RESEARCH PAPER FOR PRE-MSC

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RESEARCH PAPER FOR PRE-MSC

Healthcare Needs of ICT to Improve Quality of Care

by

Jean Marc Mirza

University of Groningen

Faculty of Economics and Business

Pre-MSc Supply Chain Management

June 2020

Supervisor: Michael Fröhlke

Kleine Bergstraat 33a 9717 NA (06)-47349779

j.m.mirza@student.rug.nl

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ABSTRACT

Healthcare quality has major consequences on the life of the patient. In this paper we evaluate how the flow of informationbetween healthcare organisations and workers has a direct impact on the quality of care, and how information technology contributes positively or negatively to this flow of information. Our case study, based on five healthcare providers, shows that the use of technology limits the loss of patient information and facilitates collaboration between practitioners which improves the quality of care. However, excessive reliance on technology as a medium to collaborate, can lead to a loss of tacit knowledge which in turn can harm the patients.

Keywords:

Information and communication technology Quality of care

Collaboration

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INTRODUCTION

Healthcare quality has major consequences on the life of the patient as any errors may cause death, disability, or morbidity (Kapoor, 2011). Moreover, Gupta and Rokade (2016) stated that a high percentage of death caused by medical negligence could be prevented, so the quality of care is important. The World Health Organization (2020) defines the quality of care as “the extent to which healthcare services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”

An increase in healthcare quality can be achieved through collaboration (Beckett, & Kipnis, 2009). On the other hand, Information and Communication Technology (ICT) is used as a facilitator for collaboration in many industries (Schröder, 2013). In healthcare, ICT has the potential to increase access to healthcareas well as enable the smooth transfer of knowledge (Sheng, Chang, Teo, & Lin, 2013).

This paper explores the use of ICT solutions in healthcare organizations; more specifically the benefits of using them in a developed and standardized manner. ICT solutions open new communication channels that facilitate knowledge transfer and coordination among healthcare practitioners (Idowu, Ogunbodede, & Idowu, 2003). ICT can also lead to organizational benefits by improving communication among practitioners, creating a stronger referral system, and collecting data efficiently (Chib, Lwin, Ang, Lin, & Santoso, 2008). An integrated information system between different hospitals would have great benefits. For instance, technology can assist the diverse but interrelated processes of diagnosing, monitoring, and treating diseases (Luz, Massodian, & Cesario, 2015).

In this paper, we divide collaboration into three types: (i) sharing knowledge among practitioners, (ii) sharing patient records between practitioners, and (iii) patient-practitioner collaboration.

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to accumulate self-knowledge and expertise. Sharing R&D knowledge between counterparts leads to an increase in quality, access, and delivery models (Preston, 2000).

Second, sharing information about past patient treatments would allow better results (Peng, & Bourne, 2009). To get the most out of it, organizations need to apply the concept of mass production and treat similar conditions in a normalized way (Lillrank, Groop & Malmstrom, 2010). Sharing patient records helps the physician to decide on the adequate type of treatment based on informed decisions and results in providing a higher quality of care (Cohn, & Allyn, 2005; Donahue, 2010).

Third, Arbuthnott and Sharpe (2009) found that increased interactions between the physician and the patient increases the patient’s adherence and results in better outcomes.

This leads to the following research question: What is the role of ICT in enhancing collaboration

in the healthcare system, and how does better collaboration on different levels lead to an increase in quality of care?

It is important to study the impact of ICT on the healthcare system since it has had many benefits in numerous industries (Cordella, & Paletti, 2018). Even though many writers have spoken about the need to implement ICT solutions in the healthcare field only a few empirical research have studied its real impact. Furthermore, e-health is on the rise due to the covid-19 crisis but its role in healthcare and its effect on integration/quality of care is not fully understood.

THEORETICAL FRAMEWORK

Collaboration

Medical error is the third cause of death in the United States (Makary, & Daniel, 2016). As defined by Grober & Bohnen (2005) an important cause of medical error “includes process faults that have the potential for, but do not necessarily lead to, adverse patient outcomes”.

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in practice and gathers a competitive advantage (Cohn, & Allyn, 2005). As mentioned by O’Dell & Grayson (1998), the profits of exchanging knowledge within the medical staff of a hospital is key for its continuity in a competitive environment, “The ultimate objective of physicians’ knowledge sharing is to elevate the quality and efficiency of care in hospitals.” (Ryu, Ho, & Han, 2003). To achieve a high quality of care, hospital staff should stimulate knowledge sharing among physicians (Ryu et al., 2003). Knowledge sharing can be stimulated through different factors; communication structure, cohesiveness, and partnerships (Gurteen, 1999; O’Dell & Grayson, 1998).

Sharing patient records improves care quality, by reducing medical errors, and unnecessary investigation, as well as, improving the interactions among care providers and patients (Manca, 2015). The medical record is a major means of communication in the healthcare field and a necessary tool for physicians “to diagnose ailments and provide efficient, effective treatments'' (Steward, 2005). The automatic sharing of patient medical records will bring relief for both the staff and the patient, because it will reduce the information deficit that contributes to the errors (Remen, & Grimsmo, 2011).

Physician-patient collaboration has many positive outcomes on the patients’ health as “greater fulfillment of patient expectations, increased satisfaction with care, better adherence to treatment regimens, shorter recovery periods, and improved general health” (Jahng et al. 2005). Stronger collaboration between the patient and the physician can lead to “better patient adherence, higher patient satisfaction with their doctor, and better treatment outcomes for the patient” (Fuertes, Toporovsky, Reyes, & Osborne, 2017). Adherence is “the extent to which a person’s behavior coincides with medical or health advice” (Arbuthnott, & Sharpe, 2009).

Information and Communication Technology

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expertise amongst healthcare professionals'' (Alpay, Toussaint, & Zwetsloot-Schonk, 2004). ICT facilitates knowledge sharing between physicians (Schneider and Wagner, 1993) and helps accordingly in the coordination of the staff to their proper assignments and medical tasks (Berg, 1999). Qureshi (2016) found that ICT was a valuable tool to contain the spread of the virus Ebola. The author added that ICT can improve care through the collection of data, analysis, and provide transparency to multiple practitioners which will help make informed decisions and lead to appropriate intervention and treatment options. Moreover, increased transparency and accountability helps in managing and reducing conflict of interest (Mechanic, 2008).

A well-known tool for records sharing in the healthcare field is the Electronic Health Records (EHR), it “represents the ability to easily share medical information among stakeholders and to have a patient's information follow him or her through the various modalities of care engaged by that individual” (Garets, & Davis, 2006). The analysis of data coming from EMR (Electronic Medical records), EHR and PHR (Personal health record) has a great potential “driving personalized care, improving public health decision making and health policy crafting”, but, might cause data security and privacy issues which must be addressed by technology developers and regulators (Heart, Ben-Assuli, & Shabtai, 2017).

The use of ICT to create specific apps which link the patient to the physician’s platform would be helpful in communicating, treating, and monitoring patients. Luz et al. (2013) found that information technologies will have a great impact on the surveillance and research of diseases, especially that user-friendly technology can improve data collection coming from an increased patient collaboration. A trustful partnership between patients and physicians as well as a patient empowerment approach based on self-management can support patients in behavioral changes and in better disease management (Lamprinos, Demski, Mantwill, Kabak, Hildebrand, & Ploessnig, 2016).

Conceptual Framework

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Figure 1: Conceptual Framework

METHODS

Research design

This study is a case study based on five semi-structured interviews with healthcare practitioners from different organizations and functions. The interviews help us capture qualitative information which fits best with the research question as empirical research for this topic is still missing. This paper shows how real-life healthcare individuals are using ICT and to which extent the use of ICT has a moderating effect on the collaboration and thus the quality of care.

Research setting

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currently active in the field. Detailed information about the interviewees and their organizations are presented in table 1.

Interviewee #A #B #C #D #E Organization Type GP Practice Physiotherapy practice 1st line care Rehabilitation center 2nd line care Pharmacy Physiotherapy practice Function of the interviewee General Practitioner Pediatric physiotherapist Pediatric physiotherapist Pharmacist Physiotherapist

Country Lebanon Netherlands Netherlands Netherlands Netherlands

Table 1: Overview of the Interviews done in this research

Data collection

In this research, five semi-structured in-depth interviews were conducted. A semi-structured interview gives the researcher the flexibility which will help him gather the needed information while keeping the research open to the interviewee’s point of view (Fuel Cycle, 2019).

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Quality of Care How do you measure the quality of care within your organization? Which objectives are important?

Does the information flow influence the quality of care?

In which ways do you use patient medical records?

Collaboration In which ways/through which channels do patients come to you?

When you refer a patient to another colleague, how do you share his medical records?

What happens when you refer a patient? How does your relationship with that patient continue?

Information and Communication Technology

What kind of technology concepts are used in the organization to transfer patient information?

In which phase of the care process (moment in the chain) do you use technology/e-Health and is information shared about the patient?

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What is the influence of information systems on the collaboration between you and other care providers?

What is your opinion on having common systems between different healthcare facilities?

Table 2: Overview of some of the questions from the interview guide prepared

Data Analysis

The five interviews that were transcribed as mentioned earlier were analyzed using a coding tree. Coding allows the researcher to better present and interpret the data in order to understand the emerging phenomena and draw conclusions (Basit, 2003). First a code tree based on a pre-set of code of the most important concept from the conceptual framework: Collaboration, quality of Care and Information and Communication Technology has been created. Then each interview transcript was read multiple times and quotes were assigned a code from the pre-set code or new emergent code that was created. Then the resulting codes were redefined, and some were deleted to end with the final code tree shown in table 3. Once the coding was done it was sorted based on the code it has received, then it was summarized and finally, it was used to find the relationship between different practices in order to retrieve findings and draw conclusions.

Most important concepts Interview topics code

Collaboration to improve quality of care

Patient records sharing and flow of information A1

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Patient-practitioner interaction A3

ICT to facilitate collaboration

Storing and sharing of information B1

New communication channels B2

Process compliance and error reduction B3

Patient interaction and involvement B4

Table 3: Overview of the coding tree used to analyze the data.

FINDINGS

This section will discuss the main findings from the interviews regarding the quality of care, collaboration, and ICT.

Patient records sharing and flow of information

All the practices used referral letters (medical records) prior to consultations, which confirms that patient records are indeed important and an easier flow of information through the use of ICT has an added value to the treatment of the patient.

(B) “Yeah, I'll read that in advance. Yes, then I have that information in advance, and I get that almost always by post.”

(A) “I read them, check them if he comes now I do it now. If I receive them before, I prepare them before he comes, and finally, I do a final check-up on everything when he comes by.”

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don't, uh well for example halfway through the treatment still find out something, which was actually uhm well important that you knew that beforehand”.

All 5 practices are using the phone, post and some are also using technology such as zorgmail (secure medical email provider), which implies that technology did indeed open a new channel of communication between practices and that ICT facilitates the sharing of information. The ones that are not using technology, 1st, and 2nd line pediatric physiotherapy, claimed the cause of not having a linked system to other healthcare providers, but indicated it would be helpful. This can be interpreted as; they would use it if it was available. In Lebanon, sharing information was done through social platforms such as WhatsApp because there are no laws that prevent them from sharing information through unsecured channels like the AVG law (Algemene verordening gegevensbescherming which means assistance General data protection regulation) in the Netherlands.

(A) “It depends from patient to another; but now, they are mostly using WhatsApp”.

(B) “We almost always get them in the post. Mostly by post, yes. That has to do with the fact that our care product is not yet linked”. “And how do you feel if there would be one of those? That you do have a system that links to, say, the hospital? Yeah, would be fine. Would just speed things up, I guess, or information that does not come directly to us for some reason”.

(E) “Basically, everything goes through zorgmail and through spot on medics”. “Via spot on medics, everything is uh in terms of safety, is a safe system. So that's why we do everything via spot on medics uh nowadays”.

The Lebanese GP claimed that if she received a very big file of a patient, she usually wouldn’t read it, which implies that to have an efficient collaboration, and to avoid overloading the physician, the fast communication channel created by ICT should transfer summarized and well-defined information.

(A) “for example one time a patient sent me a file of 49 pages, I didn’t open it one the internet, it takes a lot of time to see”.

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feared that it’s not feasible in the short term, this confirms that ICT does make exchange of information easier but it is not easy to implement and it will require considerable effort.

(A) “national ICT helps a lot of course, now there is some system already installed between laboratories, inside the hospital between different services, but if it can be on a national scale it can also help a lot”.

(C) “Well, how would I feel about that? Well, when, let me put it this way, when it's user-friendly, both for me and for all my external colleagues, I think that would be an added value. But I also see a lot of bumps on the road”.

Knowledge sharing

ICT helped practitioners to communicate and exchange knowledge especially that most interviewees expressed their difficulties to get in contact with each other over the phone as they are mostly busy. This implies that ICT facilitates communication and interaction among physicians.

(C) “The disadvantage of calling is that I deal with colleagues who are often busy and that's what also, what I do, so everyone is not always easy to reach. The mail makes it easier”.

(D) “Well, at least in Pharmacom and Medicom that link makes for a very good easy collaboration. That you just all have the overview. And that you can communicate quickly”.

(E) “Now it is uh more difficult to get in contact with uhm nah an orthopedist for example. Must always be by phone again. And then they are not reachable, so that yes”.

As mentioned before ICT increases the interaction among healthcare workers but nonetheless the interviewees indicated that communicating through an online platform might cause some misunderstandings that would have been easily avoided through a phone call. This implies that the use of ICT should be moderate or provide a system with more tools to limit interpretations, avoid loss of information and minimize errors.

(C) “The mail makes it easier, but then you have: does my colleague interpret this correctly? And do you sometimes need 10 emails where you would normally have made 1 phone call”.

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Participants in this research had also their own point of view regarding the use of ICT. A GP in Lebanon indicated that technology had great advantages in sharing the latest news and practices. This implies that ICT is beneficial to sharing knowledge and best practices.

(A) “yes we help each other to solve the case and treat our patient. and we use it also to receive the latest practices or the latest information related to medicine”.

Both 1st and 2nd line pediatric physiotherapists thought that technology encourages the building of a collaborative network, both talked about DCD (a medical network), suggesting that ICT supports healthcare integration as a way to link different practices, form partnerships and increase team-based care.

(C) “Things we are working on, are to see if we can also within that DCD network. DCD is a patient category that we see here. To see if we have first-line physiotherapists in the area, so where we refer to a lot but they also refer to us through the GP, to build up a bit of a network. As soon as I know which 1st line is specialized in this and when those are writing problems, I can send them to them or when those are sports problems, I can send them to them.”.

Patient-practitioners interaction

The research was done during the COVID-19 crisis, all participants were using technology to treat patients, especially that during that period, there were laws that prohibited physical contact between physicians and patients unless there was an urgent situation, in this instance an ICT platform is a key channel to treat patients where in-person healthcare services are hard to access. The interviewees also expressed their positive view of such a system and stated that e-health use will remain after the crisis. In other words, the use of e-health will be useful alongside face-to-face consultations for its positive impact on the treatment of patients.

(C) “We've only really rolled out that app in a couple of weeks, but it works, I have to say. I've had a positive experience with that”.

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(B) “I think it will stay in some way after that”.

Even though all of them saw positive results using e-health, they indicated the need for to-face consultation from time to time. Basically, ICT and online consultations cannot replace to- face-to-face consultations, as physical contact is still vital for capturing information that is hard to express or that cannot be codified in a digital system.

(A) “Nothing really replaces the live consultation between the doctor and patient but it is helpful now in the case of COVID-19.”

(B) “I think it will stay in some way after that. But you can't give a full treatment by video calling. That's not possible in physiotherapy”.

(C) “you need the contact and now we are in that Corona time and we have to do it in another way. But normally I would like to see them once a week and then in combination with the app or something like that”.

DISCUSSION

Interpretation of results

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with cumbersome details, which might, adversely, negatively impact the effectiveness of such a system (Sittig, & Singh, 2012).

In this case study, the transfer of information was done through different channels. However, the most commonly used channel was physical mail due to the need to preserve patients' privacy and because some practices were not linked to others through a digital system. Nevertheless, all of the practitioners agreed on the fact that a national information system would have an added value. This result further demonstrates the need for a unified healthcare platform to collaborate and facilitate the supply of information while preserving the patients' privacy. As mentioned by Mechanic (2008) “The value of IT for making medical decisions more transparent and accountable and facilitating peer influence has been noted”, but also some of the participants manifested concerns about the difficulties to create such a complex system, “Building a truly integrated clinical IT system for the country is a large and very expensive undertaking” (Hillestad et al. 2005; Mechanic, 2008).

Communication between healthcare workers is mostly done by phone, even though all agreed on the usefulness of ICT to make the contact easier, they also feared that talking to each other through an online platform may lead to miscommunication and information asymmetry. This finding urges us to draw the limit on the type of information that can be shared online and the ones that should be shared orally. Michel (2017), researched the interaction between physicians and nurses in a hospital in France and another one in America, where communication between workers was different, in America a more developed information system is used whereas in France the communication was done orally. The author concluded that oral communication was more efficient. Shannon (2012), also found the need of maintaining direct conversation between physicians to prevent medical errors. The writer stated an example of a man who suffered from a cardiac arrest due to miscommunication, the author also claimed the use of mail, text message, and electronic health record as an inhibitor of direct conversation.

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In this matter, periodical face to face consultations are still needed alongside any application where both the patient and physician can track the treatment, communicate, and make appointments. When a patient needs self-care due to a chronic illness or long-term injury rehabilitation, the online treatment should be followed by periodic consultation to achieve the best outcomes. (Dedding, Van Doorn, Winkler, & Reis, 2011; Ouschan et al. 2006).

Implication for Theory

This study contributes to the theory presented, it extends the knowledge on the contribution of ICT to improve collaboration and increase the quality of care. Although at the beginning of the literature we thought that ICT would only increase the collaborative practice between stakeholders, our findings prove that this view stands up to a certain degree. The application of ICT with no boundaries may provoke misunderstanding and the loss of tacit knowledge necessary for a better quality of care. These findings can also be extended to the collaborative relationship between the patient and the physician where e-health practices were found useful to increase interaction and adherence to the treatment, but face-to-face consultations were still irreplaceable.

Implication for practices

This study invites healthcare organizations to develop their ICT in order to increase collaboration among healthcare workers as well as patients. But it also invites them to take precautions not to overrule face-to-face consultations as those are fundamental in the treatment of patients, e-health alone is not enough as diagnosis through video is not as sufficient. Secondly, healthcare workers should still use direct communication between each other as miscommunication through online channels can occur. The healthcare system should apply EHR practices but in a well-defined and controlled manner, where information is easily manipulated and analyzed in order to prevent an increase of the physician’s workload and overburden him.

Critical reflection

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a varied number of practices, its diversity is somewhat limited as it does not include hospitals which are considered as a major player in the healthcare sector. Therefore we suggest future research to have a look on the use of ICT in hospitals. Secondly, the plan was to focus on the Dutch healthcare system, but due to the COVID-19 crisis, we did also interview a GP in Lebanon which had some repercussions on this study. The legal system in Lebanon is less restrictive regarding the allowed digital communication channels. Finally, due to the COVID-19 pandemic, there was a rush in the use of e-health tools, some practitioners had, only recently, started using these channels. Further research in the future would have a better understanding of their use. New findings may prevail, nonetheless, the conclusions from this research stand as ground rules for future research.

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RESEARCH PAPER FOR PRE-MSC