Journal:Advancing laboratory medicine in hospitals through health information exchange: A survey of specialist physicians in Canada

Full article title	Advancing laboratory medicine in hospitals through health information exchange: A survey of specialist physicians in Canada
Journal	BMC Medical Informatics and Decision Making
Author(s)	Raymond, Louis; Maillet, Éric; Trudel, Marie-Claude; Marsan, Josianne; de Guniea, Ana Ortiz; Paré, Guy
Author affiliation(s)	Université du Québec à Trois-Rivières, Université de Sherbrooke, HEC Montréal, Université Laval
Primary contact	Online contact form
Year published	2020
Volume and issue	20
Article #	44
DOI	10.1186/s12911-020-1061-z
ISSN	1472-6947
Distribution license	Creative Commons Attribution 4.0 International
Website	https://link.springer.com/article/10.1186/s12911-020-1061-z
Download	https://link.springer.com/content/pdf/10.1186/s12911-020-1061-z.pdf (PDF)

Abstract

Background: Laboratory testing occupies a prominent place in healthcare. Information technology systems have the potential to empower laboratory experts and to enhance the interpretation of test results in order to better support physicians in their quest for better and safer patient care. This study sought to develop a better understanding of which laboratory information exchange (LIE) systems and features specialist physicians are using in hospital settings to consult their patients’ laboratory test results, and what benefit they derive from such use.

Methods: As part of a broader research program on the use of health information exchange systems for laboratory medicine in Quebec, Canada, this study was designed as on online survey. Our sample is composed of 566 specialist physicians working in hospital settings, out of the 1,512 physicians who responded to the survey (response rate of 17%). Respondents are representative of the targeted population of specialist physicians in terms of gender, age, and hospital location.

Results: We first observed that 80% of the surveyed physicians used the province-wide interoperable electronic health records (iEHR) system, and 93% used a laboratory results viewer (LRV) to consult laboratory test results, while most (72%) use both systems to retrieve lab results. Next, our findings reveal important differences in the capabilities available in each type of system and in the use of these capabilities. Third, there are differences in the nature of the perceived benefits obtained from the use of each of these two systems. Last, the extent of use of an LRV is strongly influenced by the IT artefact itself (i.e., the hospital’s LRV available capabilities), while the use of the provincial iEHR system is influenced by its organizational context (i.e., the hospital’s size and location).

Conclusions: The main contribution of this study lies in its insights into the role played by context in shaping physicians’ choices about which LIE systems to adopt, which features to use, and the different perceptions they have about benefits arising from such use. One related implication for practice is that success of LIE initiatives should not be solely assessed with basic usage statistics.

Keywords: laboratory information exchange, information systems, laboratory medicine, specialist physician, hospital, perceived benefits, online survey research

Background

Laboratory testing occupies a prominent place in healthcare. For instance, more than seven billion laboratory tests are performed each year in the United States. It is also reported that about 70% of all medical decisions are based on laboratory test results. In hospital settings, which are the focus of the present study, 98% of admitted patients have one or more laboratory tests prescribed. To provide services across a broad continuum and to perform increasingly complex tests, laboratories require sophisticated medical technologies and highly qualified staff. Faced with this growing complexity, treating physicians must be able to rely on consistent clinical support provided by laboratory medicine specialists such as radiologists and pathologists.

A recent study found that among seven countries, Canada ranked second in terms of physician self-reported errors in laboratory and diagnostic processes, as well as delays in reporting abnormal results. One way to improve the quality and safety of patient care is to emphasize prevention and error management using well-designed information technology (IT) systems. Indeed, the laboratory testing process involves the constant exchange of information among patients, physicians, nurses, and laboratory specialists which, nowadays, is supported by multiple IT systems and platforms.

Missing laboratory results may have considerable consequences for patients and are due to several factors, including the way systems and practices are used to monitor test results, how critical results are managed, and how care is transitioned across settings. To prevent medical errors, medical laboratories have deployed laboratory information systems (LIS) with user-friendly interfaces, tracking tools, and electronic alerts; computerized physician order entry (CPOE) systems; and clinical decision support systems. These systems empower laboratory specialists to enhance the interpretation of test results in order to better support physicians in their quest for better and safer patient care. Although physicians may have access to an LIS, these systems are primarily designed to meet the needs of laboratory personnel. Therefore, other laboratory information exchange (LIE) systems are required to improve the reliability of the laboratory testing process and, hence, need to be integrated with other clinical information systems physicians use in hospitals such as electronic health records (EHRs).

Prior research in the information systems (IS) field draws two main conclusions that are pertinent to this study. First, the mere adoption of a given IT system is not enough to achieve improvements in performance. In fact, prior investigations of the relationship between IT system use (i.e., duration or frequency of use) and individual and organizational performance outcomes have yielded contradictory and inconclusive results. Instead, it appears that performance improvements depend more on how a given IT system is used than on for how long. More precisely, recent research shows that the extended use of a given IT system (i.e., conceptualized as the extent to which system features are utilized) is positively related to performance outcomes. Research in the medical informatics field has recently corroborated the relationship between extended use of a system and performance outcomes such as quality of care, efficiency, operational performance, and economic performance. Second, the IS literature has, for the most part, failed to conceptualize the IT artifact objectively. That is, instead of capturing the features available in a system, researchers have focused on mental representations of the system (e.g., perceived ease of use, perceived usefulness). Such mental representations are not of practical use, as they do not give any information about how the capabilities available in a system shape its extended use, nor do they provide concrete feedback to system designers about the criticality of certain features or the need for additional ones. As a result, IT systems, such as LIE, need to be better conceptualized in terms of their key functionalities or features.

Considering the above, the present study pursues two main objectives. First, it sought to develop a better understanding of which LIE systems and features specialist physicians (SPs) working in hospital settings are using to consult their patients’ laboratory test results, and what benefits they derive from such usage. More precisely, we attempt to provide answers to the following research questions: What is the nature of LIE usage in hospitals, and what types of information systems and features are being used by SPs for laboratory medicine purposes? How extensive is this use? What are the benefits obtained by SPs from extended LIE usage? Second, this study attempts to identify the contextual factors that lead to or influence the extended use of LIE systems by SPs. While medical informatics researchers have investigated the facilitators and barriers related to the adoption of EHRs in hospital settings, to our knowledge no prior study has focused on the antecedents to LIE system usage per se. The present study attempts to fill this gap. As explained below, inspired by prior research on EHRs we investigated the individual, organizational, and IT artefactual antecedents to LIE use.

Methods

As shown in Fig. 1, a conceptual framework was developed to describe and explain SPs’ use of health information exchange (HIE) systems for laboratory medicine in hospital settings, as well as the potential antecedents and performance outcomes of such use. This framework guided the design of the survey administered to find answers to our research questions. The framework is founded on prior research on HIE use in hospital settings and on the impacts of such use on laboratory testing in particular. Moreover, we followed Burton-Jones and Grange in assuming that using HIE systems per se does not necessarily enable laboratory medicine in hospital care. Our conceptual framework thus implies that only an “extended” use of LIE systems can have a positive impact on the practice of laboratory medicine by SPs, in terms of their efficiency and the quality of the care services provided to their patients.

Figure 1. Conceptual framework

As part of a broader research program on the use of HIE systems for laboratory medicine in the province of Quebec, Canada, this study was designed as an online survey. As described below, we followed best practices concerning web-based survey methodology. The survey questionnaire was built following the previously mentioned review of the extant literature and a series of interviews with 25 physicians located in 11 different regions of Quebec. Survey respondents were recruited with the help of the Quebec’s Ministry of Health and Social Services, which emailed an invitation letter to the 9005 physicians who had authorized access to the province-wide interoperable electronic health record (iEHR), called the Quebec Health Record (QHR). The letter included a hyperlink and a QR code for mobile devices, directing respondents to access the survey questionnaire through a secure web page. Developed with the Qualtrics online survey platform, the survey instrument was first approved by the province’s health authorities and then pre-tested with 10 physicians. Each physician was interviewed about the questionnaire’s format and instructions, as well as the wording of questions and possible answers, to ensure that they were interpreted as intended by the researchers. Following a few minor adjustments to the survey instrument, the study received final approval from the ethics committee of each researcher’s institution. Two reminder letters were sent to all targeted physicians seven and 14 days after the initial invitation.

Our sample is composed of 566 SPs providing secondary or tertiary care in hospital settings, out of the 1,512 physicians who fully responded to the survey (for a 17% response rate). The potential for non-response bias was ascertained by comparing the 112 “late” respondents (i.e., those who answered after receiving the second reminder) with the 454 “early” respondents. No significant differences were found between these two groups, thus indicating the absence of such a bias. The data were then analyzed through descriptive statistics, Chi-squared analysis, structural equation modeling (using SmartPLS software), cluster analysis, and analysis of variance and covariance (using SPSS software). The internal validity of the two index measures of HIE use was ascertained with “item analysis,” in which we confirmed that each measure correlated sufficiently with its component items. The internal validity of the two scale measures of the impacts of HIE systems use was tested with Cronbach’s α coefficient (> 0.6 threshold for exploratory research).

Results

As shown in Table 1 (see top section), 49% of the SPs in our sample were women. In terms of clinical experience, 34% had less than 10 years of experience, 35% had 10 to 24 years, and 31% had 25 years or more. All major medical specialties are represented, including psychiatry, anesthesiology, pediatrics, radiology, internal medicine, surgery, obstetrics-gynecology, cardiology, and others. Respondents were asked to indicate what their main work affiliation was and to describe their use of HIE systems in this context. All SPs practiced in hospital settings; 44% in small or medium-size establishments (1 to 149 specialists), and 56% in large ones (150 or more specialists). As to their location, 70% practiced in a hospital located in a central or urban region, whereas 30% worked in peripheral or rural regions. It is worth noting that our respondents are representative of the targeted population of SPs in terms of gender (46% are women), age (average is 49 years old) and location (65% work in hospitals located in central or urban regions).

Table 1. Context of HIE use by specialist physicians (SPs) for laboratory medicine: a Quebec Health Record; b For viewing lab results provided by a LIS, a CIS, and/or a regional HIE platform; * The χ2 value indicates a significant difference (p < 0.05 | p < 0.001) between iEHR users and non-users Characteristics of the SPs (user context) All specialist physicians iEHRa users iEHR non-users Chi-squared statistic (N = 566) freq. (%) (n = 451) freq. (%) (n = 115) freq. (%) Gender    Female 278 (49.1) 221 (49.0) 57 (49.6) 0.0    Male 288 (50.9) 230 (51.0) 58 (50.4) Age    29 years old or less 7 (1.2) 6 (1.3) 1 (0.9) 5.6    30–49 years old 317 (56.0) 256 (56.8) 61 (53.1)    50–59 years old 137 (24.2) 101 (22.4) 36 (31.3)    60 years old or more 105 (18.6) 88 (19.5) 17 (14.8) Clinical experience    5 years or less 85 (15.0) 72 (16.0) 13 (11.3) 5.9    5–9 years 107 (18.9) 85 (18.8) 22 (19.1)    10–24 years 196 (34.6) 156 (34.6) 40 (34.8)    25 years or more 178 (31.4) 138 (30.6) 40 (34.8)

Notes

This presentation is faithful to the original, with only a few minor changes to presentation, grammar, and punctuation. In some cases important information was missing from the references, and that information was added. To more easily differentiate footnotes from references, the original footnotes (which where numbered) were updated to use lowercase letters.