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BackgroundPatients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions. ObjectiveThe aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. MethodsA cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. ResultsThe response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). ConclusionsAlthough patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Studies have identified the importance of hospitals' organisational culture in clinical information system diffusion, but few have quantified its role. This study measured organisational culture in two Australian hospitals to explore whether clinicians' perceptions of culture related to their attitudes to, and satisfaction with, a computerised provider order entry system (CPOE). Data were collected using the Organisational Culture Inventory and a user-satisfaction survey administered to a population of 249 clinicians from the two hospitals. One hospital used CPOE to order clinical laboratory and radiology tests and view results, and the other used the test viewing function only, the ordering facility being planned for later implementation. We found a relationship between culture and clinicians' attitudes, with those in the constructive culture hospital more likely to express positive attitudes towards CPOE, whereas those in the agressive/defensive hospital were more likely to be negative. The relationship between culture and attitudes towards clinical information systems should be taken into account when planning for their adoption. Keywords: Australia; Organisational culture; Hospital information systems; Clinical information systems; Computerised provider order entry systems (CPOE)

Abstract Background The disruptive potential of the Nurse Practitioner (NP) is evident in their ability to offer services traditionally provided by primary care practitioners and their provision of a health promotion model of care in response to changing health trends. No study has qualitatively investigated the role of the Emergency NP in Australia, nor the impact of Information and Communication Technology (ICT) on this disruptive workforce innovation. This study aimed to investigate ways in which Nurse Practitioners (NP) have incorporated the use of ICT as a mechanism to support their new clinical role within Emergency Departments. Methods A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior physicians and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the ED nurse practitioner role and the influences of ICT upon the role. Member checking of results was achieved by revisiting the sites to clarify findings with participants and further explore emergent themes. Results The role of the ENP was distinguished from those of Emergency nurses and physicians by two elements: advanced practice and holistic care, respectively. ICT supported the advanced practice dimension of the NP role in two ways: availability and completeness of electronic patient information enhanced timeliness and quality of diagnostic and therapeutic decision-making, expediting patient access to appropriate care. The ubiquity of patient data sourced from a central database supported and improved quality of communication between health professionals within and across sites, with wider diffusion of the Electronic Medical Record holding the potential to further facilitate team-based, holistic care. Conclusions ICT is a facilitator through which the disruptive impact of NPs can be extended. However, integration of ICT into work practices without detracting from provider-patient interaction is crucial to ensure utilisation of such interventions and realisation of potential benefits.

Abstract Background Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standards through research and expert views. They then apply standards, criteria and performance indicators, testing their effects, and monitoring compliance with them. The accreditation process has been widely adopted. The international investments in accreditation are considerable. However, reliable evidence of its efficiency or effectiveness in achieving organizational improvements is sparse and the value of accreditation in cost-benefit terms has yet to be demonstrated. Although some evidence suggests that accreditation promotes the improvement and standardization of care, there have been calls to strengthen its research base. In response, the ACCREDIT (Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork) project has been established to evaluate the effectiveness of Australian accreditation in achieving its goals. ACCREDIT is a partnership of key researchers, policymakers and agencies. Findings We present the framework for our studies in accreditation. Four specific aims of the ACCREDIT project, which will direct our findings, are to: (i) evaluate current accreditation processes; (ii) analyse the costs and benefits of accreditation; (iii) improve future accreditation via evidence; and (iv) develop and apply new standards of consumer involvement in accreditation. These will be addressed through 12 interrelated studies designed to examine specific issues identified as a high priority. Novel techniques, a mix of qualitative and quantitative methods, and randomized designs relevant for health-care research have been developed. These methods allow us to circumvent the fragmented and incommensurate findings that can be generated in small-scale, project-based studies. The overall approach for our research is a multi-level, multi-study design. Discussion The ACCREDIT project will examine the utility, reliability, relevance and cost effectiveness of differing forms of accreditation, focused on general practice, aged care and acute care settings in Australia. Empirically, there are potential research gains to be made by understanding accreditation and extending existing knowledge; theoretically, this design will facilitate a systems view of accreditation of benefit to the partnership, international research communities, and future accreditation designers. "Accreditation of health-care organisations is a multimillion dollar industry which shapes care in many countries. Recent reviews of research show little evidence that accreditation increases safety or improves quality. It's time we knew about the cost and value of accreditation and about its future direction." [Professor John Øvretveit, Karolinska Institute, Sweden, 7 October 2009]

Abstract Background Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care. Design A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care. Discussion A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.

Abstract Background Communities of practice and social-professional networks are generally considered to enhance workplace experience and enable organizational success. However, despite the remarkable growth in interest in the role of collaborating structures in a range of industries, there is a paucity of empirical research to support this view. Nor is there a convincing model for their systematic evaluation, despite the significant potential benefits in answering the core question: how well do groups of professionals work together and how could they be organised to work together more effectively? This research project will produce a rigorous evaluation methodology and deliver supporting tools for the benefit of researchers, policymakers, practitioners and consumers within the health system and other sectors. Given the prevalence and importance of communities of practice and social networks, and the extent of investments in them, this project represents a scientific innovation of national and international significance. Methods and design Working in four conceptual phases the project will employ a combination of qualitative and quantitative methods to develop, design, field-test, refine and finalise an evaluation framework. Once available the framework will be used to evaluate simulated, and then later existing, health care communities of practice and social-professional networks to assess their effectiveness in achieving desired outcomes. Peak stakeholder groups have agreed to involve a wide range of members and participant organisations, and will facilitate access to various policy, managerial and clinical networks. Discussion Given its scope and size, the project represents a valuable opportunity to achieve breakthroughs at two levels; firstly, by introducing novel and innovative aims and methods into the social research process and, secondly, through the resulting evaluation framework and tools. We anticipate valuable outcomes in the improved understanding of organisational performance and delivery of care. The project's wider appeal lies in transferring this understanding to other health jurisdictions and to other industries and sectors, both nationally and internationally. This means not merely publishing the results, but contextually interpreting them, and translating them to advance the knowledge base and enable widespread institutional and organisational application.

* The introduction of computerized provider order entry (CPOE) systems is associated with major changes in work processes. Implementation strategies need to consider how the technology will affect and be affected by the organization in which it is being installed. The aim of this study was to examine the potential effect of the introduction of a CPOE system on key work processes in a hospital blood bank by using qualitative data from focus groups, interviews, and participant observation and quantitative data of telephone communication. We found that work practices in the blood bank are made up of a mosaic of collaborative processes underpinned by communication channels to facilitate safe and efficient work practices. The introduction of CPOE systems requires consideration of these channels and of the ways that CPOE may disrupt existing communication processes. There needs to be high levels of staff preparedness to minimize patient risk and optimize performance., Pathology services have been described as the "hidden science that saves lives." (1) They make an essential contribution to the effective prevention, detection, and management of disease but are still [...]

Objective: This group-randomized control trial examined the efficacy of guided coping and emotion regulatory self-reflection as a means to strengthen resilience by testing the effects of the training on anxiety and depression symptoms and perceived stressor frequency after an intensive stressor period. Method: The sample was 226 officer cadets training at the Royal Military College, Australia. Cadets were randomized by platoon to the self-reflection (n = 130) or coping skills training (n = 96). Surveys occurred at 3 time points: baseline, immediately following the final reflective session (4-weeks postbaseline), and longer-term follow-up (3-months postinitial follow-up). Results: There were no significant baseline differences in demographic or outcome variables between the intervention groups. On average, cadets commenced the resilience training with mild depression and anxiety symptoms. Analyses were conducted at the individual-level after exploring group-level effects. No between-groups differences were observed at initial follow-up. At longer-term follow-up, improvements in mental health outcomes were observed for the self-reflection group, compared with the coping skills group, on depression (Cohen's d = 0.55; 95% Cl [0.24, 0.86]), anxiety symptoms (Cohen's d = 0.69; 95% Cl [0.37, 1.00]), and perceived stressor frequency (Cohen's d = 0.46; 95% Cl [0.15, 0.77]). Longitudinal models demonstrated a time by condition interaction for depression and anxiety, but there was only an effect of condition for perceived stressor frequency. Mediation analyses supported an indirect effect of the intervention on both anxiety and depression via perceived stressor frequency. Conclusions: Findings provide initial support for the use of guided self-reflection as an alternative to coping skills approaches to resilience training. [ABSTRACT FROM AUTHOR]

Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions. [ABSTRACT FROM AUTHOR]

Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part in determining the nature of change that an electronic result acknowledgement system is likely to produce. [ABSTRACT FROM AUTHOR]

Socio-technical approaches to health information systems evaluation are particularly relevant to the study of Computerised Provider Order Entry (CPOE) systems. Pathology services are made up of a number of departments each with unique and complex tasks and requirements. These different components of pathology have received very little research attention. This study used qualitative methods to identify key organisational and work process along with repercussions of the implementation of CPOE through a comparison of the Haematology and Clinical Chemistry departments of a hospital pathology service. The results focus attention on areas where the departments face similar challenges along with those areas where work practices diverged. This underlined the key importance of understanding the context and setting of pathology laboratories. The study also draws attention to the importance of cross departmental and multi-disciplinary negotiation in the implementation process and highlights the potential for technology to affect and be affected by the organisational context in which it is placed. [ABSTRACT FROM AUTHOR]