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Greenhalgh, T., Stramer, K., Bratan, T., Byrne, E., Russell, J., & Potts, H. W. W. (2010). Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. Bmj, 340, c3111.
Abstract: OBJECTIVE: To evaluate a national programme to develop and implement centrally stored electronic summaries of patients' medical records. DESIGN: Mixed-method, multilevel case study. SETTING: English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively. RESULTS: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme's fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. CONCLUSIONS: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.
Keywords: Clinical Governance; Data Collection; England; Humans; Medical Records Systems, Computerized/*organization & administration; Program Evaluation; Qualitative Research
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Bergmo, T. S. (2009). Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost Eff Resour Alloc, 7, 18.
Abstract: BACKGROUND: Telemedicine has been advocated as an effective means to provide health care services over a distance. Systematic information on costs and consequences has been called for to support decision-making in this field. This paper provides a review of the quality, validity and generalisability of economic evaluations in telemedicine. METHODS: A systematic literature search in all relevant databases was conducted and forms the basis for addressing these issues. Only articles published in peer-reviewed journals and written in English in the period from 1990 to 2007 were analysed. The literature search identified 33 economic evaluations where both costs (resource use) and outcomes (non-resource consequences) were measured. RESULTS: This review shows that economic evaluations in telemedicine are highly diverse in terms of both the study context and the methods applied. The articles covered several medical specialities ranging from cardiology and dermatology to psychiatry. The studies analysed telemedicine in home care, and in primary and secondary care settings using a variety of different technologies including videoconferencing, still-images and monitoring (store-and-forward telemedicine). Most studies used multiple outcome measures and analysed the effects using disaggregated cost-consequence frameworks. Objectives, study design, and choice of comparators were mostly well reported. The majority of the studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis. CONCLUSION: As this paper demonstrates, the majority of the economic evaluations reviewed were not in accordance with standard evaluation techniques. Further research is needed to explore the reasons for this and to address how economic evaluation in telemedicine best can take advantage of local constraints and at the same time produce valid and generalisable results.
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Westbrook, J. I., Braithwaite, J., Iedema, R., & Coiera, E. W. (2004). Evaluating the impact of information communication technologies on complex organizational systems: a multi-disciplinary, multi-method framework. Stud Health Technol Inform, 107(Pt 2), 1323–1327.
Abstract: The health informatics research community has been undertaking work at the organization-technology intersection for some time now. However there is no one place in the literature which presents a rigorously-defined evaluation framework for use by practitioners and researchers seeking to assess the impact of information and communication technologies on organizational processes and outcomes. There are two main challenges. One is to conceptualize the design features of such an evaluation framework. The second is to specify what data will be gathered and how. This paper aims to address each of these problems.
Keywords: Academic Medical Centers/organization & administration; *Evaluation Studies as Topic; Health Facilities/*organization & administration; Health Services Research/methods; *Informatics; *Medical Informatics Applications; Organizational Culture; Organizational Innovation; Sociology; Technology Assessment, Biomedical
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Rojas, S. V., & Gagnon, M. - P. (2008). A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemed J E Health, 14(9), 896–904.
Abstract: Telehomecare is considered one of the most successful applications of telehealth. However, despite increasing evidence of telehomecare benefits, the diffusion of these services is still limited. Decision-makers need strong evidence in order to expand the development of telehomecare to various populations, regions, and health conditions. The objective of this review is to provide a basis for decision-making by identifying common indicators from the literature on telehomecare. A comprehensive review of the literature on the cost-effectiveness of telehomecare was conducted in specialized bibliographic databases. A total of 23 studies met the inclusion criteria. First, selected studies were analyzed to identify and classify the indicators that better addressed the cost-effectiveness impacts of telehomecare projects. Then, a synthesis of the evidence was done by exploring the relative cost-effectiveness of telehomecare applications. The analyses show that there is fair evidence of cost-effectiveness for many telehomecare applications. However, the heterogeneity among cost-effectiveness indicators in the applications reviewed and the methodological limitations of the studies impede the possibility of generalizing the findings. This suggests the need for a set of common indicators that could be applied for assessing the costeffectiveness of telehomecare projects. This review provides knowledge on the indicators available for assessing cost-effectiveness in telehomecare projects. It appears that the specific context in which the projects take place, meaning different patients, environments, technologies, and healthcare systems, should be taken into account when selecting indicators for assessing telehomecare cost-effectiveness.
Keywords: Cost-Benefit Analysis; Health Personnel/organization & administration; Health Services/economics/utilization; Home Care Services/*economics/organization & administration; Humans; Models, Statistical; Patient Satisfaction; Telemedicine/*economics/organization & administration
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Harris, P., Harris-Roxas, B., Harris, E., & Kemp, L. Health. (2007). Impact Assessment: A Practical Guide, Sydney. Sydney: Centre for Health Equity Training, Research and Evaluation (CHETRE). Part of the UNSW Research Centre for Primary Health Care and Equity, UNSW.
Abstract: Harris, P., Harris-Roxas, B., Harris, E., & Kemp, L. Health
Impact Assessment: A Practical Guide, Sydney: Centre for
Health Equity Training, Research and Evaluation (CHETRE).
Part of the UNSW Research Centre for Primary Health
Care and Equity, UNSW.
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