Publications by authors named "Craig Kuziemsky"

129 Publications

Evidence-Based Health Informatics as the Foundation for the COVID-19 Response: A Joint Call for Action.

Methods Inf Med 2021 May 11. Epub 2021 May 11.

Center for Biomedical Data Science, Yale University, New Haven, Connecticut, United States.

Background:  As a major public health crisis, the novel coronavirus disease 2019 (COVID-19) pandemic demonstrates the urgent need for safe, effective, and evidence-based implementations of digital health. The urgency stems from the frequent tendency to focus attention on seemingly high promising digital health interventions despite being poorly validated in times of crisis.

Aim:  In this paper, we describe a joint call for action to use and leverage evidence-based health informatics as the foundation for the COVID-19 response and public health interventions. Tangible examples are provided for how the working groups and special interest groups of the International Medical Informatics Association (IMIA) are helping to build an evidence-based response to this crisis.

Methods:  Leaders of working and special interest groups of the IMIA, a total of 26 groups, were contacted via e-mail to provide a summary of the scientific-based efforts taken to combat COVID-19 pandemic and participate in the discussion toward the creation of this manuscript. A total of 13 groups participated in this manuscript.

Results:  Various efforts were exerted by members of IMIA including (1) developing evidence-based guidelines for the design and deployment of digital health solutions during COVID-19; (2) surveying clinical informaticians internationally about key digital solutions deployed to combat COVID-19 and the challenges faced when implementing and using them; and (3) offering necessary resources for clinicians about the use of digital tools in clinical practice, education, and research during COVID-19.

Discussion:  Rigor and evidence need to be taken into consideration when designing, implementing, and using digital tools to combat COVID-19 to avoid delays and unforeseen negative consequences. It is paramount to employ a multidisciplinary approach for the development and implementation of digital health tools that have been rapidly deployed in response to the pandemic bearing in mind human factors, ethics, data privacy, and the diversity of context at the local, national, and international levels. The training and capacity building of front-line workers is crucial and must be linked to a clear strategy for evaluation of ongoing experiences.
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http://dx.doi.org/10.1055/s-0041-1726414DOI Listing
May 2021

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

Objective: Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned.

Methods: IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives.

Results: All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits.

Conclusions: Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.
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http://dx.doi.org/10.1055/s-0041-1726489DOI Listing
April 2021

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Sri Sathya Sai Central Trust, Puttaparthi, India.

Objectives: Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response.

Methods: We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems.

Results: Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response.

Conclusion: COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.
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http://dx.doi.org/10.1055/s-0041-1726484DOI Listing
April 2021

Participatory simulation modeling to inform colorectal cancer screening in a complex remote northern health system: Canada's Northwest Territories.

Int J Med Inform 2021 Apr 8;150:104455. Epub 2021 Apr 8.

Office of Research Services, MacEwan University, Edmonton, AB, Canada.

Background & Aims: Colorectal cancer (CRC) mortality in the Northwest Territories (NWT), a northern region of Canada, could be reduced by implementing a CRC screening program. However, this may require additional colonoscopy resources. We used participatory simulation modeling to predict colonoscopy demand and to develop strategies for implementing a feasible and effective CRC screening program in this complex remote northern health system.

Methods: Using a participatory simulation modeling approach, we first developed a conceptual model of CRC screening with local collaborators. This approach informed our parameter adjustments of an existing microsimulation model, OncoSim-CRC, using data from a retrospective cohort review of CRC screening between 2014-2019 and secondary data. Model scenarios reflecting program implementation were run for 500 million cases. Validity was assessed, and outputs analyzed with collaborators. Alternative scenarios were developed to reduce colonoscopy demand and results were presented to end-users.

Results: We estimated that colonoscopy demand with a CRC screening program phased-in over 5 years would surpass capacity within 2 years. If demand is met, screen-detected cancers would increase by 110 %, and clinically-detected cases would reduce by 26 % over the next 30 years. We also found that prolonging the phase-in period, or revising adenoma follow-up guidelines would reduce colonoscopy demand while still improving cancer detection. Both strategies were considered feasible by collaborators. The adjusted model was valid, and the projections informed local end-users plans for CRC screening delivery.

Conclusions: Using participatory simulation modeling, we projected that a screening program would improve CRC detection but surpass current colonoscopy capacity. Phasing-in the screening program and reducing endoscopic adenoma follow-up would enhance feasibility of a CRC screening program in the NWT and help maintain its effectiveness.
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http://dx.doi.org/10.1016/j.ijmedinf.2021.104455DOI Listing
April 2021

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review.

BMC Med Inform Decis Mak 2021 02 19;21(1):67. Epub 2021 Feb 19.

School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada.

Background: Despite a substantial increase in the adoption of electronic medical records (EMRs) in primary health care settings, the use of advanced EMR features is limited. Several studies have identified both barriers and facilitating factors that influence primary care physicians' (PCPs) use of advanced EMR features and the maturation of their EMR use. The purpose of this study is to explore and identify the factors that impact PCPs' mature use of EMRs.

Methods: A systematic review was conducted in accordance with the Cochrane Handbook. The MEDLINE, Embase, and PsycINFO electronic databases were searched from 1946 to June 13, 2019. Two independent reviewers screened the studies for eligibility; to be included, studies had to address factors influencing PCPs' mature use of EMRs. A narrative synthesis was conducted to collate study findings and to report on patterns identified across studies. The quality of the studies was also appraised.

Results: Of the 1893 studies identified, 14 were included in this study. Reported factors that influenced PCPs' mature use of EMRs fell into one of the following 5 categories: technology, people, organization, resources, and policy. Concerns about the EMR system's functionality, lack of physician awareness of EMR functionality, limited physician availability to learn more about EMRs, the habitual use of successfully completing clinical tasks using only basic EMR features, business-oriented organizational objectives, lack of vendor training, limited resource availability, and lack of physician readiness were reported as barriers to PCPs' mature use of EMRs. The motivation of physicians, user satisfaction, coaching and peer mentoring, EMR experience, gender, physician perception, transition planning for changes in roles and work processes, team-based care, adequate technical support and training, sharing resources, practices affiliated with an integrated delivery system, financial incentives, and policies to increase EMR use all had a favorable impact on PCPs' use of advanced EMR features.

Conclusions: By using a narrative synthesis to synthesize the evidence, we identified interrelated factors influencing the mature use of EMRs by PCPs. The findings underline the need to provide adequate training and policies that facilitate the mature use of EMRs by PCPs.

Trial Registration: PROSPERO CRD42019137526.
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http://dx.doi.org/10.1186/s12911-021-01434-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893965PMC
February 2021

Impact of colorectal cancer screening participation in remote northern Canada: A retrospective cohort study.

World J Gastroenterol 2020 Dec;26(48):7652-7663

Office of Research Services, MacEwan University, Edmonton T5J4S2, Alberta, Canada.

Background: Screening provides earlier colorectal cancer (CRC) detection and improves outcomes. It remains poorly understood if these benefits are realized with screening guidelines in remote northern populations of Canada where CRC rates are nearly twice the national average and access to colonoscopy is limited.

Aim: To evaluate the participation and impact of CRC screening guidelines in a remote northern population.

Methods: This retrospective cohort study included residents of the Northwest Territories, a northern region of Canada, age 50-74 who underwent CRC screening by a fecal immunohistochemical test (FIT) between January 1, 2014 to March 30, 2019. To assess impact, individuals with a screen-detected CRC were compared to clinically-detected CRC cases for stage and location of CRC between 2014-2016. To assess participation, we conducted subgroup analyses of FIT positive individuals exploring the relationships between signs and symptoms of CRC at the time of screening, wait-times for colonoscopy, and screening outcomes. Two sample Welch -test was used for normally distributed continuous variables, Mann-Whitney-Wilcoxon Tests for data without normal distribution, and Chi-square goodness of fit test for categorical variables. A value of < 0.05 was considered to be statistically significant.

Results: 6817 fecal tests were completed, meaning an annual average screening rate of 25.04%, 843 (12.37%) were positive, 629 individuals underwent a follow-up colonoscopy, of which, 24.48% had advanced neoplasia (AN), 5.41% had CRC. There were no significant differences in stage, pathology, or location between screen-detected cancers and clinically-detected cancers. In assessing participation and screening outcomes, we observed 49.51% of individuals referred for colonoscopy after FIT were ineligible for CRC screening, most often due to signs and symptoms of CRC. Individuals were more likely to have AN if they had signs and symptoms of cancer at the time of screening, waited over 180 d for colonoscopy, or were indigenous [respectively, estimated RR 1.18 95%CI of RR (0.89-1.59)]; RR 1.523 (CI: 1.035, 2.240); RR 1.722 (CI: 1.165, 2.547)].

Conclusion: Screening did not facilitate early cancer detection but facilitated higher than anticipated AN detection. Signs and symptoms of CRC at screening, and long colonoscopy wait-times appear contributory.
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http://dx.doi.org/10.3748/wjg.v26.i48.7652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789056PMC
December 2020

Barriers to colonoscopy in remote northern Canada: an analysis of cancellations.

Int J Circumpolar Health 2020 12;79(1):1816678

Office of Research Services, MacEwan University , Edmonton, AB, Canada.

Colonoscopy is a critical diagnostic and therapeutic procedure that is challenging to access in northern Canada. In part, this is due to frequent cancellations. We sought to understand the trends and reasons for colonoscopy cancellations in the Northwest Territories (NWT). A retrospective review of colonoscopy cancellations January, 2018 to May, 2019 was conducted at Stanton Territorial Hospital, NWT. Cancellation details and rationale were captured from the endoscopy cancellation logs. Thematic analysis was used to group cancellation reasons. Descriptive statistics were generated, and trends were analysed using run chart. Of the scheduled colonoscopies, 368(28%) were cancelled during the 16 month period, and cancellations occurred, on average, 27 days after booking. Cancellation reasons were grouped into 15 themes, encompassing personal, social, geographic and health system factors. The most frequently cited theme was work/other commitments (69 respondents; 24%). Cancellations due to travel and accommodation issues occurred more frequently in the winter. Over one in four booked colonoscopies were cancelled and the reasons for cancellations were complex. Initiatives focusing on communication and support for patients with personal or occupational obligations could dramatically reduce cancellations. Ongoing collaborative efforts are needed to inform and optimise access to colonoscopy in this region.
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http://dx.doi.org/10.1080/22423982.2020.1816678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534278PMC
December 2020

Quality of telephone nursing services for adults with cancer and related non-emergent visits to the emergency department.

Can Oncol Nurs J 2020 1;30(3):193-199. Epub 2020 Jul 1.

Provincial Head-Cancer Nursing, Cancer Care Ontario, Toronto, ON.

A quality improvement project was conducted to determine the quality of telephone nursing for patients with cancer symptoms. Eligible patients were ones who telephoned the nurse about cancer symptom(s) within four weeks prior to an emergency department (ED) visit not requiring hospital admission. Experienced oncology nurses extracting data indicated appropriateness of ED visits and opportunities for improvement. The Symptom Management Analysis Tool was used to analyze nurse documentation. For 77 patients, 87% ED visits occurred within four days of calls about symptoms (e.g., pain, breathlessness, constipation, diarrhea, nausea/vomiting) and 91% could have been managed by more complete telephone assessment and/or an urgent clinic visit. Quality of nurse documentation revealed few patients were assessed adequately (38%), received any symptom-specific medication review (49%), or were guided in self-care strategies (17%). There was low-quality telephone symptom management by nurses and a need for alternative options for patients requiring urgent face-to-face assessments. Our findings highlight a gap in use of guidelines for informing telephone symptom management.
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http://dx.doi.org/10.5737/23688076303193199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583570PMC
July 2020

MyPath to Home Web-Based Application for the Geriatric Rehabilitation Program at Bruyère Continuing Care: User-Centered Design and Feasibility Testing Study.

JMIR Form Res 2020 Sep 14;4(9):e18169. Epub 2020 Sep 14.

Faculty of Engineering, University of Ottawa, Ottawa, ON, Canada.

Background: When older adults return home from geriatric rehabilitation in a hospital, remembering the plethora of medical advice and medical instructions provided can be overwhelming for them and for their caregivers.

Objective: The overall objective was to develop and test the feasibility of a novel web-based application called MyPath to Home that can be used to manage the personalized needs of geriatric rehabilitation patients during their transition from the hospital to home.

Methods: This study involved (1) co-designing a patient- and clinician-tailored web-based application and (2) testing the feasibility of the application to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we followed a user-centered design process integrated with the modern agile software development methodology to iteratively co-design the application. The approach consisted of three cycles in which we engaged patients, caregivers, and clinicians to design a series of prototypes (cycles 1-3). In phase 2, we conducted a single-arm feasibility pilot test of MyPath to Home. Baseline and follow-up surveys, as well as select semistructured interviews were conducted.

Results: In phase 1, semistructured interviews and talk-aloud sessions were conducted with patients/caregivers (n=5) and clinicians (n=17) to design the application. In phase 2, patients (n=30), caregivers (n=18), and clinicians (n=20) received access to use the application. Patients and their caregivers were asked to complete baseline and follow-up surveys. A total of 91% (21/23) of patients would recommend this application to other patients. In addition, clinicians (n=6) and patients/caregivers (n=6) were interviewed to obtain further details on the value of the web-based application with respect to engaging patients and facilitating communication and sharing of information with the health care team.

Conclusions: We were successful at designing the MyPath to Home prototype for patients and their caregivers to engage with their clinicians during the transition from geriatric rehabilitation to home. Further work is needed to increase the uptake and usage by clinicians, and determine if this translates to meaningful changes in clinical and functional outcomes.

International Registered Report Identifier (irrid): RR2-10.2196/11031.
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http://dx.doi.org/10.2196/18169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522728PMC
September 2020

Shared care in surgery: Practical considerations for surgical leaders.

Healthc Manage Forum 2021 Mar 1;34(2):77-80. Epub 2020 Sep 1.

12365Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.

The recent COVID-19 pandemic has highlighted limitations in current healthcare systems and needed strategies to increase surgical access. This article presents a team-based integration model that embraces intra-disciplinary collaboration in shared clinical care, professional development, and administrative processes to address this surge in demand for surgical care. Implementing this model will require communicating the rationale for and benefits of shared care, while shifting patient trust to a team of providers. For the individual surgeon, advantages of clinical integration through shared care include decreased burnout and professional isolation, and more efficient transitions into and out of practice. Advantages to the system include greater surgeon availability, streamlined disease site wait lists, and promotion of system efficiency through a centralized distribution of clinical resources. We present a framework to stimulate national dialogue around shared care that will ultimately help overcome system bottlenecks for surgical patients and provide support for health professionals.
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http://dx.doi.org/10.1177/0840470420952485DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464050PMC
March 2021

Quality of telephone-based cancer symptom management by nurses: a quality improvement project.

Support Care Cancer 2021 Feb 4;29(2):841-849. Epub 2020 Jun 4.

Cancer Care Ontario, Toronto, Ontario, Canada.

Purpose: To determine the quality of cancer symptom management when evidence from clinical practice guidelines are used in telephone-based oncology nursing services.

Methods: Guided by the Knowledge to Action Framework, we conducted a quality improvement (QI) project focused on "monitoring knowledge use" (e.g., use of practice guides) and "measuring outcomes." In 2016, 15 Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) practice guides that synthesize evidence from guidelines were implemented with training for all oncology nurses at a regional ambulatory oncology program. Eighteen months post-implementation, Symptom Management Analysis Tool (SMAT) was used to analyze audio-recorded calls and related documentation of cancer symptom management.

Results: Of 113 audio-recorded calls, 66 were COSTaRS symptoms (58%), 43 other symptoms (38%), and 4 medically complex situations (4%). Of 66 recorded calls, 63 (95%) were documented. Average SMAT quality score was 71% (range 21-100%) for audio-recordings and 63% (range 19-100%) for documentation of calls. COSTaRS practice guide use was documented in 33% calls. For these calls, average SMAT quality scores were 74% with COSTaRS versus 69% without COSTaRS for audio-recording and 73% (range 33-100%) with COSTaRS versus 58% without COSTaRS for documentation. Patient outcomes indicated symptom was resolved (38%), worse (25%), unchanged (3%), or unknown (33%). Eight patients (13%) had an ED visit within 14 days post that was related to the symptom discussed.

Conclusions: Only a third of nurses indicated use of COSTaRS practice guides. There were higher quality symptom management scores when COSTaRS use was reported. Nurses documented less than what they discussed.
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http://dx.doi.org/10.1007/s00520-020-05551-5DOI Listing
February 2021

Key factors for national spread and scale-up of an eConsult innovation.

Health Res Policy Syst 2020 Jun 3;18(1):57. Epub 2020 Jun 3.

C.T. Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Ottawa, Canada.

Background: Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada.

Methods: We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research.

Results: This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes.

Conclusions: Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.
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http://dx.doi.org/10.1186/s12961-020-00574-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268606PMC
June 2020

Identifying best approaches for engaging patients and family members in health informatics initiatives: a case study of the Group Priority Sort technique.

Res Involv Engagem 2020 18;6:25. Epub 2020 May 18.

1Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, M6J 1H4 ON Canada.

Background: Patient engagement strategies in health service delivery have become more common in recent years. However, many healthcare organizations are challenged in identifying the best methods to engage patients in health information technology (IT) initiatives. Engaging with important stakeholders to identify effective opportunities can inform the development of a resource that addresses this issue and supports organizations in their endeavors. The purpose of this paper is to share our experience and lessons learned from applying a novel consensus-building technique in order to identify key elements for effective patient engagement in health IT initiatives. This will be done through a case study approach.

Methods: Patients, family members of patients, health professionals, researchers, students, vendor representatives and individuals who work in health IT roles in health organizations were engaged through a one-day symposium in Toronto, Canada in September, 2018. During the symposium, the Group Priority Sort technique was used to obtain structured feedback from symposium attendees in the context of small group discussions. Descriptive statistics and a content analysis were undertaken to analyze the data collected through the Group Priority Sort as well as participant feedback following the symposium.

Results: A total of 37 participants attended the symposium from a variety of settings and organizations. Using the Group Priority Sort technique, 30 topics were classified by priority to be included in a future resource. Participant feedback pertaining to the symposium and research methods was largely positive. Several areas of improvement, such as clarity of items, were identified from this case study.

Conclusions: The Group Priority Sort technique was an efficient method for obtaining valuable suggestions from a diverse group of stakeholders, including patients and family members. The specific priorities and feedback obtained from the symposium will be incorporated into a resource for healthcare organizations to aid them in engaging patients in health IT initiatives. Additionally, five important considerations were identified when conducting future work with the Group Priority Sort technique and are outlined in this paper.
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http://dx.doi.org/10.1186/s40900-020-00203-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236324PMC
May 2020

Simulation modeling validity and utility in colorectal cancer screening delivery: A systematic review.

J Am Med Inform Assoc 2020 06;27(6):908-916

Office of Research Services, MacEwan University, Edmonton, Alberta, Canada.

Objective: This study sought to assess the impact and validity of simulation modeling in informing decision making in a complex area of healthcare delivery: colorectal cancer (CRC) screening.

Materials And Methods: We searched 10 electronic databases for English-language articles published between January 1, 2008, and March 1, 2019, that described the development of a simulation model with a focus on average-risk CRC screening delivery. Included articles were reviewed for evidence that the model was validated, and provided real or potential contribution to informed decision making using the GRADE EtD (Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision) framework.

Results: A total of 43 studies met criteria. The majority used Markov modeling (n = 31 [72%]) and sought to determine cost-effectiveness, compare screening modalities, or assess effectiveness of screening. No study reported full model validation and only (58%) reported conducting any validation. Majority of models were developed to address a specific health systems or policy question; few articles report the model's impact on this decision (n = 39 [91%] vs. n = 5 [12%]). Overall, models provided evidence relevant to every element important to decision makers as outlined in the GRADE EtD framework.

Discussion And Conclusion: Simulation modeling contributes evidence that is considered valuable to decision making in CRC screening delivery, particularly in assessing cost-effectiveness and comparing screening modalities. However, the actual impact on decisions and validity of models is lacking in the literature. Greater validity testing, impact assessment, and standardized reporting of both is needed to understand and demonstrate the reliability and utility of simulation modeling.
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http://dx.doi.org/10.1093/jamia/ocaa022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7309251PMC
June 2020

Use of Simulation Modeling to Inform Decision Making for Health Care Systems and Policy in Colorectal Cancer Screening: Protocol for a Systematic Review.

JMIR Res Protoc 2020 May 13;9(5):e16103. Epub 2020 May 13.

Office of Research Services, MacEwan University, Edmonton, AB, Canada.

Background: Simulation modeling has frequently been used to assess interventions in complex aspects of health care, such as colorectal cancer (CRC) screening, where clinical trials are not feasible. Simulation models provide estimates of outcomes, unintended consequences, and costs of an intervention; thus offering an invaluable decision aid for policy makers and health care leaders. However, the contribution that simulation models have made to policy and health system decisions is unknown.

Objective: This study aims to assess if simulation modeling has supported evidence-informed decision making in CRC screening.

Methods: A preliminary literature search and pilot screening of 100 references were conducted by three independent reviewers to define and refine the inclusion criteria of this systematic review. Using the developed inclusion criteria, a search of the academic and gray literature published between January 1, 2008, and March 1, 2019, will be conducted to identify studies that developed a simulation model focusing on the delivery of CRC screening of average-risk individuals. The three independent reviewers will assess the validation process and the extent to which the study contributed evidence toward informed decision making (both reported and potential). Validation will be assessed based on adherence to the best practice recommendations described by the International Society for Pharmacoeconomics and Outcomes Research-Society for Medical Decision Making (ISPOR-SMDM). Criteria for potential contribution to decision making will be defined as outlined in the internationally recognized Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision (GRADE EtD) framework. These criteria outline information that the health system and policy decision makers should consider when making an evidence-informed decision including an intervention's resource utilization, cost-effectiveness, impact on health equity, and feasibility. Subgroup analysis of articles based on their GRADE EtD criteria will be conducted to identify methods associated with decision support capacity (ie, participatory, quantitative, or mixed methods).

Results: A database search of the literature yielded 484 references to screen for inclusion in the systematic review. We anticipate that this systematic review will provide an insight into the contribution of simulation modeling methods to informed decision making in CRC screening delivery and discuss methods that may be associated with a stronger impact on decision making. The project was funded in May 2019. Data collection took place from January 2008 to March 2019. Data analysis was completed in November 2019, and are expected to be published in spring 2020.

Conclusions: Our findings will help guide researchers and health care leaders to mobilize the potential for simulation modeling to inform evidence-informed decisions in CRC screening delivery. The methods of this study may also be replicated to assess the utility of simulation modeling in other areas of complex health care decision making.

International Registered Report Identifier (irrid): DERR1-10.2196/16103.

Trial Registration: PROSPERO no. 130823; https://www.crd.york.ac.uk/PROSPERO.
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http://dx.doi.org/10.2196/16103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254289PMC
May 2020

Challenges and Best Practices in Ethical Review of Human and Organizational Factors Studies in Health Technology: a Synthesis of Testimonies.

Yearb Med Inform 2020 Aug 17;29(1):58-70. Epub 2020 Apr 17.

Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, INSERM-CIC-IT 1403/Evalab, Lille, France.

Objective: Human and Organizational Factors (HOF) studies in health technology involve human beings and thus require Institutional Review Board (IRB) approval. Yet HOF studies have specific constraints and methods that may not fit standard regulations and IRB practices. Gaining IRB approval may pose difficulties for HOF researchers. This paper aims to provide a first overview of HOF study challenges to get IRB review by exploring differences and best practices across different countries.

Methods: HOF researchers were contacted by email to provide a testimony about their experience with IRB review and approval. Testimonies were thematically analyzed and synthesized to identify and discuss shared themes.

Results: Researchers from seven European countries, Argentina, Canada, Australia, and the United States answered the call. Four themes emerged that indicate shared challenges in legislation, IRB inefficiencies and inconsistencies, general regulation and costs, and lack of HOF study knowledge by IRB members. We propose a model for IRB review of HOF studies based on best practices.

Conclusion: International criteria are needed that define low and high-risk HOF studies, to allow identification of studies that can undergo an expedited (or exempted) process from those that need full IRB review. Enhancing IRB processes in such a way would be beneficial to the conduct of HOF studies. Greater knowledge and promotion of HOF methods and evidence-based HOF study designs may support the evolving discipline. Based on these insights, training and guidance to IRB members may be developed to support them in ensuring that appropriate ethical issues for HOF studies are considered.
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http://dx.doi.org/10.1055/s-0040-1701979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442520PMC
August 2020

Ethical Use of Electronic Health Record Data and Artificial Intelligence: Recommendations of the Primary Care Informatics Working Group of the International Medical Informatics Association.

Yearb Med Inform 2020 Aug 17;29(1):51-57. Epub 2020 Apr 17.

Clnical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Eagle House, 7 Walton Well Road, Oxford, OX2 6ED, UK.

Objective: To create practical recommendations for the curation of routinely collected health data and artificial intelligence (AI) in primary care with a focus on ensuring their ethical use.

Methods: We defined data curation as the process of management of data throughout its lifecycle to ensure it can be used into the future. We used a literature review and Delphi exercises to capture insights from the Primary Care Informatics Working Group (PCIWG) of the International Medical Informatics Association (IMIA).

Results: We created six recommendations: (1) Ensure consent and formal process to govern access and sharing throughout the data life cycle; (2) Sustainable data creation/collection requires trust and permission; (3) Pay attention to Extract-Transform-Load (ETL) processes as they may have unrecognised risks; (4) Integrate data governance and data quality management to support clinical practice in integrated care systems; (5) Recognise the need for new processes to address the ethical issues arising from AI in primary care; (6) Apply an ethical framework mapped to the data life cycle, including an assessment of data quality to achieve effective data curation.

Conclusions: The ethical use of data needs to be integrated within the curation process, hence running throughout the data lifecycle. Current information systems may not fully detect the risks associated with ETL and AI; they need careful scrutiny. With distributed integrated care systems where data are often used remote from documentation, harmonised data quality assessment, management, and governance is important. These recommendations should help maintain trust and connectedness in contemporary information systems and planned developments.
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http://dx.doi.org/10.1055/s-0040-1701980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442527PMC
August 2020

Ethics in Telehealth: Comparison between Guidelines and Practice-based Experience -the Case for Learning Health Systems.

Yearb Med Inform 2020 Aug 17;29(1):44-50. Epub 2020 Apr 17.

School of Health Sciences, University of Canterbury, New Zealand.

Objectives: To understand ethical issues within the tele-health domain, specifically how well established macro level telehealth guidelines map with micro level practitioner perspectives.

Methods: We developed four overarching issues to use as a starting point for developing an ethical framework for telehealth. We then reviewed telemedicine ethics guidelines elaborated by the American Medical Association (AMA), the World Medical Association (WMA), and the telehealth component of the Health Professions council of South Africa (HPCSA). We then compared these guidelines with practitioner perspectives to identify the similarities and differences between them. Finally, we generated suggestions to bridge the gap between ethics guidelines and the micro level use of telehealth.

Results: Clear differences emerged between the ethics guidelines and the practitioner perspectives. The main reason for the differences were the different contexts where telehealth was used, for example, variability in international practice and variations in the complexity of patient-provider interactions. Overall, published guidelines largely focus on macro level issues related to technology and maintaining data security in patient-provider interactions while practitioner concern is focused on applying the guidelines to specific micro level contexts.

Conclusions: Ethics guidelines on telehealth have a macro level focus in contrast to the micro level needs of practitioners. Work is needed to close this gap. We recommend that both telehealth practitioners and ethics guideline developers better understand healthcare systems and adopt a learning health system approach that draws upon different contexts of clinical practice, innovative models of care delivery, emergent data and evidence-based outcomes. This would help develop a clearer set of priorities and guidelines for the ethical conduct of telehealth.
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http://dx.doi.org/10.1055/s-0040-1701976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442533PMC
August 2020

An ontology-driven framework to support the dynamic formation of an interdisciplinary healthcare team.

Int J Med Inform 2020 04 7;136:104075. Epub 2020 Jan 7.

Telfer School of Management, University of Ottawa, 55 Laurier Ave E, Ottawa, ON, K1N 6N5, Canada; Business Analytics Solutions, IBM, 3600 Steeles Avenue, East Markham, ON, L3R 9Z7, Canada.

Background And Purpose: Teamwork has become a modus operandi in healthcare and delivery of patient care by an interdisciplinary healthcare team (IHT) is now a prevailing modality of care. We argue that a formal and automated support framework is needed for an IHT to properly leverage information technology resources. Such a framework should allow for patient preferences and expand a representation of a clinical workflow with a formal model of dynamic formation of a team, especially with regards to team leader- and membership, and the assignment of tasks to team members. Our goal was to develop such a support framework, present its prototype software implementation and verify the implementation using a proof-of-concept use case. Specifically, we focused on clinical workflows for in-patient tertiary care and on patient preferences with regards to selecting team members and team leaders.

Materials And Methods: Drawing on the research on clinical teamwork we defined the conceptual foundations for the proposed framework. Then, we designed its architecture and used ontology-driven design and first-order logic with associated reasoning methods to create and operationalize architectural elements. Finally, we incorporated existing solutions for business workflow modeling and execution as a backend for implementing the proposed framework.

Results: We developed a Team and Workflow Management Framework (TWMF) with semantic components that allow for formalizing and operationalizing team formation in in-patient tertiary care setting and support provider-related patient preferences. We also created a prototype software implementation of TWMF using the IBM Business Process Manager platform. This implementation was evaluated in several simulated patient scenarios.

Conclusions: TWMF integrates existing workflow technologies and extends them with the capabilities to support dynamic formation of an IHT. Results of this research can be used to support real-time execution of clinical workflows, or to simulate their execution in order to assess the impact of various conditions (e.g., patterns of work shifts, staffing) on IHT operations.
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http://dx.doi.org/10.1016/j.ijmedinf.2020.104075DOI Listing
April 2020

Primary Care Physicians' Experience Using Advanced Electronic Medical Record Features to Support Chronic Disease Prevention and Management: Qualitative Study.

JMIR Med Inform 2019 Nov 29;7(4):e13318. Epub 2019 Nov 29.

School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada.

Background: Chronic diseases are the leading cause of death worldwide. In Canada, more than half of all health care spending is used for managing chronic diseases. Although studies have shown that the use of advanced features of electronic medical record (EMR) systems improves the quality of chronic disease prevention and management (CDPM), a 2012 international survey found that Canadian physicians were the least likely to use 2 or more EMR system functions. Some studies show that maturity vis-à-vis clinicians' EMR use is an important factor when evaluating the use of advanced features of health information systems. The Clinical Adoption Framework (CAF), a common evaluation framework used to assess the success of EMR adoption, does not incorporate the process of maturing. Nevertheless, the CAF and studies that discuss the barriers to and facilitators of the adoption of EMR systems can be the basis for exploring the use of advanced EMR features.

Objective: This study aimed to explore the factors that primary care physicians in Ontario identified as influencing their use of advanced EMR features to support CDPM and to extend the CAF to include primary care physicians' perceptions of how their use of EMRs for performing clinical tasks has matured.

Methods: Guided by the CAF, directed content analysis was used to explore the barriers and facilitating factors encountered by primary care physicians when using EMR features. Participants were primary care physicians in Ontario, Canada, who use EMRs. Data were coded using categories from the CAF.

Results: A total of 9 face-to-face interviews were conducted from January 2017 to July 2017. Dimensions from the CAF emerged from the data, and one new dimension was derived: physicians' perception of their maturity of EMR use. Primary care physicians identified the following key factors that impacted their use of advanced EMR features: performance of EMR features, information quality of EMR features, training and technical support, user satisfaction, provider's productivity, personal characteristics and roles, cost benefits of EMR features, EMR systems infrastructure, funding, and government leadership.

Conclusions: The CAF was extended to include physicians' perceptions of how their use of EMR systems had matured. Most participants agreed that their use of EMR systems for performing clinical tasks had evolved since their adoption of the system and that certain system features facilitated their care for patients with chronic diseases. However, several barriers were identified and should be addressed to further enhance primary care physicians' use of advanced EMR features to support CDPM.
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http://dx.doi.org/10.2196/13318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911232PMC
November 2019

Beyond TAM and UTAUT: Future directions for HIT implementation research.

J Biomed Inform 2019 12 17;100:103315. Epub 2019 Oct 17.

Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States.

The Technology Acceptance Model (TAM) and Unified Theory of Acceptance and Use of Technology (UTAUT) have been used widely in studies of health information technology (HIT) implementation. However, TAM and UTAUT have also been criticized for being overly simplistic (TAM) and for taking a narrow perspective, which focuses only on individual adopters' beliefs, perceptions and usage intention. Furthermore, with thousands of studies using these theories, their contribution to knowledge has reached a plateau. In this commentary, we discuss some of the criticism of TAM and UTAUT, and argue that biomedical informatics research would benefit from shifting attention from these theories to multi-dimensional approaches that can better capture the complexity of issues surrounding implementation and use of HIT. We propose a number of future undertakings which, in our opinion, are more likely to move the field forward.
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http://dx.doi.org/10.1016/j.jbi.2019.103315DOI Listing
December 2019

Using Patient and Family Engagement Strategies to Improve Outcomes of Health Information Technology Initiatives: Scoping Review.

J Med Internet Res 2019 10 8;21(10):e14683. Epub 2019 Oct 8.

Centre for Addiction and Mental Health, Toronto, ON, Canada.

Background: Many health care organizations around the world have implemented health information technologies (ITs) to enhance health service efficiency, effectiveness, and safety. Studies have demonstrated that promising outcomes of health IT initiatives can be obtained when patients and family members participate and engage in the adoption, use, and evaluation of these technologies. Despite knowing this, there is a lack of health care organizations using patient and family engagement strategies to enhance the use and adoption of health ITs, specifically.

Objective: This study aimed to answer the following three research questions (RQs): (1) what current frameworks or theories have been used to guide patient and family engagement in health IT adoption, use, implementation, selection, and evaluation?, (2) what studies have been done on patient and family engagement strategies in health IT adoption, use, implementation, selection, and evaluation?, and (3) what patient and family engagement frameworks, studies, or resources identified in the literature can be applied to health IT adoption, use, implementation, selection, and evaluation?

Methods: This scoping review used a five-step framework developed by Arksey and O'Malley and adapted by Levac et al. These steps include the following: (1) identifying the RQ, (2) identifying relevant studies, (3) selecting studies, (4) charting relevant data, and (5) summarizing and reporting the result. Retrieved academic and grey literature records were evaluated using a literature review software based on inclusion and exclusion criteria by two independent reviewers. If consensus was not achieved, two reviewers would resolve conflicts by discussion. Research findings and strategies were extracted from the studies and summarized in data tables.

Results: A total of 35 academic articles and 23 gray literature documents met the inclusion criteria. In total, 20 of the 35 included studies have been published since 2017. Frameworks found include the patient engagement framework developed by Healthcare Information and Management Systems Society and the patient and family engagement framework proposed by Carman et al. Effective strategies include providing patients with clear expectations and responsibilities and providing reimbursement for time and travel. The gray literature sources outlined key considerations for planning and supporting engagement initiatives such as providing patients with professional development opportunities, and embedding patients in existing governance structures.

Conclusions: Several studies have reported their findings regarding successful strategies to engage patients and family members in health IT initiatives and the positive impact that can emerge when patients and family members are engaged in such initiatives in an effective manner. Currently, no framework has consolidated all of the key strategies and considerations that were found in this review to guide health care organizations when engaging patients and family members in a health IT-specific project or initiative. Further research to evaluate and validate the existing strategies would be of value.
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http://dx.doi.org/10.2196/14683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806121PMC
October 2019

Three Methods for Engaging Patients and Care Partners in Patient Portal Research.

Stud Health Technol Inform 2019 Aug;264:1984-1985

Information Management Group, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.

There has been a significant increase in the volume of research conducted on patient portals in recent years. Similarly, there has been a number of benefits described in the literature when patients are engaged in research at all stages. This poster will provide an overview of three ways that patients can be engaged in patient portal research. The methods are based on those used in mental health patient portal research in Canada.
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http://dx.doi.org/10.3233/SHTI190746DOI Listing
August 2019

Usability Across Health Information Technology Systems: Searching for Commonalities and Consistency.

Stud Health Technol Inform 2019 Aug;264:649-653

Telfer School of Management, University of Ottawa, Ottawa, ON, Canada.

Usability of health information technology (HIT) remains a predominant concern - one often exacerbated by clinicians' need to access information created by many different professionals in different settings, often using very dissimilar EHRs or even different configurations of the same EHR. Because of these variations, we argue that we must no longer think of usability as anchored in one setting, one EHR, one data standard, or one type of clinician. Rather, usability must be understood as a collective and constantly evolving process. This paper seeks to address that reality by 1) substantially expanding our previously-developed conceptual matrix of the wide range of settings and interfaces comprising modern HIT and 2) presenting actual examples of EHR usability issues with similar data but very different displays or processes.
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http://dx.doi.org/10.3233/SHTI190303DOI Listing
August 2019

Context and Meaning in EHR Displays.

Stud Health Technol Inform 2019 Aug;265:69-73

Jacobs School of Medicine, University at Buffalo, SUNY, Buffalo, NY, USA.

Many Electronic Health Record (EHRs) data displays are insensitive to their settings, contexts, and to clinicians' needs. Yet, the contexts in which the data are displayed critically affect EHR usability and patient safety. Medication prescribing is a complex task; especially sensitive to contextual variation in EHR displays as vast variations in formats and logic are often unnecessarily confusing, leading to unwanted cognitive burdens and medical errors. With examples of EHR screenshots, we illustrate contextual variations in medication and allergy displays across different EHR systems and implementations-noting often seemingly haphazard differences that can lead to misunderstandings and misinterpretations.
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http://dx.doi.org/10.3233/SHTI190140DOI Listing
August 2019

Sustainable Health Informatics: Health Informaticians as Alchemists.

Stud Health Technol Inform 2019 Aug;265:3-11

Univ. Lille, INSERM, CHU Lille, CIC-IT/Evalab 1403 - Centre d'Investigation clinique, EA 2694, F-59000 Lille, France.

The digital transformation of health care delivery remains an elusive work in progress. Contextual variation continues to be a significant barrier to the development of sustainable health information systems. In this paper we characterize health informaticians as modern alchemists and use this characterization to describe informatics progress in addressing four key healthcare challenges. We highlight the need for informaticians to be diligent and loyal to basic methodological principles while also appreciating the role that contextual variation plays in informatics research. We also emphasize that meaningful health systems transformation takes time. The insight presented in this paper helps informaticians in our quest to develop sustainable health information systems.
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http://dx.doi.org/10.3233/SHTI190129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323624PMC
August 2019

Artificial Intelligence in Primary Health Care: Perceptions, Issues, and Challenges.

Yearb Med Inform 2019 Aug 25;28(1):41-46. Epub 2019 Apr 25.

Department of Clinical & Experimental Medicine, University of Surrey, Guildford, Surrey, UK.

Background: Artificial intelligence (AI) is heralded as an approach that might augment or substitute for the limited processing power of the human brain of primary health care (PHC) professionals. However, there are concerns that AI-mediated decisions may be hard to validate and challenge, or may result in rogue decisions.

Objective: To form consensus about perceptions, issues, and challenges of AI in primary care.

Method: A three-round Delphi study was conducted. Round 1 explored experts' viewpoints on AI in PHC (n=20). Round 2 rated the appropriateness of statements arising from round one (n=12). The third round was an online panel discussion of findings (n=8) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups.

Results: PHC and informatics experts reported AI has potential to improve managerial and clinical decisions and processes, and this would be facilitated by common data standards. The respondents did not agree that AI applications should learn and adapt to clinician preferences or behaviour and they did not agree on the extent of AI potential for harm to patients. It was more difficult to assess the impact of AI-based applications on continuity and coordination of care.

Conclusion: While the use of AI in medicine should enhance healthcare delivery, we need to ensure meticulous design and evaluation of AI applications. The primary care informatics community needs to be proactive and to guide the ethical and rigorous development of AI applications so that they will be safe and effective.
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http://dx.doi.org/10.1055/s-0039-1677901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697547PMC
August 2019

Role of Artificial Intelligence within the Telehealth Domain.

Yearb Med Inform 2019 Aug 25;28(1):35-40. Epub 2019 Apr 25.

IBM Research, Brazil.

Objectives: This paper provides a discussion about the potential scope of applicability of Artificial Intelligence methods within the telehealth domain. These methods are focussed on clinical needs and provide some insight to current directions, based on reports of recent advances.

Methods: Examples of telehealth innovations involving Artificial Intelligence to support or supplement remote health care delivery were identified from recent literature by the authors, on the basis of expert knowledge. Observations from the examples were synthesized to yield an overview of contemporary directions for the perceived role of Artificial Intelligence in telehealth.

Results: Two major focus areas for related contemporary directions were established. These were first, quality improvement for existing clinical practice and service delivery, and second, the development and support of new models of care. Case studies from each focus area have been chosen for illustration purposes.

Conclusion: Examples of the role of Artificial Intelligence in delivery of health care remotely include use of tele-assessment, tele-diagnosis, tele-interactions, and tele-monitoring. Further developments of underlying algorithms and validation of methods will be required for wider adoption. Certain key social and ethical considerations also need consideration more generally in the health system, as Artificial-Intelligence-enabled-telehealth becomes more commonplace.
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http://dx.doi.org/10.1055/s-0039-1677897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697552PMC
August 2019

A tactical framework for EMR adoption.

Healthc Manage Forum 2019 May 4;32(3):148-152. Epub 2019 Apr 4.

2 Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada.

Hospitals and other health settings across Canada are transitioning from paper or legacy information systems to Electronic Medical Records (EMR) systems to improve patient care and service delivery. The literature speaks to benefits of EMR systems, but also challenges, such as adverse patient events and provider workflow interruptions. Theoretical models have been proposed to help understand the complex interaction between health information technologies and the healthcare environment, but a shortcoming is the transition from conceptual models to actual clinical settings. The health ecosystem is filled with human diversity and organizational culture considerations that cannot be separated from technical implementation strategies. This paper analyzes literature on EMR implementation and adoption to develop a tactical framework for EMR adoption. The framework consists of six categories, each with a set of seed questions to consider when leading technology adoption projects.
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http://dx.doi.org/10.1177/0840470419829844DOI Listing
May 2019