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Front. ICT | doi: 10.3389/fict.2019.00009

Understanding health information technologies as complex interventions with the need for thorough implementation and monitoring to sustain patient safety

  • 1Wissenschaftliches Institut der TK für Nutzen und Effizienz im Gesundheitswesen (WINEG), Germany
  • 2Jacobs University Bremen, Germany

Abstract
Health information technology (HIT) transforms health care with increasing speed. However, if not implemented and monitored thoroughly, HIT can also cause harm to patients despite opposite intentions. The risk for an implementation failure emerges. Understanding HIT as complex interventions can not only help to guide their implementation and monitoring to avoid implementation failure, but also their development with the aim to avoid patient harm. By that, we are be able to gain a better understanding of working mechanisms and potential problems that might arise when implementing HIT in specific settings like hospitals. The present article highlights the relevance of this issue and provides a model with key elements of the development and evaluation process of complex HIT interventions.

Keywords: patient safety, complex interventions, implementation failure, health information technology, health care

Introduction
As stated by the Institute of Medicine: "It is widely believed that health IT, when designed, implemented, and used appropriately, can be a positive enabler to transform the way care is delivered. Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences, for example dosing errors, failure to detect fatal illnesses, and delayed treatment due to poor human–computer interactions or loss of data"(1). In fact, health information technology (HIT) has the potential to increase performance of delivered services, increase health care quality, save costs and involve patients as effective partners of their own health care. However, thorough implementation and monitoring of HIT that have proven effective into regular health care delivery is a central concern of patient safety research. If not implemented and monitored correctly, HIT has the potential to pose a severe threat to the patient’s health with a chance for lethal consequences due to implementation failure. Implementation failure is defined as failure to deliver a program as intended which can result in failure to achieve the intended intervention effects or even adverse intervention effects (e.g. due to lack of acceptance) (2-5). Besides concrete harm for the patient due to implementation failure, additional risks are frustration and demoralization of staff as well as time loss which impede team performance in the delivery of care and, as a results, can also impact successful implementation (6-8). Though studies predominantly report positive consequences on patient safety parameters when using HIT (e.g. reduction of adverse events) few studies also report on negative consequences (e.g. increase in mortality due to adverse events) which could have been avoided with thorough implementation and monitoring resulting in lives saved (9,10).

Health Information Technologies are Complex Interventions
However, implementing and monitoring HIT while also considering patient safety as a central aim of digital transformation in health care is often easier said than done. By nature, HIT follow the principle rules of complex interventions which have impact on several parts of organizational and team structures ranging from IT infrastructures to the point of care. As change agents, HIT affects health care delivery in predictable (e.g. reorganization of processes) and unpredictable ways (e.g., interrupt care delivery) (11)
They do so by covering several dimensions of complexity: 1) Number of and interactions between components; 2) Number and difficulty of behaviors required by those delivering or receiving the intervention; 3) Number of groups or organizational levels targeted by the intervention; 4) Number and variability of outcomes; 5) Degree of flexibility or tailoring of the intervention permitted (4). Therefore, complex interventions not only call for thorough implementation, but also evaluation methods to display and understand if and how different parts of complex interventions work in different contexts and how these parts might be improved to facilitate overall success of the implementation of HIT and its’ effectiveness. As a result, complex interventions may work best if tailored to local circumstances rather than being completely standardized. According to Craig et al. it is best practice to develop complex interventions systematically by using the best available evidence and theory, followed by a series of pilot studies to target key uncertainties in the design, an explorative and a definitive evaluation. The evaluations' results are to be disseminated as widely and persuasive as possible, with additional research to assist and monitor the process of implementation (4).

Implementing Complex Health Information Technologies in High Reliability Health Care Organizations
As health care organizations can be described as high reliability organizations (HRO) special emphasize needs to be put on the implementation of complex interventions to avoid implementation failure and potential harm to the patient. HROs in health care can be described by the following characteristics: 1) Preoccupation with failure; 2) Reluctance to simplify; 3) Sensitivity to operations; 3) Deference of expertise; 4) Commitment to resilience. According to the Agency for Healthcare Research and Quality, "the principles of high reliability go beyond standardization; high reliability is better described as a condition of persistent mindfulness within an organization. High reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures" (12).
To ensure quality and increase effectiveness of health care in HROs, implementation science provides the necessary repository of ideas and instruments to facility implementation and monitoring of HIT Implementation science is defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services” (13). Therefore, increasing patient safety by improving quality and effectiveness of delivered health care go hand in hand with a major goal of implementation science. One of such instruments is the Consolidated Framework for Implementation Research (CFIR) as a pragmatic meta-theoretical framework (14). The CFIR represents the synthesis of 19 theories associate with implementation science to summarize potential barriers and facilitators of implementation and to ensure consistent use of constructs across studies and support their comparability. These constructs are broadly subsumed under five categories: 1) Intervention characteristics; 2) Outer setting; 3) Inner setting; 4) Characteristics of individuals; 5) Process. These categories can complement the proposed key elements of the development and evaluation process of complex interventions by Craig et al. as displayed in the modified model for complex HIT interventions (see Figure 1) (4,14).

[Figure 1 about here]

Figure 1. Key elements of the development and evaluation process of complex HIT interventions based on Craig et al. (4) and Damschroder et al. (14)

A Patient Safety Example for Implementation Failure of Complex Health Information Technologies
One particular example is a study by Han et al., which reported an unexpected increase in mortality after implementing a computerized physician order entry system (CPOE) in children who are transported for specialized care to an intensive care unit (ICU). Though implementing the CPOE had the opposite intent (i.e. to reduce mortality), the authors report that observed mortality nearly doubled, increasing from 2.80% to 6.57% (10). In non-survivors, the CPOE was used more often (48.0% vs 27.4%; P<.001) and was an independent predictor of mortality in the final logistic regression model (OR = 3.28; 95% CI 1.94-5.55; P<.001). The authors describe in detail the restructured processes after the CPOE was implemented, highlighting diverse problems such as delay of care due to a complex ordering process which can only start when the patient is fully registered, communication bandwidth problems using wireless communication due to increased overall traffic in the hospital computer system, dislocation of medical personal as one physician was now needed to place orders for the first 15 to 60 minutes if a patient arrived in extremis, and the removal of a satellite medication dispenser for critical medication from the ICU as all medication now had to be located at the central pharmacy. Furthermore, medical staff at the ICU was logged out when a pharmacist accessed the placed order for further processing, delaying additional order entries.
Though the displayed problems might not be exhaustive, they still underline the importance of thorough implementation of HIT as complex interventions. Referring to Figure 1, the authors report on problems that emerged regarding intervention characteristics (e.g. external intervention source which was poorly adapted to the needs of the ICU and not tested on a small scale to identify potential problems despite the potential to increase complexity of health care delivery in the ICU), the outer setting (i.e. not considering the patient needs for immediate care and treatment sufficiently), and process (poor planning of the implementation with no simulations or practice sessions for ICU staff or incremental implementation of parts of the intervention which might have provided important information at an early stage as well as a poor reflection and subsequent adaptation at an early stage of the implementation due to a lack of such "dry runs"). The majority of the reported problems might transpired because the CPOE was externally developed, tested for feasibility and evaluated, and was not well implemented in the ICU resulting in an increase in mortality. An implementation failure happened that had likely cost lives.

Conclusion
The above example highlights that keeping in mind that HIT interventions are complex interventions by nature can help guiding their development, evaluation, and implementation. Special emphasize needs to be put on the successful implementation of HIT to ensure high quality of care and patient safety with the aim to avoid potential harm for patients. The proposed model introduced in this article can help to identify potential elements implementation failures or understand adverse effects of HIT interventions by drawing on key elements of complex interventions with a special emphasize on the implementation by including the Consolidated Framework for Implementation Research (CFIR).

Declarations
Conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: None.

Keywords: Patient Safety, complex interventions, Implementation Failure, health information technology, Health Care

Received: 05 Sep 2018; Accepted: 08 Apr 2019.

Edited by:

Sandra C. Buttigieg, University of Malta, Malta

Reviewed by:

Dalia Kriksciuniene, Vilnius University, Lithuania
Shameer Khader, Ph.D, Northwell Health, United States  

Copyright: © 2019 Wienert. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Julian Wienert, Wissenschaftliches Institut der TK für Nutzen und Effizienz im Gesundheitswesen (WINEG), Hamburg, Germany, j.wienert@gmx.net