A qualitative study of health information technology in the Canadian public health system

Background: Although the adoption of health information technology (HIT) has advanced in Canada over the past decade, considerable challenges remain in supporting the development, broad adoption, and effective use of HIT in the public health system. Policy makers and practitioners have long recognized that improvements in HIT infrastructure are necessary to support effective and efficient public health practice. The objective of this study was to identify aspects of health information technology (HIT) policy related to public health in Canada that have succeeded, to identify remaining challenges, and to suggest future directions to improve the adoption and use of HIT in the public health system. Methods: A qualitative case study was performed with 24 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology. Results: Identified benefits of HIT in public health included improved communication among jurisdictions, increased awareness of the need for interoperable systems, and improvement in data standardization. Identified barriers included a lack of national vision and leadership, insufficient investment, and poor conceptualization of the priority areas for implementing HIT in public health. Conclusions: The application of HIT in public health should focus on automating core processes and identifying innovative applications of HIT to advance public health outcomes. The Public Health Agency of Canada should develop the expertise to lead public health HIT policy and should establish a mechanism for coordinating public health stakeholder input on HIT policy

Caractéristiques des médecins prescrivant des psychotropes davantage aux femmes qu’aux hommes

Les différences observées dans l'état de santé et l'utilisation des services médicaux, selon le sexe, se sont avérées insuffisantes pour expliquer une plus grande consommation de psychotropes chez les femmes que chez les hommes dans les pays industrialisés. Nous avons testé l'hypothèse selon laquelle les habitudes de prescription des médecins expliquent une partie importante de cette observation. Nous démontrons, à l'aide des données de la Régie de l'assurance-maladie du Québec pour les personnes âgées de 65 ans et plus, que le profil socio-démographique et le style de gestion des médecins prescripteurs sont associés de façon significative au pourcentage d'hommes et de femmes ayant obtenu une ordonnance de psychotrope dans leurs pratiques.In industrialized countries, gender differences observed in health condition and the use of medical services appear insufficient to explain a greater consumption of psychotropic drugs in women than men. The authors have tested the hypothesis that physician prescribing patterns largely explains this observation. They demonstrate, using data from the Régie de l'assurance maladie du Québec for people aged 65 and over, that physicians' sociodemographic and practice characteristics are significantly associated with the percentage of men and women who receive a psychotropic drug prescription in their practice

The Health System Impact Fellowship: Perspectives From the Program Leads; Comment on “CIHR Health System Impact Fellows: Reflections on ‘Driving Change’ Within the Health System”

As the Canadian Institutes of Health Research (CIHR) leads in designing and implementing the new Health System Impact (HSI) Fellowship program, we congratulate Sim et al for their thoughtful contribution to the nascent literature on embedded research, and for advancing our own learning about the HSI Fellowship experience. In our commentary, we describe the HSI Fellowship and its key components, discuss the factors that motivated and inspired the creation of the program, and highlight successes thus far

Progress and Peril in the Championing Process

This paper explores the process of championing, as it occurs over the course of an information technology (IT) innovation implementation. It begins by describing the case of a championed IT project, and goes on to identify three championing behaviors that emerge from it: inoculated persistence, limited leveraging and discriminating outreach. While most previous work has described championing behaviors which are unequivocally positive, we find that each of these behaviors are primarily positive, but come with caveats. We suggest that the primarily positive nature of these behaviors accounts for the commonly held view that champions help an innovation’s progress, while the perils posed by the behaviors could explain why champions are sometimes implicated in spectacular innovation project failures

Impacts of Stress, Satisfaction and Behavioral Intention on Continued Usage: Evidence from Physicians Transitioning to a New Drug Management System

A survey of physicians taking part in a pilot study involving the transition from an e-prescribing system to a new integrated drug management system was conducted. Data about physicians’ level of stress induced by the system transition, satisfaction with the new system, and intention to continue to use the system, were collected as well as system usage logs before, during, and after the transition. Results indicate that physicians experiencing higher level of stress used the new system less during the transition as well as during the two months post-transition than their counterparts who reported lower level of stress. Although satisfaction with the new system was positively related to physicians’ intention to use, it was not significantly related to actual usage. A discussion of our results and their implications for research and practice concludes the paper

Patterns of opioid utilization in the 90-days post hospital discharge and risk of re-admissions and emergency department visits

Introduction Over the past 20 years, increases in opioid prescribing rates and average prescription volumes have been documented in both the United States and Canada. As prescription opioid use and overdose has steadily increased in North America, a dramatic rise in hospitalizations resulting from opioid poisonings has also been witnessed. Objectives and Approach To describe opioid utilization patterns for patients admitted to a tertiary care hospital in Montreal between 2014 and 2016, and to estimate the association between opioid use and risk of adverse health outcomes in the 90-days post discharge. Opioid utilization was measured using medication dispensing data from the provincial healthcare databases (RAMQ) while hospital/ED visits were obtained from RAMQ medical services. Patient characteristics and discharge prescriptions were obtained from the hospital chart. Time-varying utilization of opioids was modeled as: 1) current use, 2) cumulative duration of past use, and 3) duration of use of past 10 days, using Cox models. Results Of the 3,308 included patients mean age was 70 (SD 14), 57% were male and 47% were discharged from surgical units. 856 (26%) patients had a history of opioid use in the 1-year prior to admission, 1528 (46%) were prescribed an opioid at discharge and 1481 (45%) filled an opioid in the 90-days post discharge. Among patients prescribed an opioid at discharge, 79\% filled their prescription post discharge, where opioid naïve patients were less likely to fill their prescriptions compared to those with a history of opioid use (40% vs 81%). Our multivariable Cox models suggested that cumulative duration of opioid exposure in the past 10 days was associated with a 10% increased risk of ED visits and hospitalizations. Conclusion/Implications Patients with a history of opioid use were more likely to both receive an opioid prescription at hospital discharge and fill their prescription post-discharge. Our findings suggest that longer-term utilization patterns of these medications after hospitalization may increase risk of re-admissions and ED visits

The Importance of Relevance: Willingness to Share eHealth Data for Family Medicine Research

Objective: To determine the proportion of family medicine patients unwilling to allow their eHealth data to be used for research purposes, and evaluate how patient characteristics and the relevance of research impact that decision.Design: Cross-sectional questionnaire.Setting: Acute care respiratory clinic or an outpatient family medicine clinic in Montreal, Quebec.Participants: Four hundred seventy-four waiting room patients recruited via convenience sampling.Main Outcome Measures: A self-administered questionnaire collected data on age, gender, employment status, education, mother tongue and perceived health status. The main outcome of was self-reported relevance of three research scenarios and willingness or refusal to share their anonymized data. Responses were compared for family practice vs. specialty care patients.Results: The questionnaire was completed by 229 family medicine respondents and 245 outpatient respondents. Almost a quarter of all respondents felt the research was not relevant. Family medicine patients (15.7%) were unwilling to allow their data to be used for at least one scenario vs. 9.4% in the outpatient clinic. Lack of relevance (OR 11.55; 95% CI 5.12–26.09) and being in family practice (OR 2.13; 95% CI 1.06–4.27) increased the likelihood of refusal to share data for research.Conclusion: Family medicine patients were somewhat less willing to share eHealth data, but the overall refusal rate indicates a need to better engage patients in understanding the significance of full access to eHealth data for the purposes of research. Personal relevance of the research had a strong impact on the responses arguing for better efforts to make research more pertinent to patients

Using linked administrative, clinical and primary data to explore the impact of and factors associated with non-adherence to in-hospital medication changes in 30-days post hospital discharge

Introduction Identifying strategies to prevent hospital readmissions remains elusive since the reasons for returning to hospital can include a number of interlinked patient, health provider and system level factors. The impact of patient medications are of significant interest since a large proportion of re-admissions are related to adverse drug events. Objectives and Approach The objective was to determine which factors are associated with non-adherence to in-hospital medications and the impact of non-adherence on re-hospitalization, emergency department visits and death in the 30-days post discharge for patients admitted at two tertiary care academic hospitals in Montreal, Quebec between October 2014 and May 2016. Non-adherence to in-hospital changes was measured by comparing patient discharge prescriptions (patient chart) to medications filled in community 30-days post-discharge (dispensing data) and included i) community medications stopped in-hospital and filled post-discharge, ii) community medications modified in-hospital but not filled at the modified daily-dose, and iii) new medications not filled post-discharge. Results Among 2,895 included patients, mean age was 70 (SD 15) and 58% were males. A median of 4 in-hospital medication changes were made (IQR:3-6) and 54% of patients were non-adherent to at least one change. Multivariable Poisson models suggested that the most important factor associated with the number of new medications not filled post discharge was out of pocket cost; for each additional $10 increase in costs there was a 20% increase in the number of new medications not filled. Multivariable time-varying Cox models suggested that in patients who filled medications post-discharge, selective non-adherence to new and discontinued medications reduced the risk adverse health outcomes in 30-days, while not filling any medications post discharge more than doubled the risk of an adverse event in 30-days. Conclusion/Implications Not only did the majority of patients not follow all medication changes that were made during hospitalization, the extent to which this occurred significantly impacted the risk of hospital re-admissions and ED visits. Policy and patient level interventions should be developed specifically targeting barriers for adherence to medication changes

International Comparison in Opiate Prescribing for New Users in Primary Care using Electronic Medical Record Data

Introduction The opioid epidemic in North America has, in part, been attributed to an increase in opiate use for non-cancer pain and the prescription of more potent molecules. In contrast, the United Kingdom appears unaffected by this crisis, possibly because of differences in primary care prescribing, or health system policies. Objective To determine if there are differences in opiate prescribing for new users in primary care in the United Kingdom, United States, and Canada. Approach Electronic health record data from Quebec, Canada (MOXXI), the United States (Partners Health Care, Boston MA), and the United Kingdom (CPRD random sample of 600,000) were used to identify new users of opiates (no prior prescription in 2 years), at least 18 years old between 2006-2016. Cancer patients were excluded after harmonizing equivalent READ and ICD9/10 codes. Generic drug names in each jurisdiction were mapped to the WHO ATC classification, and characterized using morphine milligram equivalents (MME). Results Overall 655,877 new users were identified, of whom 78% of 58,286 (U.S.), 88% of 6,251 (Canada), and 96% of 600,000 (UK) were non-cancer patients. Mean age of new users was 49 (SD 16) in the US, 57 (SD 16) in Canada, and 52 (SD 19) in the UK. 57.6% (UK) to 67.3% (US) of new users were women. In the UK, 86.5% of patients were started on codeine (MME:0.15), compared to 43.9% in Canada and 8.5% in the U.S. In the U.S 65.0\% were started on oxycodone (MME:1.5), and 10.9% on hydrocodone (MME:1). In Canada, tramadol (18.2%; MME: 0.1) followed by oxycodone (13.2%) were the next most commonly prescribed drugs. Conclusion/Implications Substantial differences in opioid prescribing practices for non-cancer pain were observed between the UK and Canadian and United States sites. The predilection to start patients on more potent opiates in North America may be a contributing cause to the opiate epidemic