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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.

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management. A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare, policymakers from national, provincial, and regional organizations, researchers, and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities. Participants proposed 4 research categories: Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

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.

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.

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.

Systematic performance management for complex patient care is challenging. Heterogeneous healthcare data silos and inconsistent patient identity, coupled with patient privacy regulations, limit our ability to correlate healthcare data for complex patients. Cloud computing is an emerging technology that could be leveraged to address the issue of heterogeneous healthcare data silos if a regional health authority provided data hosting with appropriate data sharing agreements and identity management, in order to correlate healthcare data for complex patients. This paper introduces a configurable identity matching algorithm for correlating shared data from multiple stakeholders into a common data model to support performance management of community healthcare. The authors illustrate its use in a case study of cloud-hosted performance management for community care of complex patients at a regional health authority in Canada.

Symptoms experienced by clients with cancer often occur at home and can become life-threatening, posing serious safety concerns. This study evaluated implementation of evidence-informed symptom practice guides to enhance quality of cancer symptom support by homecare nurses. A comparative case study was conducted using the Knowledge to Action Framework. Case were created for each of six agencies providing nursing care within a regional homecare authority. A team of researchers and knowledge users (e.g., managers, educators, family member): (1) assessed factors influencing practice guide use (survey, interviews) at six agencies, (2) adapted 15 practice guides for local use, (3) implemented with interventions to address barriers, and (4) monitored use. Analysis was within and across cases. Of six nursing agencies, one withdrew and five participated. In the baseline survey, 51% of nurses reported using guidelines but nurses did not describe using them in their current practice during the interviews. To overcome barriers, 489 nurses in five agencies were trained in how to use the practice guides, principles were established for documenting cancer symptom management, and practice guides were made available in various formats. Success with implementation varied across the participating cases. Chart audits conducted in three agencies revealed evidence of practice guide use for 16%, 22%, and 70% client visits, respectively. Implementation of evidence-informed practice guides in nursing required an approach tailored for each agency. Training, integration in documentation, and easy access to practice guides increased use for some nurses but ongoing support and reinforcement from nurse leaders is required.

Purpose While previous studies have described structural, process and social aspects of the healthcare communication space there is no overall model of it. Such a model is an essential first step to improving the operationalization and management of healthcare communication. The paper aims to discuss these issues. Design/methodology/approach This paper used a case study approach to study team-based communication on a palliative care unit. Non-participant observation, interviews and documents were analyzed using qualitative content analysis. Findings The analysis developed an overall model of the healthcare communication space that consists of five stages: purpose, practices and workflows, structures, implementation, and the development of common ground to support team-based communication. The authors’ findings emphasized that implicit communication remains a predominant means of communication and workflow issues at the individual level are a frequent cause of unnecessary group communication tasks. Originality/value To improve team-based communication we first need to develop protocols that support team communication needs such as loop closing of group communication tasks in order to minimize unnecessary individual communication tasks. We also need to develop common ground at the protocol, document and terminology levels as part of supporting team-based communication.

Background: Patients' access to their computerised medical records (CMRs) is a legal right in many countries. However, little is reported about the benefit-risk associated with patients' online access to their CMRs. Objective: To conduct a consensus exercise to assess the impact of patients' online access to their CMRs on the quality of care as defined in six domains by the Institute of Medicine (IoM), now the National Academy of Medicine (NAM). Method: A five-round Delphi study was conducted. Round One explored experts' (n = 37) viewpoints on providing patients with access to their CMRs. Round Two rated the appropriateness of statements arising from Round One (n = 16). The third round was an online panel discussion of findings (n = 13) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups. Two additional rounds, a survey of the revised consensus statements and an online workshop, were carried out to further refine consensus statements. Results: Thirty-seven responses from Round One were used as a basis to initially develop 15 statements which were categorised using IoM's domains of care quality. The experts agreed that providing patients online access to their CMRs for bookings, results, and prescriptions increased efficiency and improved the quality of medical records. Experts also anticipated that patients would proactively use their online access to share data with different health care providers, including emergencies. However, experts differed on whether access to limited or summary data was more useful to patients than accessing their complete records. They thought online access would change recording practice, but they were unclear about the benefit-risk of high and onerous levels of security. The 5-round process, finally, produced 16 consensus statements. Conclusion: Patients' online access to their CMRs should be part of all CMR systems. It improves the process of health care, but further evidence is required about outcomes. Online access improves efficiency of bookings and other services. However, there is scope to improve many of the processes of care it purports to support, particularly the provision of a more effective interface and the protection of the vulnerable.

Objectives: Connected healthcare is an essential part of patient-centred care delivery. Technology such as telehealth is a critical part of connected healthcare. However, exchanging health information brings the risk of privacy issues. To better manage privacy risks we first need to understand the different patterns of patient-centred care in order to tailor solutions to address privacy risks. Methods: Drawing upon published literature, we develop a business model to enable patient-centred care via telehealth. The model identifies three patient-centred connected health patterns. We then use the patterns to analyse potential privacy risks and possible solutions from different types of telehealth delivery. Results: Connected healthcare raises the risk of unwarranted access to health data and related invasion of privacy. However, the risk and extent of privacy issues differ according to the pattern of patient-centred care delivery and the type of particular challenge as they enable the highest degree of connectivity and thus the greatest potential for privacy breaches. Conclusion: Privacy issues are a major concern in telehealth systems and patients, providers, and administrators need to be aware of these privacy issues and have guidance on how to manage them. This paper integrates patient-centred connected health care, telehealth, and privacy risks to provide an understanding of how risks vary across different patterns of patient-centred connected health and different types of telehealth delivery.

Introduction Disparities in colorectal cancer outcomes and screening rates exist between rural and urban populations as well as indigenous and non-indigenous patients. While screening access is a strategic health priority, various health system complexities impede screening access. Understanding the health system complexities is a necessary first step for system transformation to enable increased screening access to improve cancer outcomes. Methods Semi-structured interviews with health care providers (N = 29) involved in colorectal cancer screening were performed from September to December 2015. A framework integrating Collaborative Information Behaviour (CIB) and Continuity of Care (COC) was designed to conceptualize and understand health system complexity within colorectal cancer screening in order to inform screening access solutions. Results Eighteen different models of colorectal screening access were identified after which access problems were identified and characterized as high or low complexity. We also identified a set of contextual factors that influence complexity. Conclusions Colorectal cancer screening in remote regions is a complex health systems problem. It is important to distinguish high and low complexity issues as they require different approaches to solving the issues. Contextual factors such as social determinants of health and locum based practice must also be considered. Ultimately, solutions for colorectal cancer screening access in sociocultural diverse remote regions will require a balance between high and low system complexity.

Nurses are instrumental in helping clients safely manage at home and triage potentially life-threatening symptoms from cancer. The purpose of this study was to assess factors influencing home care nurses’ use of 15 evidence-informed symptom practice guides for providing telephone or in-home nursing services to clients with cancer. A mixed-methods descriptive study was guided by the Knowledge-to-Action Framework. All six nursing agencies within a regional home care authority participated. Data collection included retrospective audit of symptom management in 50 patient records, 14 interviews, and barriers survey from 150 of 243 (61.7%) registered nurses and registered practical nurses providing cancer symptom support in home care. Chart audit revealed more than 80% of clients were on chemotherapy and common symptoms were nausea/vomiting (44%), constipation (32%), fatigue (32%), loss of appetite (32%), and pain (20%). Nurses had positive intentions ( M = 5.4 out of 7; SD = 1.3) and felt capable of using the symptom practice guides ( M = 5.4; SD = 1.0), held strong beliefs about the consequences ( M = 5.8; SD = 1.1) and moral norms of using them ( M = 5.7; SD = 1.1), and identified neutral to low social influence ( M = 3.0; SD = 1.6). Common barriers were inadequate time in practice, learning curve, need to integrate into documentation, and competing system changes. Common facilitators were being comprehensive, an evidence-based resource for use in practice, and having consistent symptom management guides across settings. Overall, the symptom guides were well received by the nurses. Interventions nurses identified to overcome barriers were education, clear organizational mandate for implementation, and integration with documentation.

Managing patients with chronic and complex health conditions poses significant challenges to community healthcare in terms of quality and cost of care delivery. These challenges can be addressed through systematic performance management of care processes. However, heterogeneous healthcare data silos and inconsistent patient identity, coupled with patient privacy regulations, limit our ability to achieve systematic performance management of community healthcare. Cloud computing is an emerging technology that could be leveraged to address the issue of heterogeneous healthcare data silos, if a regional health authority provided data hosting with appropriate data sharing agreements and identity management. In this paper, we present a Patient Identity Matching Service for correlating cloud-hosted data from multiple stakeholders into a common data model to support performance management of community healthcare. We illustrate its use in a case study of performance management for community care of chronic and complex health conditions at a regional health authority in Canada.

There is an increasing need for an interoperable healthcare data system that provides a shared common view of the essential data for a person to any healthcare provider involved in the circle of care regardless of where provider or person are physically located or what organization they belong to. This paper introduces a framework that characterizes the essential elements of such a system: minimal data set, information technology architecture, and legal governance. We evaluate related work and propose a cloud-based portal and a web-service API for accessing and managing shared data. The proposal is evaluated and compared using a representative usage scenario from community care.

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.

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.

Despite decades of research and development on interoperability standards, semantic interoperability among electronic health (eHealth) systems has largely remained an elusive goal. Interoperability functionality that has been implemented as part of national or provincial initiatives often ends up being considered unreliable in practice. We believe that a stronger focus on workflows and other pragmatic aspects of interoperability functions may be a key to overcoming these difficulties. Specifically, we argue that eHealth system interoperability should be modelled as dynamically evolving socio-technical processes, rather than as technical functions of certified devices. In this paper, we explore the example of patient referrals to highlight common problems with eHealth system interoperability. We define a system-theoretic model of the socio-technical e-referral system to derive two pragmatic interoperability workflow patterns to address these problems. The presented research is carried out in collaboration with industry.

Care coordination strategies have focused on effective data sharing for a specific application (e.g. geriatric rehabilitation after discharge from hip surgery) but not the means of ensuring system level patient-centered data sharing beyond a specific application. The MyPHR framework provides a systematic approach to enable sharing of patient's healthcare data across a system-wide circle of care independent of a specific application. This paper uses the example of Path-to-Home (P2H), an application to support coordination of healthcare within a patient's circle of care for geriatric rehabilitation after discharge from hip surgery, to illustrate how the MyPHR framework can provide guidance on how to support data sharing at a "system level" within a broader system-wide circle of care. Our findings contribute to the broader research problem of enabling healthcare data interoperability.

As team-based healthcare delivery becomes more ubiquitous we need to develop approaches that characterize different contexts of teamwork to enable us to better design HIT to support healthcare teams. This research helps address that need by using the O-MaSE method to develop a multi-agent framework for healthcare teamwork. Our framework enables us to characterize a patient case as needing a multi or interdisciplinary team and then describes the structural, behavioral and interface configurations needed to support healthcare teamwork for the patient case. The research presented in this paper helps us understand the complex nature of healthcare teamwork and HIT design to support it.

Digital process innovation in healthcare enables us to enhance functionality beyond what is enabled in physical process execution. However, the movement from paper artifacts and manual processes to the use of information and communication technologies (ICTs) to support healthcare delivery is challenging because system design requirements for digital processes can be much less structured and more difficult to define than for physical processes. This paper addresses the above issue and presents on our research in converting paper-based cancer symptom management practice guides to digital format for use by patients. We provide an overall architecture and three system design considerations for digital process innovation to support patient centered cancer symptom management.

Radiation therapists play an important role in helping patients to safely manage and triage potentially life-threatening symptoms. The purpose of the present study was to assess factors influencing the use by radiation therapists of evidence-informed symptom practice guides for patients experiencing cancer treatment&ndash, related symptoms. In a mixed-methods descriptive study guided by the Knowledge-to-Action framework, interviews and a barriers survey were conducted. Two independent reviewers conducted a content analysis of interview transcripts. Barriers survey data were analyzed using frequency distributions and univariate descriptive statistics. Open-ended data from the surveys underwent content analysis and were triangulated with interview findings. Of 90 radiation therapists approached, 58 completed the survey (64%), and 14 were interviewed. Of the 98% who reported providing symptom management to patients undergoing radiation treatment, 53% used evidence-informed practice guidelines. Radiation therapists had moderate moral norms (4.6 of 7) and beliefs about the consequences of using costars (pan-Canadian Oncology Symptom Triage and Remote Support) practice guides (4.8), but neutral intention (3.4) and beliefs about their own capabilities (3.9). Environmental barriers included lack of time (2.0), lack of access (2.5), and neutral organizational support (3.0). Radiation therapists identified a need for training (5.5). Common unique barriers to practice guide use were lack of time during radiation treatments, unclear fit with scope of practice, disparate focus on site-specific symptoms, and lack of medication knowledge. The symptom practice guides were perceived by the radiation therapists to benefit patients, enhance their own knowledge of symptom management, and promote consistent practice. Additional work is required to identify the scope of practice of radiation therapists within the interprofessional team.

Achieving systematic performance management of care processes across a health region requires an architecture that balances interoperability and data standardization with data governance and privacy compliance. This paper presents a case study of a successful pilot of cloud-hosted performance management for community care by a Regional Health Authority mandated with coordinating home care amongst 54 Community Support Services agencies. Cloud-hosted data services enabled data integration to a common data model. Formal data sharing agreements and privacy definition documents controlled aggregation and data masking to protect privacy while enabling accurate and comprehensive performance management services for all agencies.

While several societal and economic factors have necessitated more team-based care delivery, it remains a challenge to implement it in practice. Health information technology (IT) can support team-based care delivery, but there is currently a gap between the workflow of teams and the technology that we design to support it. To address this gap, we first formalize team-based workflows according to structural and behavioral aspects. Then, we describe collaborative workflows, and considerations for health IT design to support collaborative workflows. Health IT design for collaborative workflow goes beyond just automating the task at hand, as collaborative workflows are a social construction between data, people and processes; and we need to understand how these connections form prior to introducing technology to automate it. Collaborative workflows are not static, but rather dynamic processes. Health IT design therefore needs to be flexible so that it can evolve along with the collaborative processes that it is automating.

Background While health information technology (HIT) is playing a key role in transforming the healthcare system into a collaborative patient centered system, it is common for unintended consequences (UICs) to emerge post-HIT implementation. Healthcare delivery is a complex adaptive system and UICs occur because of multiple interactions between technology, users, organizational policies, and other situational contexts. Understanding the nature of these interactions and the manner in which they occur is a necessary first step to managing UICs from HIT implementation.

Introduction Members of the healthcare team must access and share patient information to coordinate interprofessional collaborative practice (ICP). Although some evidence suggests that electronic health records (EHRs) contribute to in-team communication breakdowns, EHRs are still widely hailed as tools that support ICP. If EHRs are expected to promote ICP, researchers must be able to longitudinally study the impact of EHRs on ICP across communication types, users, and physical locations. Objective This paper presents a data collection and analysis tool, named the Map of the Clinical Interprofessional Communication Spaces (MCICS), which supports examining how EHRs impact ICP over time, and across communication types, users, and physical locations. Methods The tool's development evolved during a large prospective longitudinal study conducted at a Canadian pediatric academic tertiary-care hospital. This two-phased study [i.e., pre-implementation (phase 1) and post implementation (phase 2)] of an EHR employed a constructivist grounded theory approach and triangulated data collection strategies (i.e., non-participant observations, interviews, think-alouds, and document analysis). The MCICS was created through a five-step process: (i) preliminary structural development based on the use of the paper-based chart (phase 1); (ii) confirmatory review and modification process (phase 1); (iii) ongoing data collection and analysis facilitated by the map (phase 1); (iv) data collection and modification of map based on impact of EHR (phase 2); and (v) confirmatory review and modification process (phase 2). Results Creating and using the MCICS enabled our research team to locate, observe, and analyze the impact of the EHR on ICP, (a) across oral, electronic, and paper communications, (b) through a patient's passage across different units in the hospital, (c) across the duration of the patient's stay in hospital, and (d) across multiple healthcare providers. By using the MCICS, we captured a comprehensive, detailed picture of the clinical milieu in which the EHR was implemented, and of the intended and unintended consequences of the EHR's deployment. The map supported our observations and analysis of ICP communication spaces, and of the role of the patient chart in these spaces. Conclusions If EHRs are expected to help resolve ICP challenges, it is important that researchers be able to longitudinally assess the impact of EHRs on ICP across multiple modes of communication, users, and physical locations. Mapping the clinical communication spaces can help EHR designers, clinicians, educators and researchers understand these spaces, appreciate their complexity, and navigate their way towards effective use of EHRs as means for supporting ICP. We propose that the MCICS can be used "as is" in other academic tertiary-care pediatric hospitals, and can be tailored for use in other healthcare institutions.

SummaryObjectives: The objectives of this paper are to review and discuss the methods that are being used internationally to report on, mitigate, and eliminate technology-induced errors.Methods: The IMIA Working Group for Health Informatics for Patient Safety worked together to review and synthesize some of the main methods and approaches associated with technology-induced error reporting, reduction, and mitigation. The work involved a review of the evidence-based literature as well as guideline publications specific to health informatics.Results: The paper presents a rich overview of current approaches, issues, and methods associated with: (1) safe HIT design, (2) safe HIT implementation, (3) reporting on technology-induced errors, (4) technology-induced error analysis, and (5) health information technology (HIT) risk management. The work is based on research from around the world. Conclusions: Internationally, researchers have been developing methods that can be used to identify, report on, mitigate, and eliminate technology-induced errors. Although there remain issues and challenges associated with the methodologies, they have been shown to improve the quality and safety of HIT. Since the first publications documenting technology-induced errors in healthcare in 2005, we have seen in a short 10 years researchers develop ways of identifying and addressing these types of errors. We have also seen organizations begin to use these approaches. Knowledge has been translated into practice in a short ten years whereas the norm for other research areas is of 20 years.

Objective While health information technology (HIT) offers great potential for supporting healthcare delivery, interoperability issues can be a barrier to effective use of HIT. While technical and semantic interoperability issues have been well studied there is a shortage of research that addresses process interoperability. Methods This paper uses a two year case study of a Palliative Care Information System (PAL-IS) to study process interoperability and health information technology (HIT). We describe the design of PAL-IS and develop and describe three types of process interoperability issues that arose from its implementation. Results The implementation of PAL-IS caused care delivery, clinical practice and administrative process interoperability issues. Further, many of these issues emerged over time and a solution to address one type of process interoperability issue often led to a different type of issue. We used our evaluation of PAL-IS to develop a general framework for understanding process interoperability and HIT. Conclusion Designing HIT to support care delivery is a complex sociotechnical endeavor that can result in different types of process interoperability issues. Evaluating process interoperability takes time and longitudinal studies are necessary to understand the overall ecosystem where technology, processes, and people interact. The framework developed in this paper provides a starting point for the evaluation of process interoperability and HIT.

Background The pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) team developed 13 evidence-informed protocols for symptom management. Aim To build an effective and sustainable approach for implementing the COSTaRS protocols for nurses providing telephone-based symptom support to cancer patients. Methods A comparative case study was guided by the Knowledge to Action Framework. Three cases were created for three Canadian oncology programs that have nurses providing telephone support. Teams of researchers and knowledge users: (a) assessed barriers and facilitators influencing protocol use, (b) adapted protocols for local use, (c) intervened to address barriers, (d) monitored use, and (e) assessed barriers and facilitators influencing sustained use. Analysis was within and across cases. Results At baseline, >85% nurses rated protocols positively but barriers were identified (64-80% needed training). Patients and families identified similar barriers and thought protocols would enhance consistency among nurses teaching self-management. Twenty-two COSTaRS workshops reached 85% to 97% of targeted nurses (N = 119). Nurses felt more confident with symptom management and using the COSTaRS protocols (p < .01). Protocol adaptations addressed barriers (e.g., health records approval, creating pocket versions, distributing with telephone messages). Chart audits revealed that protocols used were documented for 11% to 47% of patient calls. Sustained use requires organizational alignment and ongoing leadership support. Linking Evidence to Action Protocol uptake was similar to trials that have evaluated tailored interventions to improve professional practice by overcoming identified barriers. Collaborating with knowledge users facilitated interpretation of findings, aided protocol adaptation, and supported implementation. Protocol implementation in nursing requires a tailored approach. A multifaceted intervention approach increased nurses’ use of evidence-informed protocols during telephone calls with patients about symptoms. Training and other interventions improved nurses’ confidence with using COSTaRS protocols and their uptake was evident in some documented telephone calls. Protocols could be adapted for use by patients and nurses globally.

The importance of IT in healthcare continues to grow, driven by disruptive changes, including financial pressure, an aging population, the spread of connectivity and mobile technology, and significant advances in the biology of disease and the practice of medicine. These changes demand new advances in health IT. This special issue discusses the most recent trends in IT for healthcare and well-being.

The aim of this scoping review was to examine interventions used by nurses in the home setting for symptom management of adults with cancer. Databases were searched (CINAHL, Medline, PubMed, EBM Reviews, Joanna Briggs Institute EBP) with key words cancer, home, nursing, symptom, and protocol. Out of 390 identified citations, five met the inclusion criteria. Studies were conducted from 1989 to 2009. Findings revealed that home care nursing services improved symptom management, promoted independence, maintained quality of life, and decreased use of health care services. Two studies used evidence-based guidelines for cancer symptom management. Although few studies have explored nursing interventions for cancer symptom management in the home setting, their evidence suggests some improved client- and system-level outcomes.

Governments and healthcare providers are under increasing pressure to streamline their processes for efficiency, to reduce operational costs while improving service delivery and quality of care. Systematic performance management of healthcare processes is important in determining if quality of care goals are being met at all levels of the healthcare ecosystem. The challenge is that reaching these goals requires the aggregation and analysis of large amounts of data from various stakeholders in the healthcare industry. With the lack of interoperability between stakeholders in current healthcare compute and storage infrastructure as well as the volume of data involved, our ability to measure quality of care across the healthcare system is either limited or non-existent. Cloud computing is an emerging technology that can provide the needed interoperability and management of large volumes of data across the entire healthcare system. In this paper, we review various cloud computing applications for surveillance and performance management of quality of care in healthcare. We also introduce a framework for achieving systematic surveillance and performance management across the entire healthcare system.

SummaryBackground: A significant challenge associated with practicing evidence-based medicine is to provide physicians with relevant clinical information when it is needed. At the same time it appears that the notion of relevance is subjective and its perception is affected by a number of contextual factors.Objectives: To assess to what extent physi -cians agree on the relevance of evidence in the form of systematic reviews for a common set of patient cases, and to identify possible contextual factors that influence their perception of relevance.Methods: A web-based survey was used where pediatric emergency physicians from multiple academic centers across Canada were asked to evaluate the relevance of systematic reviews retrieved automatically for 14 written case vignettes (paper patients). The vignettes were derived from prospective data describing pediatric patients with asthma exacerbations presenting at the emer gency department. To limit the cognitive burden on respondents, the number of reviews associated with each vignette was limited to three.Results: Twenty-two academic emergency physicians with varying years of clinical practice completed the survey. There was no consensus in their evaluation of relevance of the retrieved reviews and physicians’ assessments ranged from very relevant to irrelevant evidence, with the majority of evaluations being somewhere in the middle. This indicates that the study participants did not share a notion of relevance uniformly. Further analysis of commentaries provided by the physicians allowed identifying three possible contextual factors: expected speci ficity of evidence (acute vs chronic condition), the terminology used in the systematic reviews, and the micro environment of clinical setting.Conclusions: There is no consensus among physicians with regards to what constitutes relevant clinical evidence for a given patient case. Subsequently, this finding suggests that evidence retrieval systems should allow for deep customization with regards to physi -cian’s preferences and contextual factors, including differences in the micro environment of each clinical setting.

Health information technology frequently leads to unintended consequences (UICs) post implementation. We believe a key cause of UICs are various HIT mediated connections between people and processes. To better manage UICs we first need to understand the nature of these connections. Business Process Management (BPM) approaches can help support HIT design but to date there are no methods focused on identifying patterns of HIT connectivity. This poster describes our three stage method to identify and model HIT connectivity patterns and then map the patterns to existing BPM workflow patterns. We use our method to analyze a case study of a perioperative information system to provide preliminary examples of individual and collaborative connectivity patterns.

This paper explores our efforts to support the expansion of a regional electronic consultation (eConsult) service on a national level by addressing potential policy barriers. We used an integrated knowledge translation (IKT) strategy based on five key activities leading to a National eConsult Policy Think Tank meeting: (1) identifying potential policy enablers and barriers; (2) engaging national and provincial/territorial partners; (3) including patient voices; (4) undertaking co-design and planning; and (5) adopting a solution-based approach. We successfully leveraged a diverse set of stakeholders in strategic discussions, culminating in actionable suggestions for next steps, which will serve to inform a national implementation strategy.

IntroductionTwenty per cent of Canadians will experience a mental illness in any year. Mental health patient portals have been developed to support these individuals in taking more control over their own mental health and care. This may be done through electronic access to their health records and other supportive functions like completion of online self-assessments. To date, there has been limited research into the value that these portals may provide within mental health contexts. This study will identify what value mental health patient portals may offer to patients and their family members.Methods and analysisThis study will use a mixed-methods design. Patients will complete a survey consisting of validated instruments at the time of enrolment in the portal, and at 3 and 6 months of portal use. Patient and family member focus groups will be conducted. Portal usage data will be collected to identify if there are differences in outcomes based on usage. The study will be done at Canada’s largest mental health and addiction teaching hospital, and will be conducted using a patient and family-oriented research approach, engaging these important representatives in all stages of the research process. The primary data analysis for the survey portion of the study will be done using linear mixed-effect models, assessing the differences between patients with different portal usage levels. A thematic analysis will be conducted of the focus group transcripts.Ethics and disseminationApproval from the study site’s Research Ethics Board has been obtained. The dissemination of findings of this study will be done through presentations at conferences, as well as a formal peer-reviewed journal article. Additionally, the research team will work with a group of patients and family members to identify opportunities to complete knowledge translation and dissemination activities in non-traditional venues.

The field of Connected Health (CH) has emerged in response to growing demands for improved connectivity to deliver patient-centred care through innovative healthcare management systems. As a result, there is a growing need to develop new healthcare delivery models and new ways of thinking about how information and communication technology can support healthcare delivery. This paper examines the role of software engineering in CH and presents the CH Delivery Framework as a first step to encapsulate key factors software engineers need to consider.

Complex patient health needs and care delivery models such as patient participatory medicine require the ability to share data across multiple touch points. Achieving systematic performance management of care processes require an infrastructure that addresses interoperability and data standardization while supporting data governance and privacy compliance. In this paper, we present a framework for operationalizing privacy compliance for correlated cloud-hosted data using Data Sharing Agreements (DSAs) in support of performance management of community healthcare. Our focus is to show how DSAs can be used to operationalize privacy compliance for a cloud-hosted surveillance and performance management infrastructure by leveraging selective anonymization based on both organizational and patient consents. This allows a cloud-computing infrastructure to configure processes and services, including anonymization to ensure privacy compliance and a systematic approach to data governance.

Summary Adding physician extenders (PEs) to surgical teams has the potential to affect care delivery in multiple ways. To develop evidence-based recommendations on integrating PEs into surgical teams, we must recognize that patient care is a complex, adaptive system and requires a health systems perspective to understand how changes will affect outcomes. It is the best method of assessing the system adaptations and trade-offs of adding PEs prior to implementation. Such work would help to optimize research and management of limited health care resources.

Big data analytics is an emerging topic that has the potential to significantly improve customer acquisition for inside salespeople, the fastest growing role in the sales industry. However, there has been limited application of Big data analytics in inside sales, especially in regard to the best strategies to engage customers through sales lead optimization. This paper intends to close this gap by providing a comprehensive and longitudinal study of the value of Big data analytics for both B2B and B2C inside sales. Data collected from 43 companies representing several industries through a leading provider of sales by phone software and containing about 47 million call history logs made to over 13 million leads from 2005 to 2016 reveal the best time and best way to optimize lead management practices. Theoretical and managerial contributions are highlighted.

Display Omitted We reviewed studies of collaboration in biomedical informatics from 1990-2015.Studying collaboration is complex as it is often intertwined with other concepts.Studies can be examined based on technology, context, processes, and outcomes.The collaboration space model is an approach to integrate these characteristics.We also need to evaluate whether HIT features explicitly support collaboration. PurposeOur objective was to identify and examine studies of collaboration in relation to the use of health information technologies (HIT) in the biomedical informatics field. MethodsWe conducted a systematic literature review of articles through PubMed searches as well as reviewing a variety of individual journals and proceedings. Our search period was from 1990-2015. We identified 98 articles that met our inclusion criteria. We excluded articles that were not published in English, did not deal with technology, and did not focus primarily on individuals collaborating. ResultsWe categorized the studies by technology type, user groups, study location, methodology, processes related to collaboration, and desired outcomes. We identified three major processes: workflow, communication, and information exchange and two outcomes: maintaining awareness and establishing common ground. Researchers most frequently studied collaboration within hospitals using qualitative methods. DiscussionBased on our findings, we present the "collaboration space model", which is a model to help researchers study collaboration and technology in healthcare. We also discuss issues related to collaboration and future research directions. ConclusionWhile collaboration is being increasingly recognized in the biomedical informatics community as essential to healthcare delivery, collaboration is often implicitly discussed or intertwined with other similar concepts. In order to evaluate how HIT affects collaboration and how we can build HIT to effectively support collaboration, we need more studies that explicitly focus on collaborative issues.

A mixed methods descriptive study explored 38 nurses’ perceptions of usability and factors influencing the use of 13 symptom management protocols when caring for patients with cancer in the home. Descriptive analysis of the usability survey revealed protocols had high readability, right amount of information, appropriate terms, and were self-evident to complete. Thematic analysis of transcripts identified barriers to using the protocols including lack of time, paper-based documentation systems, and length of the protocols. Facilitating factors included high usability of the protocols, integration of a remote symptom support nursing role, and the usefulness for education and training. In summary, the protocols were described as a useful resource and beneficial for nursing orientation but required support to overcome some barriers and improve fit with clinical workflow.

Summary Background: Primary care delivers patient-centred and coordinated care, which should be quality-assured. Much of family practice now routinely uses computerised medical record (CMR) systems, these systems being linked at varying levels to laboratories and other care providers. CMR systems have the potential to support care. Objective: To achieve a consensus among an international panel of health care professionals and informatics experts about the role of informatics in the delivery of patient-centred, coordinated, and quality-assured care.Method: The consensus building exercise involved 20 individuals, five general practitioners and 15 informatics academics, members of the International Medical Informatics Association Primary Care Informatics Working Group. A thematic analysis of the literature was carried out according to the defined themes. Results:The first round of the analysis developed 27 statements on how the CMR, or any other information system, including paper-based medical records, supports care delivery. Round 2 aimed at achieving a consensus about the statements of round one. Round 3 stated that there was an agreement on informatics principles and structures that should be put in place. However, there was a disagreement about the processes involved in the implementation, and about the clinical interaction with the systems after the implementation. Conclusions: The panel had a strong agreement about the core concepts and structures that should be put in place to support high quality care. However, this agreement evaporated over statements related to implementation. These findings reflect literature and personal experiences: whilst there is consensus about how informatics structures and processes support good quality care, implementation is difficult.

Objectives This paper reviews organizational and social issues (OSIs) in health information technology (HIT). Methods A review and synthesis of the literature on OSIs in HIT was conducted. Results Five overarching themes with respect to OSIs in HIT were identified and discussed: scope and frameworks for defining OSIs in HIT, context matters, process immaturity and complexity, trade-offs will happen and need to be discussed openly, and means of studying OSIs in HIT. Conclusions There is a wide body of literature that provides insight into OSIs in HIT, even if many of the studies are not explicitly labelled as such. The two biggest research needs are more explicit and theoretical studies of OSI in HITs and more research on integrating micro and macro perspectives of HIT use in organizations.

Common ground is necessary for developing collaboration as part of building resilience for public health preparedness. While the importance of common ground as an essential component of collaboration has been well described, there is a need for studies to identify how common ground develops over time, across individual and group dimensions, and the contexts that influence its development. This paper studied common ground development in three Canadian communities between October 2010 and March 2011 through a project on capacity building for disaster management. Disaster management requires the integration of paid and volunteer participants across public and private sectors and is therefore a good domain to study common ground development. We used directed qualitative content analysis to develop a model of common ground development over time that describes its progression through coordinative, cooperative and collaborative common ground. We also identified how common ground develops at micro (individual) and macro (group) levels, as well as how agency, technology and geographical contexts influence its development. We then use the four phases of disaster management to illustrate how our model can support longitudinal common ground development. Our findings provide useful insight to enable proactive development of common ground in collaborative health communities.

Reducing the rate of adverse events and preventable harm associated with healthcare delivery is a policy priority across healthcare systems internationally. Care transitions or handovers in clinical care introduce risk to patients that can lead to adverse events. Building on the literature showing the impact of governing boards on the quality and safety of healthcare services, this study builds a predictive model between governance and safety at care transitions. Analysis was based on 490 Canadian healthcare organizations across six sectors of care. Organizational compliance with the Accreditation Canada Governance Standards was shown to be a predictor of organizational performance with the Medication Reconciliation Required Organizational Practice. Results indicate that among a comprehensive set of governance standards, a set of 11 central governance elements predict organizational medication reconciliation practice. Implications for healthcare leaders are discussed including the role of organizational leadership in medication reconciliation practices. The importance of a governance process cycle that encompasses board prioritization of desired goals, monitoring of performance regularly, and communicating results with stakeholders is shown.

Health information technology (HIT) offers great potential for supporting healthcare delivery, particularly collaborative care delivery that is provided across multiple settings and providers. To date much of HIT design has focused on digitizing data or processes on a departmental or healthcare provider basis. However, this bounded approach has not scaled well for supporting community based care across disparate providers or settings because of the lack of boundaries (e.g. disprate data and processes) that exist in community based care. Cloud computing approaches that leverage mobile form applications for developing integrated HIT solutions have the potential to support collaborative healthcare delivery in the community. However, to date there is a shortage of methods that describe how to develop integrated cloud computing solutions to support community based care delivery. In particular there is a need for methods that identify how to incorporate boundaries into cloud computing systems design. This paper uses a three year case study of the design of the Palliative Care Information System (PAL-IS) to provide system design insight on cloud computing approaches that leverage mobile forms applications to support community care management.

Increasingly, healthcare is provided by a team of care providers from different organizations. Cross-organizational healthcare data sharing is a major issue in interoperable healthcare organizations. Studies have shown that quality of care can be put at risk when patients are transferred from one organization to another, while the need for protecting patient privacy is sometimes an inhibitor to providing information computing technology (ICT) solutions. This paper presents a systematic literature review of cross-organizational healthcare data sharing. The review includes research related to laws and regulations as well as proposed methodological and ICT solutions. Our methodology for querying, filtering and selecting relevant papers from scientific, academic and general repositories is explained and the selected papers are categorized and compared in terms of scope, contributions, and future directions. Based on this analysis, we outline a possible research direction for developing ICT solutions that healthcare providers and regulators would be willing to adopt. Based on our review, we concluded that inspite of the liberal regulations around data sharing among authorized healthcare providers, these organizations are utterly reluctant to collaborate on patient information. Fear of a breech of personal health information, and the shortage of technological facilitators that are compatible with the existing health information systems, are the main causes of the cross-organizational interoperability problems in the healthcare sector. The existing collaborative technologies require considerable initial investments that the current healthcare system is not willing to spend funds on.