Search

Over the last decade, the explosion of "Big Data" and its fusion with AI has led many to believe that the development and integration of AI systems in healthcare will usher in a transformative revolution that democratises access to high quality healthcare and collectively improve patient outcomes. However, the nature of market forces in the evolving data economy, has started to show evidence that the opposite is more likely to be true. This paper argues that there is a poorly understood "Inverse Data Law" that will exacerbate the widening health divide between affluent and marginalised communities because: (1) data used to train AI systems favour individuals that are already engaged with healthcare, who have the lowest burden of disease, but the highest purchasing power; and (2) data used to drive market decisions around investment in AI health technology favours tools that increase the commodification of healthcare through over-testing, over-diagnosis, and the acute and episodic management of disease, over tools that support the patient to prevent disease. This dangerous combination is more likely to cripple efforts towards preventative medicine, as data collection and utilisation tends to be inversely proportional to the needs of the patients served - the inverse data law. The paper concludes by introducing important methodological considerations in the design and evaluation of AI systems to promote systems improvement for marginalised users.

Inflammatory bowel disease (IBD) is a chronic relapsing and remitting illness. The presentation, diagnosis and management IBD are complex, and involve multi-disciplinary care with complex information requirements. The lack of an accurate and comprehensive patient record is often a stumbling block for optimal patient care. Blockchain technology therefore appears to be the perfect solution to improve IBD patient care. Blockchain technology can provide comprehensive and secure data transmission. Many current projects using blockchain for IBD care focus on information delivery. Recently, clinical research has shown that patients have different perceptions of what constitutes high-quality care, compared to healthcare professionals. Patient-centred care in IBD has increasingly taken central stage. Concurrently, blockchain in healthcare has shifted focus to argue for allowing the patient to be in the driver's seat for information access, facilitated by blockchain-enabled patient-driven interoperability and patient-driven care. This paper dissects the risks and benefits of these two approaches in using blockchain in IBD patient care. This paper then explores the socio-technical and clinical considerations in using blockchain in IBD patient care. Finally, this paper presents four key principles in using blockchain to improve IBD paper care, using collaborative participatory design involving patients, healthcare professionals, and health systems.

AI augmented clinical diagnostic tools are the latest research focus in colorectal cancer (CRC) detection. While the opportunity presented by AI-enhanced CRC diagnosis is sound, this paper highlights how its effectiveness with respect to reducing CRC-related mortality and enhancing patient outcomes may be limited by the fact that patient participation remains extremely low globally. This paper builds a foundation to consider how human factors tend to contribute to low participation rates and suggests that a more nuanced socio-technical approach to the development, implementation and evaluation of AI systems that is sensitive to the psycho-social and cultural dimension of CRC may lead to tools that increase screening uptake.

Nosocomial infections are a major public health risk more prevalent among vulnerable patients in intensive care units of lower and lower-middle income countries. Despite advances in health care, the prevalence of nosocomial infections is alarming. The reasons for these infections are multifactorial and include organisational, cultural and individual factors. This paper discusses the findings associated with research undertaken in six surgical intensive care units in Sri Lanka to evaluate the impact of an eHealth system prototype in contributing to the improvement of hand hygiene compliance and thereby reduction of nosocomial infections. Key findings include the necessity of reconsidering the way of calculating nosocomial infection rates, the importance of coupling interventions to feedbacks on outcomes and the role of the leaders as role models in inculcating positive behaviours.

Blockchain technology is often considered as the fourth industrial revolution that will change the world. The enthusiasm of the transformative nature of blockchain technology has infiltrated healthcare. Blockchain is often seen as the much needed and perfect technology for healthcare, addressing the difficult and complex issues of security and inter-operability. More importantly, the "value" and trust-based system can deliver automated action and response via its smart contract mechanism. Healthcare, however, is a complex system. Health information technology (HIT) so far, has not delivered its promise of transforming healthcare due to its complex socio-technical and context sensitive interaction. The introduction of blockchain technology will need to consider a whole range of socio-technical issues in order to improve the quality and safety of patient care. This paper presents a discussion on these socio-technical issues. More importantly, this paper argues that in order to achieve the best outcome from blockchain technology, there is a need to consider a clinical transformation from "information" to "value " and trust. This paper argues that urgent research is needed to address these socio-technical issues in order to facilitate best outcomes for blockchain in healthcare. These socio-technical issues must then be further evaluated by means of working prototypes in the medical domain in coming years.

Advances in medicine have improved health and healthcare for many around the world. The challenge is achieving the best outcomes of health via healthcare delivery to every individual. Healthcare inequalities exist within a country and between countries. Health information technology (HIT) has provided a mean to deliver equal access to healthcare services regardless of social context and physical location. In order to achieve better health outcomes for every individual, socio-cultural factors, such as literacy and social context need to consider. This paper argues that HIT while improves healthcare inequalities by providing access, might worsen healthcare inequity. In order to improve healthcare inequity using HIT, this paper argues that we need to consider patients and context, and hence the concept of context driven care. To improve healthcare inequity, we need to conceptually consider the patient's view and methodologically consider design methods that achieve participatory outcomes.

Nosocomial infections are a global public health risk. In low and middle-income countries the problem is acute with very high infection rates commonly contributing to poor patient outcomes including mortality. Organisational, cultural, and individual factors have been identified in these high rates, with poor hand hygiene compliance amongst clinicians a major risk factor. New approaches to achieving clinician behaviour change are required. User-centred approaches have proven effective to engage and support changes in clinician behaviours through the use of electronic tools. This paper reports on the experience of co-designing and implementing a mobile application with clinicians to enhance hand hygiene compliance. The peer monitoring and training supported by the application aims to directly contribute to evidence on reductions in infection rates in two surgical ICUs in Sri Lanka.

Considerable effort and resources have been dedicated to improving the quality and safety of patient care through health information systems, but there is still significant scope for improvement. One contributing factor to the lack of progress in patient safety improvement especially where technology has been deployed relates to an over-reliance on purely objective, quantitative, positivist research paradigms as the basis for generating and validating evidence of improvement. This paper argues the need for greater recognition and accommodation of evidence of improvement generated through more subjective, qualitative and pragmatic research paradigms to aid patient safety especially where technology is deployed. This paper discusses how acknowledging the role and value of more subjective ontologies and pragmatist epistemologies can support improvement science research. This paper illustrates some challenges and benefits from adopting qualitative research methods in patient safety improvement projects, particularly focusing challenges in the technological era. While adopting methods that can more readily capture, analyse and interpret direct user experiences, attitudes, insights and behaviours in their contextual settings, patient safety can be enhanced 'on the ground' and errors reduced and/or mitigated, challenges of using these methods with the younger "technologically-centred" healthcare professionals and patients needs to recognised.

Current efforts to improve nursing handover frequently use prescriptive approaches based on research evidence of handover issues within a single nursing ward or nursing specialty. Despite reported handover improvement, few studies adequately consider the transferability of results to other nursing handover environments or acknowledge the unique attributes that supported sustained improvement. With the increasing diffusion of electronic tools it has become even more critical to ensure that socio-technical issues that may impact on the quality and safety of nursing handovers are identified. This paper describes a qualitative research project that examined nursing handover in three different wards - General Medicine, General Surgery and Department of Emergency Medicine in a tertiary teaching hospital. Through conduct of a detailed analysis of nursing handover processes, this paper highlights the similarities and differences in the handover among the three different wards and presents five key socio-technical insights to support safe nursing handover.

Improving clinical communication is imperative to improving the quality and safety of patient care. Significant efforts have been made to improve clinical communication and patient safety, guided by the mantra of "the right information, to the right person, in the right place, at the right time". The design and implementation of information communication technologies (ICTs) has been considered as one of the major developments in improving patient care. Clinical communication in today's clinical practice is complex and involves multi-disciplinary teams using different types of media for information transfer. This paper argues that traditional communication theories fail to adequately capture and describe contemporary clinical communicative practices or to provide insight into how information transferred is actually assimilated and/or utilised for patient care. This paper argues for the need to more fully consider underlying assumptions about the role of information in clinical communication and to recognise how the attributes of information receivers, especially where ICTs are deployed influence outcomes. The paper presents a discussion regarding the need to consider information receivers as the foundation for clinical communication improvement and future design and development of ICTs to improve patient care.

Stimulating widespread interests of the population to participate in behavioural changes through information and technology has been an aim of much health informatics research. The recent widespread participation of the augmented reality game Pokémon Go which encourages exercises, provides significant insights into the potential of information technology to improve healthcare intervention on obesity-related disease. Does Pokémon Go point to another way of achieving health benefits using mobile devices? This paper analyses the features of Pokémon Go in relation to potential health benefits. This paper suggests from the perspective of a user on changes to the game that potentially could help with obesity, mental health cardiovascular health and vitamin D deficiencies. While the impact of augmented reality games on improving exercises might be substantial, the question of sustainability and likely long-term health outcomes remain debatable. The rapid uptake of Pokémon Go by the population around the world, however, should serve as a useful lesson for information and technological design to improve outcomes obesity-related diseases in the future.

Stimulating sustained behavioural change through information and technology has been an aim of much health informatics research. Traditional approaches use technology to mediate communications between health professionals and patients. More recent lifestyle technologies engage the patient directly with information and advice - but what of the phenomena that is Pokémon Go - does it point to another way of achieving health benefits through fun? This paper aims to explore some of the conceptual questions for health informatics stimulated by the phenomenal popularity of Pokémon Go. The paper is grounded analysis of data generated through a preliminary participatory observational study in Australia.

Governments around the world are actively promoting citizens electronic access to their health data as one of a number of ways to respond to the challenges of health care delivery in the 21st century. While numerous approaches have been utilized it is evident from cross-country comparisons that there are different conceptualizations of: both the expected and desired roles for citizens in the management of their own health; the benefits that will be delivered by citizen access and how these benefits should be measured and benchmarked over-time. This paper presents comparative analyses of the methods by which citizens are provided with access to their own health data across 11 countries. The paper aims to stimulate debate on electronic citizen access to health data and the challenges of measuring benefit as well as reflection on capacity of different citizens to engage with e-health.

Hospital discharge is associated with high risks and potential adverse events for patients. While significant efforts have been made to improve discharge, patients and their families/carers have tended to be marginalized in discharge processes. Evidence from user-centred approaches to the development of eHealth emphasize the importance of engaging end-users to optimize the safety and quality of health services. This paper promotes a patient-centred approach focusing on discharge back to the community and the development of electronic tools as a method for contributing to improving the safety and quality of discharge processes. Understanding and engaging with patients as end-users avoids simplistic techno-centric and info-centric approaches to discharge improvement.

Nosocomial infections are a health concern in hospitals both in developed and developing countries. Immuno-compromised patients in intensive care units (ICU) have been identified as being particularly vulnerable. However, despite numerous interventions, infection rates remain high and antibiotic resistance is now of global concern. In Sri Lanka, higher than anticipated infection rates appear linked to a range of factors including hierarchical work flow, poor surveillance feedback and health staff attitudes and awareness. By deploying a user-centered approach to understanding these factors this research-in-progress will develop and evaluate the capacity of an eHealth system to contribute to reduction of nosocomial infections in Sri Lankan ICUs.

This chapter explores how Techno-Anthropology can contribute to more explicitly professional and ethically responsible reflections on the socio-technical practices involved in meaningfully engaging patients in health informatics research. The chapter draws on insights from health informatics research projects focused on chronic disease and self-management conducted in Tasmania during the last 10 years. Through these projects the paper explores three topics of relevance to 'meaningful engagement' with patients: (i) Patient Self-Management and Chronic Disease (ii) Patients as Users in Health Informatics research, and, (iii) Evaluations of outcomes in Health and Health Informatics Interventions. Techno-Anthropological reflections are then discussed through the concepts of liminality, polyphony and power. This chapter argues that beyond its contribution to methodology, an important role for Techno-Anthropology in patient centred health informatics research may be its capacity to support new ways of conceptualising and critically reflecting on the construction and mediation of patients' needs, values and perspectives.

Clinical handover is a high risk scenario involving the transfer of information, responsibility and accountability for patient care. Many strategies have been proposed to improve clinical handover and reduce risks it can pose to the safety and quality of patient care. The development and implementation of electronic tools provides one mechanism for structuring and streamlining information transfer to support more standardised handover practices. However, clinical judgement remains a valued, fundamental aspect of clinical practice and its communication during handover is open to variation in ways that may compromise patient safety. This research examines these issues based on evidence generated from a user-centred approach involving clinicians in the development and implementation of an electronic clinical handover system. The paper highlights how clinical judgements and communicative practices interact with an electronic clinical handover system, and discusses their potential implications for patient safety as part of a broader clinical handover improvement project.

This paper examines the outcomes for clinicians from their involvement in the development of an electronic clinical hand-over tool developed using principles of user-centered design. Conventional e-health post-implementation evaluations tend to emphasize technology-related (mostly positive) outcomes. More recently, unintended (mostly negative) consequences arising from the implementation of e-health technologies have also been reported. There remains limited focus on the post-implementation outcomes for users, particularly those directly involved in e-health design processes. This paper presents detailed analysis and insights into the outcomes experienced post-implementation by a cohort of junior clinicians involved in developing an electronic clinical handover tool in Tasmania, Australia. The qualitative methods used included observations, semi-structured interviews and analysis of clinical handover notes. Significantly, a number of unanticipated flow-on effects were identified that mitigated some of the challenges arising during the design and implementation of the tool. The paper concludes by highlighting the importance of identifying post-implementation user outcomes beyond conventional system adoption and use and also points to the need for more comprehensive evaluative frameworks to encapsulate these broader socio-technical user outcomes.

User-centred approaches in the development and evaluation of health information systems promote the importance of involving users and understanding their social contexts to optimise the quality and safety of these systems for patient care. Simultaneously, the standardisation of clinical practices has also been advocated to improve the quality and safety of patient care. In the context of clinical handover improvement within three different departments in one tertiary teaching hospital, this paper highlights the potential for tensions between these two approaches and explores their implications. Based on a user-centred approach, the paper reports on the unique requirements identified within each of the three departments for an information system to support improved clinical handover. Each department had clinical practices, work cultures and user requirements that needed to be considered and accommodated. This led to the project developing distinct minimum data sets for each of the three departments that posed challenges for efforts to standardise handover practices across the hospital and for building an integrated information system. While on the one hand accommodating unique departmental user requirements was valuable, they revealed the potential for the introduction of quality and safety risks at the organisational level. To resolve these tensions, the project team developed an approach called flexible standardisation that has now been embedded in Australia' s national guidelines on clinical handover improvement.

The Australian Commission for Safety and Quality in Health Care (ACSQHC) coordinates national improvements in a range of complex health system problems including clinical handover, and has funded a range of handover improvement projects in Australia. One of these, the SafeTECH project in South Australia has developed guidelines for safe use of electronic handover tools. These guidelines were developed using evidence from three hospital case studies into the use of an electronic tool to support different types of shift-to-shift handover. This paper provides an overview of the project, and highlights challenges for patient safety in the design and use of electronic tools to support clinical handover in a busy clinical environment. The paper then considers these challenges within the broader context of the Australian ehealth landscape. Australia's National eHealth Transition Authority (NEHTA) is actively developing ehealth standards and infrastructure requirements for the electronic collection and secure exchange of health information. The paper argues for flexible standardisation in the design and implementation of electronic handover tools to ensure that all key dimensions of the challenges faced in ensuring patient safety are addressed.

As part of Australia's participation in the World Health Organization, the Australian Commission on Safety and Quality in Health Care (ACSQHC) is the leading federal government technical agency involved in the area of clinical handover improvement. The ACSQHC has funded a range of handover improvement projects in Australia including one at the Royal Hobart Hospital (RHH), Tasmania. The RHH project aims to investigate the potential for generalizable and transferable clinical handover solutions throughout the medical and nursing disciplines. More specifically, this project produced an over-arching minimum data set (MDS) and over-arching standardized operating protocol (SOP) based on research work on nursing and medical shift-to-shift clinical handover in general medicine, general surgery and emergency medicine. The over-arching MDS consists of five headings: situational awareness, patient identification, history and information, responsibility and tasks and accountability. The over-arching SOP has five phases: preparation; design; implementation; evaluation; and maintenance. This paper provides an overview of the project and the approach taken. It considers the implications of these standardized operating protocols and minimum data sets for developing electronic clinical handover support tools. Significantly, the paper highlights a human-centred design approach that actively involves medical and nursing staff in data collection, analysis, interpretation, and systems design. This approach reveals the dangers of info-centrism when considering electronic tools, as information emerges as the only factor amongst many others that influence the efficiency and effectiveness of clinical handover.

While the need to 'involve the user' in information technology (IT) development is almost a mantra amongst information systems specialists, numerous IT projects continue to fail because of an inability to capture user insights or respond to users needs. Although there are clearly practical difficulties in addressing and responding to the heterogeneous requirements expressed by different users, marginalizing these views ultimately is to the detriment of the systems built. This paper describes the development of an electronic clinical handover system at the Department of General Internal Medicine (DGIM), Royal Hobart Hospital (RHH). More specifically, the paper aims to highlight how to engage meaningfully with clinicians in the development of a sustainable system. It is anticipated that by drawing attention to the importance of users and by outlining the practical experience of dealing with the diversity of requirements and views expressed, the paper can contribute to a stronger recognition within the domain of eHealth for a user-centred systems approach to IT development.

This paper describes a case study into the development of an electronic support tool for clinical handover conducted in the Royal Hobart Hospital's Department of General Internal Medicine. By directly involving clinicians as co-participants in the development, and by conceptualising the system to be built as a support tool rather than as a 'total solution' this case study outlines the practical experience of dealing with a diversity of user requirements. The approach involved in-depth fieldwork to understand the factors and their inter-relationships in clinical handover processes. From an analysis of the data generated key issues relating to work processes and potential impacts on patient safety were identified and discussed with clinicians. A support tool incorporating a series of design features aimed at improving patient safety and supporting existing work processes identified as important by the clinicians was developed. Through early and continual involvement of clinicians in the project, this case study highlights how socio-cultural analysis can be translated meaningfully (in terms of the end-users) into systems design. The paper aims to contribute to a stronger recognition within the domain of eHealth of user-centred approach to systems development for patient safety.

While identifying reasons why medical errors occur and constructing models of how to manage them has proved relatively straightforward, implementing and meaningfully evaluating solutions in 'real-world' settings has proven considerably more difficult. From an information systems (IS) perspective, although the promise of technology remains powerful, the continuing high incidence of medical errors suggest that eHealth approaches are struggling to acquire a clear understanding of the complex, dynamic and multi-layered nature of acute care settings and clinical practices, and to respond effectively to address the range of errors that actually occur. Using medical handover as a field-site, this research-in-progress paper presents an adaptation of James Reason's 'Swiss Cheese Model' to conceptualize the complex factors at play in medical errors in terms of human, system and informational elements. This research paper then examines how drawing on this model it is possible to generate and implement a methodological approach that both enhances a holistic understanding of medical error management and illuminates criteria that can be used to meaningfully identify an appropriate role for information technology in medical error mitigation. This research-in-progress paper aims to make a significant contribution to research into medical error management in 'real-world' acute care settings. This research is part of a bigger project that aims to develop, implement and evaluate an information technology artefact as part of an holistic information systems approach to improving medical error management at medical handover.