretryingtoaskfor.

Networks–suchasthosebetweenorganisations,vendorsandusers–maysupportlearningcycles.90Networksprovideanopportunitytoshareexperiencesaboutimplementationandlearnfromothers’experiencesofusingdigitalhealthinterventions,ratherthanhavinganarrowfocuson‘whatworks’.Similarly,akeyinformantreportedthatonecountryusedastrategythatsupportedlocalapproachestodigitalhealthmaturity.Here,healthserviceorganisationswereencouragedtocollaborateinthedevelopmentofactionplansataregionallevel.Suchstrategiesmayhelptoformnetworksforsharingknowledge,thusdrivingsustainedimprovementsintheuptakeofbest-valueelementsofdigitalhealthacrossthesector.

Networks for promotinguptake of best-value digital health strategies

We'realsoexpectingthem tomakeprogress,notjustwithintheirownorganisation,butonamorelocal,regionalbasis,throughsharingdatamorereadilyandeasilyacrosstheirlocalpartners,thecareproviders,andalsowithprimarycareandpotentiallysocialcare.So,informationsharingwithinthatlocaleconomy,andtheuseoftechnicalstandardsandsolutionstosupportthat.Whatwe'renotdoingistryingtocreatedigitalislands.Thekeyfocusisthatthenultimatelyyou'llbeabletogointotheseorganisationsandseethemworkingpaperfreeasmuchastheycan,butitgoesbeyondthat.

5.2.2Usingdatatoimprovesafetyandquality

Theabilitytousedataimmediatelyinqualityimprovementcyclesisalsoanimportantwaytomaximisepatientsafetyandqualityoutcomes.Usingdatathiswaycaninformadjustmentstodigitalhealthinterventionsduringimplementation.Digitalplatformssuchaselectronichealthcarerecords(EHRs),computerisedphysicianorderentry(CPOE),clinicaldecision-supportsystems(CDSSs)andelectronicpatientportalsprovidewaystocollectdata.Theseplatformsmayalsohelptoquicklyidentifypatientsafetyandqualityissues,andthendevelopstrategiestodealwiththem.93Forinstance,onekeyinformantdescribedusingEHRsandCPOEtoidentifyanddealwithapatientsafetyissue–anexcessivedemandforservicesfrominfusioncentresduetoincreasedvolumeoforders.

Using electronic health records and computerised physician order entryto identifyanddealwith patient safetyissues

Trackinginvolvesthreephasesbasically.Lookingatwho'susingit,andthevolumeandhowoftenthey'reusingit.That'sphysiciansandnursing.Thenlookingatthechainsofworkflowandgettingareportaroundthat.Thatwasthekeything.Wehadprintedreportswiththechemoinfusionorders,andwereworriedifwe'dhaveabackupintheinfusioncentres,soweputmetricsaroundthatandweevengotacontingencyplan.Ourteam–whichwasmyself,someITpeople,pharmacists,nursingstaff,medicalstaff–we'dtrytosolveitandifitgotevenworse,itwouldgouptoexecutiveleadership.

Datacanalsobeusedtoconsiderunsubstantiateduserconcernsaboutdigitalhealthinterventions,byprovidingtheevidencenecessarytosupportdevelopmentofpositiveattitudestowardsaplan.Forexample,indescribingtheimplementationofanewdecisionruleinahospitalsetting,onekeyinformantdescribedtheuseofdatageneratedbyEHRsandCDSSsasawaytodirectlyaddressclinicianconcerns.

Using data to support attitude change towardsdigital health interventions

Thepeopleinkeypositionsgotfrustratedwiththefalsepositives,butitwasanopinion.Andthenwegotthedataofthenumberoffalsepositivesand,well,‘Weunderstandyouropinion,buthere'stheraw,irrefutabledatainyourunit’,andturnedhertobecomeanadvocate.

Digitalhealthinterventionshavethepotentialtoenableaccesstodatathatcouldbeusedtopromotesafetyandqualityoutcomes.However,itisessentialtoensurethatthenecessarypolicyinfrastructureisinplacetorealisethispotential.Forexample,onekeyinformantspokeofthepotentialofdataintheMyHealthRecordsystemtoimprovepatientsafetyandqualityofcare.However,thereisagapinthemodelsthatwouldallowthedatatobeusedinthisway.

Thepotential of data in theMyHealthRecord system

IfwehadaframeworkthatallowedustousethedataintheMyHealthRecordsystemforsecondarypurposes,wecouldimproveourunderstandingofthewaysystemscouldberunmoreefficiently.Wecouldlookatthewaythesystemcouldsupportustopredictwheremedicationerrorsmightbegoingtooccur.Wecouldavoidthoseerrorsfromhappening.Wecouldavoidunnecessaryhospitaladmissionsthroughamedicationerror,andthingslikethat.There'salotofwaysthattheinformationinthesystemcouldbemorecleverlyused,operatinginasaferway,operatingin amoreefficientway,andoperatingsothatpeoplegetbetterhealthoutcomes.

5.3Attentiontoworkflow

Theimpactofdigitalhealthinterventionsonworkflowisacriticalfactorinimprovingpositivesafetyandqualityoutcomes.90Well-integratedCPOEsystems,forinstance,hadthestrongestevidencefor:

• Significantlyincreasingclinicians’adherencetoguidelines
• Increasingtheappropriatenessofdiseaseandtreatmentmonitoring

• Optimising medication use.60

Thus,thesesystemsmayhaveanindirecteffectonsafetyandqualityoutcomes.Yet,formanyhealthserviceorganisations,theeffectsofdigitalhealthinterventionimplementationsonworkflowandefficiencyhavenotbeenwellassessed.Forinstance,alackofharmonisationofdigitalhealthinterventionswithclinicalpathwaysandexistingsystemsmaydisruptworkflow.63,64Thisinturncouldleadtoadverseeffectsonusability,accentuatedimplementationcomplexityandreducedpatientsafety.54,67Securemessagingbetweenconsumersandclinicianshasthepotentialtoimprovepatientsafetyandquality,butmayconcurrentlyincreaseclinicians’workloadconsiderably,andimpedetheirabilitytorespondtoconsumermessagesontime13,apotentialrisktopatientsafety.Keyinformantsconcurredthatdigitalhealthinterventionsmustbeintegratedintoworkflowtosupportuptakeand,ultimately,toachievepositiveoutcomes.

TheMyHealth Record system and integrationwithworkflow

Youcanimagineinabusy [generalpractitioner’s]life,youjustdon'thavealotoftimetobejumpingoutofyourclinicalinformationsystemandontoawebsitesomewhere,andenteringdata.Youneedittobeseamless.Therealityofthesituationisthatthemajorityofcliniciansonlyseethethingthroughtheirmedicalpractice,whateveritisthatthehospitalinterfacehasgotsetup.

Keyinformantsalsocitedexampleswhenintegrationofdigitalinterventionswithworkflowwerecriticalsuccessfactorsinachievingpositivepatientoutcomes.Forexample,onekeyinformantdescribedtheinteractionbetweenanewCDSSruleandclinicianworkflow,andhowtheseweresuccessfullyaddressedthroughlearningcyclesandimmediateuseofdataincontinualimprovementcycles.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

Integration of a clinicaldecision-support systemwithworkflow supports positiveoutcomes

Wecreatedaclinicaldecisionruleforsepsis.Inthatorganisation,wereducedthemortalityfromsepsis.WhenIwasherein2014,IlookedatAustralianfiguresanditwasbelow30%,butwemoveditdowntothelowteens inmyorganisation.It’sbeenreplicatedacrosstheworld.

Isawbreakpointsintheworkflowthatwouldstoppatientsgettingtreatmentinatimelyway.Thetechnologyispartofit,butit'stheprocessandthepeopleaspect,aswell.You'vegottohaveanaccurateandsensitivealert,butyou'vegottohavesomebodywhopicksitup.Werealisedthatwehitaplateaubelow30%,becausepeopleweremissingtheiralerts.Nurseswereenteringvitals,writingonastickynote,andputtingitinattheendoftheirshift.Theyneededtodothisinrealtime.Therearelearningcurvethings.Haveyougottherightdatainputdevices?Arethereenoughdevices?Arethereportabledevices?Imean,whyaretheywritingonpaper?

WerealisedthattheEHR[electronichealthrecord]wasnottheoptimalvehicle.Ithinkwegotitbelow30%whenthealertfired,butyou'relookingreallyat[intensivecareunit]or[emergencydepartment]patients,andpeoplearebusyintheseareas.They'rehighintensitycareareas.Soweformedanimmediateresponseteam.

Butthinkingsomeone's goingtositataPCallday,waitingforanalerttofirewon'twork.They'retakingcareofpatients,theydon'thavetimetositandlookatthescreenforanalerttofire.Sowethenhavetolookatanalternativecommunicationmodality,andthatwasusingpagersthatwereautomatedfromthesourcecriteria,usingthattechnologybeyondtheEHR.So,you'dpickupearlypre-sepsis,engagetheimmediateresponseteamtogooutandassessthepatient,andtheninstitutesepsisprotocolsfortreatment,includinga[keyperformanceindicator]thatthepatientwouldbeassessedwithin30minutes.Thatwasthesequenceofhowwekept,stepwise,gettingbettermortalityrates.

Changesinworkflowmayhaveimplicationsforthephysicalenvironmentoforganisations.Physicalenvironmentsmayinhibitorpromotetheuseofdigitalinterventions.19Theliteraturerecommendsthat,whenimplementingdigitalhealthinterventions,theavailabilityandplacementofworkstationsaccordingtoworkflowshouldbeconsidered.ThiswasespeciallyapparentinreviewsofCPOEinemergencydepartmentsandintensivecareunits,inwhichappropriatelyplacedworkstationsfacilitatedefficientmedicationordering.16Similarly,keyinformantsreportedthatintegrationwithworkflowmaydemandchangestothephysicalenvironment,whichhighlightstheroleofimportantstakeholdersinidentifyingappropriatesolutions.

Digitalhealth interventions and thephysical environment

Astheythinkthroughthat,theyrealise,‘Ohmygod,we'rechangingourmodelofcare.We'regoingtochangethewaywedomedicationwardrooms.We'regoingtochangewherethepharmacistlooksatthemedsinformation,makesadvice,wehaveitthattheyphonetheresident’.Itchangeshowtheresidentthenmakeachangeafterthepharmacistphonesthemtosaywewantachange,andsothewholeprocessstartschanging.It'snotpickupthebitofpaperfromtheouttrayintheward.Andsotheynowrevisetheirmodelofcare.

Inrelationtothedigitalarchitecture,you'vegottochangephysicalaspectsofthehospital.Ithinkhavingalltherightpeopletothinkthrough,oh,sonowthewayweworkisgoingtobelikethis,andthatmaymeanrippingoutnurses'stationsandputtinginplaces,puttinginbenchseatswithplacestowheelyourlaptopandplugitinandmakingsureyou'vegotdenseenoughwi-fiinthatspotandallthatsortofgoodstuff.

5.4Multifaceteddigitalhealthstrategies

Giventhecomplexityofclinicalcare,itappearssimplistictoexpectthatanisolateddigitalhealthinterventionwillhavealargepositiveeffectonpatientoutcomes.31Theliteratureemphasisestheimportanceofusingamultifacetedapproachtotheimplementationofhealthtechnologies,includingeducationalandtrainingsupport,tailoredalerts,anddecisionsupporttofurtherimprovethesafetyandqualityofcare.9,10,52,66,102Targetededucationandtrainingsupportbeforeandduringimplementationhasbeenreportedasacontributingfactorforincreasedadoptionandqualityofcare.52,63,90,112Moreintensiveapproacheswerereportedtoresultingreaterimprovementstoqualityofcare.Forexample,CPOEimplementationcombinedwithreminders,performancefeedback,educationalmodulesandworkflowredesign,andtheimplementationofcomplementarydecisionsupporttoolsresultedinthemostpositiveoutcomes.8-13Keyinformantssupportedtheimplementationofmultifaceteddigitalhealthinterventionsasawaytoachievethemostimprovementstopatientsafetyandquality.Onekeyinformanthighlightedthatmultifacetedimplementationwasafeatureofexemplardigitalprojects.

Combining digital technologies

Ithinkitneedstobeabouthowwecancombinedifferentcapabilities,differenttechnicalsolutionsandaddressingissuesofwastedhealthresources.Again,Ithinkthatpreviouslyinthepastthere'smaybebeenafocusondoingitinslightlyisolatedcomponentsandthenexpectingthemtokindofdoanykindofsignificantconnecting.Youneedtoputthosethingstogether,anditdrivesimprovementsinthatarea.

ImpactofDigitalHealthon theSafetyandQualityofHealthCare1

6.Existingapproachestomeasuringdigitalhealth

Asgovernmentscontinuetoinvestheavilyindigitalhealthsystems,acoordinatedandstandardisedapproachtoappropriateinvestment,designandimplementationisessentialtoachievingnationalpriorities.96Toinformabest-practiceapproach,asystematicmeasurementofdigitalhealthinterventionsisneeded.Thiswouldallowaknowledgebasetobecreated,fromwhichthemostcost-effective,safeandscalableinterventionsforimprovingpatientoutcomescanbeidentified.113

Evaluationsofdigitalhealthpresentspecificchallenges.Ashighlightedbythisreport,thedifferentdigitalhealthinterventionsmakeitdifficulttodrawstrongconclusionsfromtheliterature.Additionally,culturalbarriers,datacollection,associatedcostsandarapidlyevolvingsociotechnicalenvironmentalsoimpedeeffectivemeasurement.90Also,anumberoffactorsmightcontributetoevaluativefindingsgoingunpublished.114Conflictofinterestscan,inparticular,makeitdifficulttopublishnegativefindings114,whichmeansthatthepotentialforpublicationbiasshouldnotbeunderestimatedinthisdiscipline.115,116Therefore,theexistingevidencebaseisoftenoflittlevaluetodecision-making.117

Inthecurrentliterature,systematicevaluationsofdigitalhealtharefew,andremainanareaofongoingresearch.118Internationally,healthserviceorganisationsandgovernmentshavebeguntodevelopdifferentapproachestomeasuringdigitalhealth.Althoughvaried,theseapproacheseachinvolvestructural,processoroutcomemeasures,suchasthatinDonabedian’sframeworkforqualityofcare.119,120Thefollowingsectionsexploreexistingapproachestodigitalhealthmeasurementfororganisations.

6.1Structuralmeasurement

AsdefinedbytheAgencyforHealthcareResearchandQuality120,structuralmeasuresevaluateanorganisation’scapacityandsystems.Usingstructuralmeasurestoevaluatedigitalhealthoftenincludestheevaluationofthehealthserviceorganisation’sdigitalmaturityaccordingtoitsreadiness,capabilitiesandinfrastructure.Structuralmeasurescanbeconductedatorganisationallevelorforsystem-widecomparison.

Thistypeofmeasurementisespeciallyimportant,becausetherearelargeinconsistenciesindigitalmaturityacrosshealthserviceorganisationsgloballyandinAustralia.Althoughtherearepocketsofexcellencefortheuptakeofdigitalhealth,theextentofadoptionishighlyvariable.Thisrepresentsacriticalsourceofinequityincaredelivery.Keyinformantsacknowledgedthegrowingvariationindigitalhealthmaturityacrossorganisations.

Iseeagreatvariationacrossthecountry.Despiteaverysignificantnationalprogramthatmadesomeprogressafewyearsago,weendedupwiththiscleargrouptowardsthetopend whoarelargelydigitised,thosewhohavecertainlydeployedmostoftechnologyinpartsormostoftheirorganisation,andarekindoffinishingthejobinthoseessentialareasandatthesametimemovingontothemoreadvancedstuff.Andthenthereareasignificantmajorityinthemiddlewhohavepartsofit,maybesomebitsbutnotacrosstheirentireorganisation.Andthenequallyasignificantnumberherearequitefarbehindandstillheavilyrelyingonpaper-basedorcertainlyatbesthybridsystemsofprocessacrossthosekeyareas.

Inthefirstphasesofmeasuringdigitalmaturity,baselinemeasurementsarefundamental.121Self-assessmentandbenchmarkingareconsideredanimportantmethodto:

• Establishthecurrentstateofdigitalhealthacrossorganisations
• Identifyareasofrelativestrengthorweaknesswithintheorganisation
• Identifythedegreeofconsistencyorvariationindigitisationbetweenorganisations.

Thesemeasuresprovideabaselinetoidentifyconsiderablegapsforprioritisationandplanning.88,90Someinformantsidentifiedthatakeyfuturedirectionofdigitalhealthistoensureconsistencyandreducevariationincarethoughincreasedaccess,uptakeanduseofdigitalplatforms.

Bydoingtheself-assessment,wewantedtogainaninsightnationallyintohoweveryone'sdoingandwhatthebiggapsare.Ata nationallevel,we'vehadafewmainconclusionsthatwehavetakenfromit,andthenwe’relookingtoaddressthese.

Weneedtotrytogetagoodtoolintoeverybody;deviceintegration,medsdecisions,andagooddesignintegratedacrosstheentirehealthsystem.

Theweaknessofstructuralmeasurementsisitsprimaryfocusonmeasuringfunctionalityasopposedtomeasuringpatientoutcomes.Asdemonstratedinthisreport,ahealthserviceorganisationmayimplementaCDSS,buthaveahighalert-overriderate,resultinginlimitedbenefittoqualityofcare.Incomparison,anotherorganisationmayimplementaCDSSinonlyonedepartment,butshowclinicallysignificantbenefits.Apurelystructuralmeasurementapproachwouldconsiderthefirstorganisationtobemoredigitallyadvanced,regardlessofwhethertheeffectsonpatientsafetyandqualityarenegligible.

6.2Processmeasurement

Processmeasurementisthemeasurementoftheproportionofhealthcarethatisrecommendedoralignswithbest-practiceguidelines.Processmeasuresevaluatethespecificstepsinaprocessthatleadtoeitherapositiveornegativeoutcome.120Indigitalhealth,processmeasuresarespecificallyrelatedtothedesign,implementationanduseofdigitalhealthinterventions.89,90,122Processmeasurestypicallyacknowledgethesociotechnicalfactorsinvolvedinthesuccessofanintervention.90SinghandSittigpositthatdigitalhealthmeasurementmustbeconsideredinthecontextofrelevantsociotechnicalfactors.123

Asopposedtostructuralmeasures,processmeasuresareintrinsictothedigitalhealthinterventionandprovideintervention-specificinsights,ratherthananoverviewofanorganisationorsystem.Asdiscussedintheimplementationsectionofthisreport,processmeasurescan,therefore,beusedinaniterativedevelopmentprocessortomonitortheinterventionprogress.90Thismethodinvolvescollectingandanalysingdatatoworkoutiftheinterventionisbeingimplementedasexpectedatmultipletimepoints.91Theknowledgegainedfromthisprocesscaninformdecisionsonhowtooptimisecontentandimplementationofthesystem.

6.3Outcomemeasurement

Outcomemeasuresreflecttheeffectoftheinterventionontheperson,populationororganisationthatisthetargetoftheintervention.124Thesemeasuresmayincludeclinicaloutcomes,person-centredoutcomes,andresourceuseandeconomicoutcomes.125

Attributingoutcomestotheinterventioncanbeanespeciallydifficultcomponentofdigitalhealthmeasurement.Outcomemeasuresshouldthereforebelinkedtothedefinedproblem,populationorhealthneedthatthedigitalhealthinterventionisintendedtoconsider.113

Outcomemeasurescanbeself-assessedandbenchmarkedatmultipletimepoints,andcomparedwithorganisationalperformanceindicators,publishedbenchmarks,andregional,nationalorinternationalperformancerates.Assessmentandbenchmarkingcanbeusedinacontinuousqualityimprovementcycletoidentifyareasthatrequireattentionandimprovement.Italsohelptorealisebenefitsandhowtheycouldbeachievedundercomparablecircumstances.93

OnekeyinformantdescribedthemeasurementofpatientoutcomesattributedtotheimplementationofCDSSalertsforsepsisriskandmanagement.Inthefirstphasesoftheprogram,sepsiswasidentifiedasasignificantlife-threateningconditionthatwasdifficulttodetect,yetrelativelysimpletotreat.TheCDSSalertsaimedtohelpcliniciansaccuratelyandquicklyidentifythosewiththecondition.

Thealgorithmfiresthealertsaying, ‘Thisisearlysepsis,orcouldbeearlysepsis.Thispatientneedstobeassessed.I'mputtinginaPKI[proteinkinaseinhibitor]thatwillbeassessedwithin30minutes.’Thisreducedthemortalityfromsepsis.IlookedatAustralianfiguresanditwasbelow30%andmyorganisationmoveditdowntothelowteens…Itwassavinglives…Nowit'sbeingreplicatedacrosstheworld.