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General practitioners (GPs) are an integral part of the multidisciplinary team that care for patients with lung cancer. It is essential that patient information including results of tests, management plans, treatment, and follow-up arrangements are communicated between hospital-based carers and the community-based GP. The aim of this study was to explore GPs' views about the information they need from hospital-based health professionals in the management of their patients with lung cancer. This exploration is undertaken within the context of a multidisciplinary model of care, a relatively new concept in service delivery for cancer patients. Data were collected using a questionnaire that was distributed to the population of 433 GPs from one Australian regional Division of General Practice. Questions related to from whom, what, when and how GPs would like to receive information from the multidisciplinary hospital-based lung cancer team. GPs reported that they wanted information from all members of the multidisciplinary hospital-based lung cancer team, not just physicians. The key triggers for communication included: any change in the patient's condition; following initial outpatient visit; at admission and discharge; and following treatment milestones. Both medical and social information were seen as important to GPs and there was strong support to receive information electronically. This study illustrates the desire by GPs to receive information from all members of the hospital-based lung cancer team if it is relevant to the ongoing care of their patient. Technology-enabled solutions, such as an electronic multidisciplinary discharge summary, the electronic health record and the person-controlled electronic health record, offer strategies to improve both timeliness and access to information.

Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.

Objective: To measure doctors' and nurses' perceptions of organisational culture and relate this to their attitudes to, and satisfaction with, a hospital-wide mandatory computerised provider order entry (CPOE) system in order to illuminate cultural compositions in CPOE use., Methods: A cross-sectional survey design was employed. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. Clinicians from the hospital had used the CPOE system since 1991 to order and view clinical laboratory and radiology tests electronically for all patients. The OCI provides a measure of culture in terms of three general styles which distinguish between: constructive; passive/defensive, and aggressive/defensive cultures. The cluster which best describes the overall culture is the one that has the highest percentile score when the percentile scores of the four cultural norms included in the cluster are averaged. The user satisfaction survey asked questions relating to satisfaction with, and attitudes to, the system., Results: We found identifiable sub-cultures based on professional divisions where doctors perceived an aggressive-defensive culture (mean percentile score = 43.8) while nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors., Conclusion: The manifestation of sub-cultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation. Identification and management of the cultural characteristics of different groups of health professionals may facilitate the successful implementation and use of clinical information systems.

A major focus of nurses is to improve patient outcomes, and any introduction of technology into their work environment should add value through enhancing patient care and contributing to the development of nursing intelligence. This study addressed whether nurses working in an emergency department (ED) perceived a relationship between using an emergency department information system (EDIS) and patient outcomes. A cross-sectional survey design was used, with data collected from the population (n=168) of nurses from five Australian metropolitan public hospital emergency departments (EDs). The questionnaire collected information on how EDIS impacted on patient outcomes in terms of waiting times, triage process, departmental accountability, documentation focus, computer interaction, and system purpose. Nurses acknowledged the value of an information system in improving the triage process and increasing the accountability of the ED, however failed to identify any impact on reducing overall ED waiting times or its relationship to improved care delivery. Over half the respondents could not identify negative effects such as compelling nurses to focus on documentation details or 'treat the computer' rather than the patient. The use of technology in this study evoked optimistic responses, however results indicated a lack of clarity about the impact of EDIS on patient outcomes.

Increases in attendance rates at emergency departments (EDs) have prompted concerns regarding inappropriate utilisation. Factors instigating patient ED attendance were examined using a cross sectional survey of 522 patients presenting to the ED of a rural hospital in Australia, during a 1-week period. The results highlighted the importance of the rural hospital ED as an additional and alternate service to existing primary care facilities, particularly outside of business hours. The findings indicated that although patients' perception of an emergency does not necessarily correspond with clinical interpretations, the primary factors prompting attendance, including general practitioner unavailability, referrals and special service needs, suggest that, from a patients' perspective, the majority of presentations to the ED are justified.

Background: Hospital discharge summaries have traditionally been paper-based (handwritten or dictated), and deficiencies have often been reported. On the increase is the utilisation of electronic summaries, which are considered of higher quality than paper-based summaries. However, comparisons between electronic and paper-based summaries regarding documentation deficiencies have rarely been made and there have been none in recent years., Objectives: (1) To study the hospital discharge summaries, which were either handwritten or electronic, of a population of inpatients, with regard to documentation of information required for ongoing care; and (2) to compare the electronic with the handwritten summaries concerning documentation of this information., Methods: The discharge summaries of 245 inpatients were examined for documentation of the items: discharge date; additional diagnoses; summary of the patient's progress in hospital; investigations; discharge medications; and follow-up (instructions to the patient's general practitioner). One hundred and fifty-one (62%) discharge summaries were electronically created and 94 (38%) were handwritten. Odds ratios (ORs) with their confidence intervals (CI) were estimated to show strength of association between the electronic summary and documentation of individual study items., Results: Across all items studied, the electronic summaries contained a higher number of errors and/or omissions than the handwritten ones (OR 1.74, 95% CI 1.26-2.39, p<0.05). Electronic summaries more commonly documented a summary of the patient's progress in hospital (OR 18.3, 95% CI 3.33-100, p<0.05) and less commonly recorded date of discharge and additional diagnoses (respective ORs 0.17 (95% CI 0.09-0.31, p<0.05) and 0.33 (95% CI 0.15-0.89, p<0.05)., Conclusion: It is not necessarily the case that electronic discharge summaries are of higher quality than handwritten ones, but free text items such as summary of the patient's progress may less likely be omitted in electronic summaries. It is unknown what factors contributed to incompleteness in creating the electronic discharge summaries investigated in this study. Possible causes for deficiencies include: insufficient training; insufficient education of, and thus realisation by, doctors regarding the importance of accurate, complete discharge summaries; inadequate computer literacy; inadequate user interaction design, and insufficient integration into routine work processes. Research into these factors is recommended. This study suggests that not enough care is taken by doctors when creating discharge summaries, and that this is independent of the type of method used. The importance of the discharge summary as a chief means of transferring patient information from the hospital to the primary care provider needs to be strongly emphasised.

Background: Information technology presents new opportunities to facilitate clinicians' access to up-to-date clinical information. Developing countries have special needs in this area and the problems encountered in obtaining clinical information have not been well researched, particularly for hospital doctors. No previous study has examined which clinical information sources Mongolian hospital doctors' use and the problems they may encounter in obtaining information. This study addressed an important knowledge gap by examining clinical information-seeking practices of Mongolian hospital doctors. The objectives of the study were to ascertain: (a) which clinical information sources were used in clinical decision-making; (b) the level of confidence in these information sources, and (c) the impact these information sources had on clinical decision-making. Also investigated was proficiency in English language and computer skills, as these factors could influence ability to obtain clinical information electronically., Methods: Self-administered questionnaires were given to 263 doctors from the two largest hospitals in Ulaanbaatar, the capital city of Mongolia. Respondents answered questions about 10 information sources: colleagues; local and foreign textbooks; local and foreign journals; personal notes; computer-aided literature searches; Mongolian clinical practice guidelines; and brief updates and health policies developed in Mongolia. Parameters of interest included: frequency of use; confidence in the sources; and perceived impact of the sources on clinical decision-making., Results: The response rate was 87% (229). The respondents indicated that discussion with colleagues was the most frequently used information source, foreign medical textbooks most commonly inspired high confidence, and discussion with colleagues was the source most often perceived as having a high impact on clinical decision-making. For all sources, high confidence and high impact were strongly associated with each other. Only 26% of respondents understood English well, and only 41% had excellent/good computer skills. English language and computer skills were strongly associated with undertaking computer-aided literature searches and with age. Female respondents were less likely than males to have excellent/good computer skills and less likely to undertake computer-aided literature searches., Conclusions: Satisfying the clinical information needs of doctors in less developed countries is particularly challenging and even though improvements in information technology can facilitate access to knowledge, there still exist barriers. Health policies which promote computer skills and English language among doctors may contribute substantially to best medical practice in Mongolia.

Objective: This paper presents a multiple perspectives model of clinical information system implementation, the CONTEXTual Implementation Model (CIM). Although other implementation models have been developed, few are grounded in data and others fail to take adequate account of the clinical environment and users' requirements., Design: The CIM arose from qualitative data collected from four clinical units in two large Australian teaching hospitals. The aim of the study was to explore physicians' test management work practices associated with the compulsory use of a hospital-wide, mandatory computerized provider order entry (CPOE) system.(1) The dataset consisted of non-participatory observations of physicians using CPOE (n=55 sessions) and interviews with health professionals (n=28) about test management work practices. Data were analyzed by two researchers independently using an iterative grounded approach., Results: A core underlying theme of 'contextual differences' emerged which explained physicians' use of the CPOE system in the sites. The CIM focuses attention on diversity at three contextual levels: the organizational level; the clinical or departmental level, and the individual level. Within each of these levels there are dimensions for consideration (for example, organizational culture, leadership and diverse ways of working) which affect physicians' attitudes to, and use of, CPOE., Conclusion: The CIM provides a contextual differences perspective which can be used to facilitate the implementation of clinical information systems. Developing a clinical information system implementation model serves as a framework to guide future implementations to ensure their safe and efficient use and also improve the likelihood of uptake by physicians.

The organisational culture of a health facility has been identified as a significant factor for successful implementation of clinical information systems. There have been no reported studies exploring the link between sub-cultures and the use of information systems. This study utilises cross sectional surveys to measure doctors' and nurses' perceptions of organisational culture and relate this to their use of a hospital-wide mandatory computerised pathology order entry (CPOE) system. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. We identified subcultures based on professional divisions where doctors perceived an aggressive/defensive culture (mean percentile score = 43.8) whereas nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors. The manifestation of subcultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation.

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 aggressive/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.

The aim of this multi-method study based at a microbiology department in a major Sydney metropolitan teaching hospital was to: i) identify the role that information and communication processes play in a paper-based test request system, and ii) examine how these processes may affect the implementation and design of Computerised Provider Order Entry (CPOE) systems. Participants in this study reported that clinical information can impact on the urgency and type of tests undertaken and affect the interpretation of test results. An audit of 1051 microbiology test request forms collected over a three-day period showed that 47% of request forms included clinical notes which provide a variety of information often vital to the test analysis and reporting process. This transfer of information plays an important role in the communication relationship between the ward and the laboratory. The introduction of new CPOE systems can help to increase the efficiency of this process but for that to be achieved research attention needs to be given to enhancing the provision and communication of clinical information.

The exchange of health information between acute care providers (e.g. hospitals) and primary care providers (e.g. general practitioners) has traditionally been via hard copy discharge summaries. In recent years the advent of sophisticated information and communication technology has fuelled developments in electronic discharge referral systems (eDRS), which are credited with enabling more timely and accurate information exchange, enhancing patient care, and ultimately improving patient outcomes. The aim of this paper is to highlight key issues regarding the development and implementation of electronic discharge referral systems. A detailed literature review of information related to electronic discharge summaries was undertaken for publications between 1992 and 2006. While eDRS appear to be beneficial, further improvements are needed before systems are dependable. Through prospective enhancements and increased availability of eDRS internationally, electronic discharge referral systems have the potential to facilitate effective communication exchange across the primary-secondary care interface.

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.

The aim of this study was to assess general practitioners' (GPs') satisfaction with the quality of information in electronic discharge summaries and the timeliness of their receipt of the summaries. The study was conducted in a 75-bed Australian public metropolitan hospital which uses an electronic discharge summary which is mailed to the patients' nominated GP. Eighty-five GPs were surveyed regarding their satisfaction with the content of the electronic discharge summary and the timeliness of receipt. the majority of respondents indicated that they had received the electronic discharge summary within two weeks of the patients' discharge from hospital. The majority also indicated that they were satisfied with all eight documentation data elements. Some GPs indicated that they would prefer to receive the electronic discharge summary electronically by email rather than by conventional mail, and that they would like more information in the "follow-up and recommendations" content areas of the summary. It was concluded that the majority of GPs agreed that the electronic discharge summary was an improvement over the manual discharge summary. Further developments in the safe and secure electronic transfer of discharge summary information needs to be addressed to meet the information needs of GPs.

Objective: To explore physicians' work practices in relation to their long-term use of a computerized physician order entry system (CPOE)., Design: A cross-sectional qualitative study was conducted in four clinical units in two large Australian teaching hospitals. One hospital had used CPOE for over 10 years to order all clinical laboratory and radiology tests and view test results and the other had used the computerized viewing facility of the system for over seven years with tests ordered manually. Data were collected by non-participatory observations of physicians (55 sessions) and 28 interviews., Measurements: Content analysis of the observation field notes, reflections on observations and interview transcripts were conducted by two researchers independently. A thematic grounded theory approach was used to derive key themes that would explain physicians work practices associated with CPOE use., Results: Three themes relating to physicians' established use of CPOE were identified: (1) the effect of the hospital and clinical environment; (2) changes to work practices; and (3) physicians' management of information. Physicians' test management work practices using CPOE were related to diversity between: the hospitals; the clinical units' environment, and the users of the system., Conclusion: Hospitals need to understand and analyze physicians' test management work practices prior to and during the implementation of CPOE to accommodate their diverse ways of working with computerized information systems. In the current mixed media environment, physicians' use of manual and computerized information systems for sourcing and recording information impacts on efficiency and patient safety.

The aim of this study was to ascertain which competencies health information managers (HIMs) working in public hospital positions perceived were important for effective performance. A health information management competency model was developed based on the Boyatzis (1982) managerial competency model and modified to take into account previous health information management competency documents and competency studies in the Australian health service management literature. A questionnaire, administered between July 1995 and June 1996, asked a sample of 306 health information managers (HIMs) from 71 New South Wales and Victorian public hospitals to rate the importance of managerial competencies for effective performance in their current roles. The study sample was split, post survey, into two groups, 'managerial HIMs' and 'coder HIMs,' in order to reflect important role differences. The results showed that the Personal and interpersonal skills competency cluster, which included leadership, motivation, problem solving, managing change and negotiation skills, was ranked as most important by managerial HIMs in NSW, and the Clinical classification skills competency cluster was ranked as most important by Victorian managerial HIMs. This difference was thought to be due to the casemix-based funding environment in Victoria at the time of data collection. Nearly all the competencies listed were perceived to be of 'high' to 'medium' importance (on a scale of 'low', 'medium' and 'high') by managerial HIMs from both states. Coder HIMs from both states perceived fewer competencies included in the developed model to be important; this highlights the divergent roles undertaken by 'coder HIMs' and 'managerial HIMs'. Further work is required on competencies of HIMs in roles other than hospital-based positions.