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Background: Serious lapses in patient care result from failure to follow-up test results.Objective: To systematically review evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients.Data Sources: Medline, CINAHL, Embase, Inspec and the Cochrane Database were searched for English-language literature from 1995 to 2010.Study Selection: Studies which provided documented quantitative evidence of the number of tests not followed up for patients attending ambulatory settings including: outpatient clinics, academic medical or community health centres, or primary care practices.Data Extraction: Four reviewers independently screened 768 articles.Results: Nineteen studies met the inclusion criteria and reported wide variation in the extent of tests not followed-up: 6.8% (79/1163) to 62% (125/202) for laboratory tests; 1.0% (4/395) to 35.7% (45/126) for radiology. The impact on patient outcomes included missed cancer diagnoses. Test management practices varied between settings with many individuals involved in the process. There were few guidelines regarding responsibility for patient notification and follow-up. Quantitative evidence of the effectiveness of electronic test management systems was limited although there was a general trend towards improved test follow-up when electronic systems were used.Limitations: Most studies used medical record reviews; hence evidence of follow-up action relied upon documentation in the medical record. All studies were conducted in the US so care should be taken in generalising findings to other countries.Conclusions: Failure to follow-up test results is an important safety concern which requires urgent attention. Solutions should be multifaceted and include: policies relating to responsibility, timing and process of notification; integrated information and communication technologies facilitating communication; and consideration of the multidisciplinary nature of the process and the role of the patient. It is essential that evaluations of interventions are undertaken and solutions integrated into the work and context of ambulatory care delivery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

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.

In this study 85 adult patients attending a Sydney general practice were asked for their views on computer-assisted consultations; 77 (91%) agreed to participate. In general, patients agreed they could still talk easily with their doctor, and felt listened to, while the doctor used the computer (87% & 75% respectively). More than half the patients felt the computer contributed to better treatment, although a quarter believed consultations were prolonged. About half the patients agreed that the doctor did not often explain the role of the computer. Given the national plans for increasing computerisation of health records (HealthConnect), this research suggests that more attention should be given to involving patients in e-health developments.