Canadian Institutes for Health Research, Partnerships in Health Systems Improvement Grant: Adverse Drug Event Reporting in PharmaNet to Improve Patient Safety and Inform Policy

Medications are widely used to treat and prevent debilitating and fatal diseases. Over 73% of Canadians over the age of 65 use at least one prescription medication daily. As a result, adverse drug events (ADEs)-the harmful and unintended consequences of medications-are common, and cause 1.7 million emergency department visits in Canada each year. Many ADEs occur because patients are re-exposed to drugs that have previously caused problems, because information about ADEs is not effectively communicated between healthcare providers (e.g. between physicians and pharmacists) or across healthcare sectors (e.g. between hospitals and community pharmacies). We have partnered with a broad range of stakeholders to design a new ADE reporting platform in PharmaNet, BC's provincial medication information system, so that front-line clinicians can communicate relevant ADE information between healthcare providers and across healthcare sectors. We will use this platform to collect data about ADEs for research and decision-making. First, we will determine how a new electronic ADE reporting platform can be integrated into the existing workflow of emergency department healthcare workers. Second, we will determine what information needs to be captured so that the ADE reports are sufficiently detailed to support clinical decisions. Then, we will develop and implement an electronic ADE reporting platform, and will develop computerized alerts that pop up when physicians or pharmacists prescribe or dispense medications that have previously caused problems. Finally, we will evaluate the ADE reports in PharmaNet. The new ADE reporting platform has a strong potential to make prescribing decisions safer, by warning healthcare providers of medications that have previously caused problems. By creating ADE reports that can be linked to other health data, we will support the data needs of researchers and decision makers to influence health programs and policy decisions.

The Technology of Art and the Art of Technology

Problem or issue to be addressed: Large scale computing infrastructures (referred to as cyberinfrastructures in the U.S. and e-science initiatives elsewhere) frequently fall far short of articulated goals and expectations. In spite of ample literature about the development and implementation of information technology (IT) in the information science, computing and business domains, stories of cost over-runs and failed systems abound. Several recent studies have suggested that only 1 in 3 IT projects succeed, where success is defined in terms of projects delivered on time, on budget and with promised features.

Research outlined here seeks to develop new insights to guide the development and implementation of cyberinfrastructures by looking in a new direction -- at how visual artists understand and interact with the technologies they use in their daily art practices.

The purpose of this project is to learn about the material characteristics of technology to inform the development of a typology to guide system design and implementation. Visual artists work with a variety of technologies in their daily art practice. For example, photographers use cameras, lenses and papers; acrylic painters use paints (in varying pigmentation strength and thickness), mediums and gels, brushes, palette knives and other technologies. As they work, artists develop knowledge of the affordances and constraints of the technologies with which they work, which they often exploit for creative effect. Artistic practices have given rise to insights about the nature of technology that may be applicable to the use of technology in other contexts-- for example that context matters (e.g., in perception of color), that altering the scale of a piece of art can change how viewers see or read it, etc.

This project seeks to develop new strategies to guide cyberinfrastructural development by focusing on the material aspects of technology. Research outlined here is rooted in science, technology and society studies, and is part of a 'new sociology of art' which seeks to apply the insights from the sociology of art to "non-art 'stuff'" and frames questions so they are compatible with social constructionism. This research addresses theoretical gaps in science, technology and society studies and information sciences literatures by focusing on the material aspects of technology. It responds to calls for bold new approaches to studying the materiality of technology and calls to compare radically different technologies by exploring the materiality of technology by investigating how visual artists think about technology, and using insights generated to develop a typology of technology affordances and constraints, which will be applied to cyberinfrastructures.

Potential Contribution of Research to the Advancement of Knowledge: This research has the potential to yield new insights about the nature of technology, which can help guide development and implementation of computing infrastructures in the future, and will contribute to the development of new theoretical models in science, technology and society studies. The resulting typology will help those involved in the design and implementation of technology in general and cyberinfrastructures in particular by serving as a means through which the complexity of technologies can be made more transparent. Developing a better understanding of the characteristics and properties of technology can help us develop strategies and mechanisms for anticipating and responding to the complexities of contemporary technological systems. This work will help build a dialogue between artists and technologists, both of whom serve to benefit from greater interaction across what is often perceived as an art/ technology divide.

Genome BC Strategic Opportunities Fund: Using Science, Technology, and Society Studies Research to Move Genomics Discoveries from Bench to Bedside: Identification of Data Integration and Socio-technical Issues Arising in Personalized Medicine & Translational Informatics

This project seeks to demonstrate the value of concepts from science, technology and society studies in addressing applied problems facing BC’s genomics researchers and businesses. It builds on BC’s strength in the area of science, technology and society studies, and particularly e-science/ cyberinfrastructure studies, and the strengths of BC’s genomics researchers and entrepreneurs by using BC’s genomics research and business sector as the site for applied research aimed at addressing data integration issues which genomics researchers in BC and elsewhere are facing as they work to integrate data from multiple sources in an effort to realize multiple goals in the domains of personal medicine and translational informatics.

Research outlined here will generate knowledge about the challenges genomics scientists face in working with multiple data sets, which in turn will contribute to the development of novel approaches to data integration, which incorporate insights about social constraints as well as technical challenges arising with data integration. This, in turn, will help BC maintain a strategic position in realizing benefits from the data intensive genome sciences. Work outlined here takes an original approach to data integration issues by focussing on insights from science, technology and society studies, particularly those from e-science and cyberinfrastructural studies, to develop insights about the challenges inherent to integration of data (e.g., from health registries, genomics data and data about social determinants of health) from multiple sources. 

Health Innovation Design and Evaluation (HeIDE) Research Team

The HeIDE Team will improve the quality of evidence used in decision making about information technologies (IT) used for collecting epidemiological data in BC by conducting research about IT use for epidemiological data collection. We will: 

• assess early technology trials to identify technological, organizational, governance and implementation challenges associated with increased use of IT for collecting epidemiological data;
• address data quality issues arising from increased use of IT for epidemiological data collection, particularly issues associated with data merging;
• improve links among researchers, decision makers and technology developers across disciplines who share an interest in e-epidemiology.

Health Innovation Design and Evaluation (HeIDE) Senior Scholar Award

The areas of focus: 

• to conduct work practice studies of new technology  implementations in the health sector;
• to conduct research that addresses the relationship between health sector technology governance and patient safety;
• to conduct research concerned with the relationship between health information technology system design and the quality and availability of health indicators.

Integrating Gender and Sex in Health and Environment Research: Development of New Methodology

Although it is common knowledge that boys and girls, men and women are biologically different and that their experiences bring them into contact differently with their physical and social environments throughout their lifespan, research in environment and health has been slow to translate this knowledge into methodologically sound studies that adequately consider sex and gender. The paucity of  information in this area has vital implications for health, health services and preventive intervention strategies for children, adolescents, family members involved in paid and non-paid work, and the elderly. The overall objective of this proposal is to integrate gender/sex considerations into research in health and environment throughout the lifespan. 

To achieve this goal, we have set up a pan- Canadian interdisciplinary research team, building on recognized Canadian expertise in environment and health and in quantitative and qualitative methods to take account of gender and sex. The emerging team will:

1. develop and refine interdisciplinary quantitative and qualitative methods for integrating gender/sex considerations in Canadian and international research in environment (including workplace and health);
2. establish strong collaborations with community-based and public health partners working in environment and health, in order to come to a richer understanding of the real-life mechanisms linking environmental health to sex and gender;
3. train and mentor young researchers;
4. initiate multi-centre, multi-disciplinary research demonstrating the scientific importance of integrating gender/sex considerations into research and intervention in health and environment. We propose a participatory structure with partners working in the field of environment and health and a 5-year progressive research and activities plan grounded in on-going research in environment and health across Canada.

Analysis of Work Practices in a Cape Town Emergency Department

"A medical registry is a place where data, records, or samples are kept and made available for research or comparative study” (Merriam-Webster, n.d.). The term registry also refers to “the systems and processes involved in the establishment, support, management, and operation” of disease registers (Medical Dictionary Online, n.d.). Research outlined here will yield an understanding of work practices in a Cape Town hospital’s emergency department. Setting up health registries—whether paper based or electronic-- requires an understanding of how work is carried out in specific medical contexts, in order to ensure that the systems and processes put in place to collect and manage registry data are compatible with existing work practices. 

Our long term goal is to develop guidelines to support development of computer supported health registries in low and middle income countries (LMICs). Research outlined here will be undertaken as a pilot study in order to demonstrate the utility of ethnographic research as a means of supporting design of health registries in LMICs. It will also showcase the contributions our team can make to improvement of epidemiological data collection in LMICs, which in turn will place us in a more competitive position in competing for international grants.

Knowledge to Action: Supporting Continuity of Care and Practice

Background: In 2003, the Vancouver Coastal Health Authority (VCH) chose Mid-Main Community Health Centre (Mid-Main) as one of the clinics to receive primary health care renewal funds. A portion of the funding has been used to purchase and implement an electronic medical record (EMR) system that has some capacity to support chronic disease management through patient registries. In implementing their electronic medical record, Mid-Main has had ongoing contact with Elaine Grenon, Director of New Practice Design with the VCH Primary Health Care Network. In addition, Mid-Main has worked with Dr. Ellen Balka (professor and research scientist at Vancouver Coastal Health) who is the principal investigator of ACTION for Health, a 4-year, $3 million project that has focussed on the role of technology in the production, consumption, and use of health information. Since 2003, several ACTION for Health research projects have been carried out at Mid-Main, including a project which investigated the implementation and use of Wolf Medical Systems’ electronic medical record. The proposed project seeks to build on existing partnerships between Mid-Main, Wolf Medical Systems, VCH, and Balka’s research group through 3 related ‘knowledge to action’ projects of interest to all parties.

Objectives:
Project objectives are to support the translation of knowledge to action through:

1. Demonstration of enhanced use of data from electronic medical records in support of continuity of care in clinical settings and practice research. This project will focus on building capacity within Mid-Main to increase use of electronic record data to support practice improvement initiatives, particularly those targeted at the population of people who live with 3 or more chronic conditions within the cardiovascular and respiratory clusters, and people with persistent mental illness, who have been identified by VCH as using disproportionately high levels of health service resources.
2. Knowledge translation (KT) from research literature to local users (Mid-Main and VCH) and from local users (Mid-Main) to decision makers (VCH) and technology producers (Wolf), and subsequently potential electronic record adapters, about challenges related to enhanced use of electronic records for management of patients with multiple chronic conditions.
3. Translation of primary research results into good practice guidelines. In B.C., the Ministry of Health has developed a chronic disease management toolkit (CDM Toolkit) used by Mid-Main and other practices. Plans for management of patients with multiple co-morbidities involve increased use of the CDM Toolkit. Primary research will be undertaken in order to better understand how the CDM Toolkit is being used, and identify issues associated with data sharing between clinics and the CDM Toolkit. Results will be disseminated as a good practice guide, suitable for use by clinics.

Hypothesis: That knowledge translation activities will result in evidence of practice changes at Mid-Main, evidence of utilization of research results by VCH, and reflected in software (Wolf).
Research Plan

• Objective 1: Develop a base-line understanding of use of EMR data at Mid-Main through observation and interviews; develop a plan for increased use of EMR data with Mid-Main; implement the plan; evaluate extent to which KT activities contributed to practice changes (through document analysis, observations, and interviews).
• Objective 2: Through on-going engagement, respond to informational needs of potential research users. Collect data about appropriateness of materials produced through post-use evaluation of research materials, and interviews with potential users aimed at assessing utilization.
• Objective 3: Conduct interviews with Mid-Main and other CDM Toolkit users about use of the CDM Toolkit; develop good practice guide (GPG) to support implementation of the CDM Toolkit; evaluate GPG through post-use surveys and interviews.    

The Role of Technology in the Production, Consumption and Use of Health Information: Implications for Policy and Practice (ACTION for Health)

Many claims have been made about the benefits of networked computing, which is often touted as a way to increase efficiency through improvements to service delivery, record keeping, and data collection and analysis. The health sector has been increasingly subject to computerization: computers are the focal point of increased data collection activities (the production of health information), the internet is increasingly being seen as a means of disseminating health information to patients and their families (the consumption of health information), and advanced data analysis is increasingly supporting policy, treatment and financial decision making (the use of health information by health sector staff)

Although government spending aimed at computerization of the health sector has been high (along with expectations about the benefits that on-line health information and computerization will yield), little has been invested in determining whether or not existing programs are meeting stated goals. The research program outlined here will determine whether or not existing programs aimed at internet delivery of health information to health consumers and computerization of health sector jobs undertaken in efforts to improve both sector efficiencies and health outcomes are achieving stated goals, and preserving what Canadians value in our health system. Our goal is to achieve a fuller understanding of the complex ways health information is produced, consumed and used by lay people, and produced and used by health sector professionals, in order to inform the design of policies and systems. We will identify socio-technical issues, challenges and constraints to the realization of Canada’s vision of the New Economy in the area of health information, through case studies employing qualitative and quantitative methods, to achieve an understanding of health information technology (HIT) which can be used to inform policy about its use, and development of new systems.

1. explore whether or not the introduction of information technology into the health sector is meeting stated policy objectives, and protecting what Canadians value in their health system (equity, compassion, individual and collective responsibility, respect for others, effectiveness and efficiency);
2. explore the use of the internet as a means of gaining access to health information, and specifically, to determine what roles information intermediaries (people and/or hardware and software who help information seekers find the information they need) fill when those around them seek health information via computers; and
3. look at the challenges that arise (including the need for computer skills, organizational and work design changes) when new IT is introduced into health sector work places.

The introduction of new technology in the health sector will be explored in relation to what Canadians value about our health system, by academics representing communications, law, computer science, psychology, social work, sociology, science, technology and society and library and information sciences, in cooperation with diverse partners in library and community settings, non acute health care settings and hospitals. Research will focus on issues emerging when IT is used in health settings by the general public, health care workers and marginal groups (e.g., low income citizens). The role of technology in the production, consumption and use of health information will be explored through multi-method case studies in Canada, Austria, Australia, the UK and Netherlands, and results will be communicated to diverse audiences including health system administrators and policy makers, academics, and other stakeholder groups. Research will focus on the use of IT by lay people (health literacy, and the role of information intermediaries in health information provision), health care professionals (e.g., related to changing work practices that accompany new information technology, as well as the challenges related to the introduction of standard practices imposed by information technology), and ethical and legal issues (e.g., privacy of health information, the ethics of identifying potential health service recipients through health data sets).

The potential for innovation in this proposal lies in its socio-technical orientation, deriving from a social informatics perspective, which gives primacy to the social contexts in which human interaction with computers occurs, and which “examines the design, uses, and consequences of information and communication technologies in ways that take into account their interaction with institutional and organizational contexts” [1: 217]. The project is also innovative in bringing together team members with proven track records working across disciplinary divides, who are skilled at bringing academic insights to bear on real world problems in meaningful ways.

See ACTION for Health Projects here.

From Work Practice to Public Policy: A Case Study Of The Canadian Health Information Infrastructure

Recent budget cuts at the provincial, territorial and federal levels have led to renewed concern about the state of the Canadian health care system. As health budgets shrink, information and communication technologies are increasingly being viewed as the means for more efficient and effective delivery of health care services. Federal, territorial and provincial personnel and finances have been allocated to the development of this health info-structure.

This research was designed to provide new information about issues of policy and practice associated with the development of the health info-structure. The objective of the research was to conduct a multi-site case study of Canadian health info-structure, using a multi-disciplinary and multiple method approach.

Behind Closed Doors and Out in Public: An Investigation of Computer Use in the Public and Private Spheres

Much is proclaimed, but little is known about the use of computers in private places (such as the home), and public places (such as public libraries). It is frequently assumed that if access to computers exists that everyone, or at least all who are interested in using them, will have access to computers. However, both anecdotal accounts and observations made during studies that have focused on related issues suggest that this may not be the case. The purpose of this study was to investigate the dynamics of computer use in public settings, as well as private settings.

Data was primarily observational in nature, supplemented by interviews wherever possible. Observations were conducted through participant observation, supplemented by video tape, where appropriate. Observations focused on:

• who uses the computer;
• what, if any difficulties users encounter in their efforts to use the computer;
• what computer users do when they have difficulties in using the computer;
• how does the presence of computers influence what occurs in the environment where the computers are located?

Skill, Gender, and User Involvement in the Design Process: A Comparative Study of Participatory Design and Ergonomics

In their efforts to solve problems related to the implementation of technology in the workplace, scholars and practitioners with a wide range of disciplinary backgrounds have turned their attention either to research that can be loosely grouped under the heading of participatory design of technology (see for example Schuler & Namioka, 1993), or to research in the area of ergonomics (see for example Wilson & Corlett, 1990). Unfortunately, researchers working on technology implementation problems from within a participatory design framework have not, to date, communicated much with researchers addressing the implementation of technology from an ergonomic perspective. And, with few exceptions, advocates of neither participatory design nor ergonomics have incorporated feminist analyses of technology into their work, despite the fact that extensive earlier work (for example Linn, 1987 and Suchman & Jordan, 1988) has shown that theoretical insights about the implementation and use of technology are gained through a focus on gender as a subject of study.

The objectives of this research were:

1. to conduct a comparative study of participatory design of technological systems and ergonomic approaches to the design of technology, with special emphasis on how each paradigm addresses skill, gender, design methodology and user participation;
2. to identify how ergonomic and participatory design practitioners accomplish the goals of the paradigm they are working within, and what factors, if any, constrain them from realizing those goals;
3. to determine to what extent system designers and engineers incorporate practices that derive from either ergonomics or participatory design into their work processes.