Purpose To explore medical and non-medical practitioners’ views of the impact of ehealth on shared care.
Method A systematic review was conducted using a meta-narrative approach with publication search dates limited from 1 January 2005 to 28 February 2011 and English language only. Search results from the databases (ASLIB, EBSCO Host, Cochrane Library, Informa Healthcare, PsycNet, Sciverse Scopus, Zetoc) were independently reviewed and data extracted by two of the authors. The review included peer reviewed papers about medical and non-medical practitioners who provide ehealth supported shared care. Articles which focused solely on searching the internet or exchange of emails were excluded.
Results Screening reduced the initial 327 papers identified to 12 which included three reviews, four qualitative, two mixed methods and three quantitative studies. Included studies collected data using combinations of questionnaires, case study, group/individual interviews, observation and extraction of data from records. Data were analysed using thematic, interpretive, analytic induction/constant comparative and statistical analysis methods. Practice settings were primary care, secondary care or both. The focus was on electronic records (7), telemedicine (2) or general ehealth implementation (3) predominantly from the perspective of doctors, nurses, IT developers, policy makers and managers plus one hospital pharmacist. The studies showed acceptance of ehealth technologies to support increasing levels of shared care but with cost effectiveness, level of resourcing and training questioned by respondents. Emerging themes across all study types were organisational, social and technical: resource and time implications, culture of the workplace and change management requirements; impact on patient consultation, extra workload, need for training suited to varying levels of IT literacy, usability, patient privacy and the practitioner's role; systems incompatibility, technological inadequacies, need for shared definition and terminology.
Conclusions Findings indicate acceptance of ehealth to support shared care but question anticipated efficiencies. Organisational, social and technical issues identified were similar to non-healthcare IT implementations and adoption of innovation theory. Evidence of medical and non-medical practitioners’ views of the impact of ehealth on shared care remains limited with further areas for pharmacy ehealth research identified.
- systematic review
- shared care
- medical practitioners
- non-medical practitioners
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Shared care, facilitated by collaborative working between healthcare professionals, has long been viewed as beneficial to patients and a more efficient use of professionals’ skills.1–7 Health strategists in the UK and worldwide promote the adoption of ehealth to support shared care, where technology facilitates medical and non-medical practitioners, such as nurses and pharmacists, working in partnership.8–13 Electronic health, or ehealth, is defined by the World Health Organisation as ‘the combined use of information and communications technologies for health.’14 This has been further refined by the European Commission Information Society (ECIS) to include ‘tools and services for health.’15
eHealth studies to date have focused on the medical practitioners’ perspective of the adoption of technology16–23 or specific ehealth applications, such as telehealth24 ,25 or electronic records.26–32 More patient-centred studies have investigated the impact of ehealth on quality and safety of care33 ,34 or confidentiality.35
Pharmacists play an increasingly accepted extended role within and between primary and secondary settings36–45 and yet their views of the impact of ehealth on shared care remain largely unknown. This systematic review was conducted to explore and report research related to medical and non-medical practitioners’ views of the impact of ehealth on shared care.
A protocol was developed46 and a systematic review conducted using a meta-narrative approach.16 This approach is designed to draw out each storyline before pulling them together in an ‘over-arching narrative’ to ‘highlight similarities and differences in the findings from different traditions.’47 Five principles of pragmatism, pluralism, historicity, contestation and peer review are applied across six phases of planning, search, mapping, appraisal, synthesis and recommendation.
In application, principles of pragmatism and pluralism challenged research team members to value their and the storylines’ diversity. Historicity drew out the context and placement of each storyline situating it within a research tradition while contestation valued disconfirming or seemingly deviant cases to help explain perceived conflicts. Periodic peer review by external advisors brought rigour and robustness through questioning motives and justification for inclusion, exclusion and interpretation of individual storylines and the subsequent recommendations.
The planning phase of the meta-narrative review involved selecting research team members from varied backgrounds, meetings, informal discussion and agreement on staged outputs and, in contrast to Cochrane reviews, openness to revising the protocol.48 The search phase involved rigorous, intuitively driven tracking down of relevant research activity as a basis for the mapping phase where influences, stakeholders and storylines were correlated. Data extraction and critical appraisal tools49–51 were applied before narrating the over-arching story in which similarities and differences were synthesised to provide recommendations. Ethical review was not required for this study of peer reviewed, published literature.
The review included medical and non-medical practitioners who provide ehealth supported shared care. Articles which focused solely on searching the internet for health or medicines information or exchange of emails, with or without attachments, or technical aspects of development or implementation were excluded as these were not considered to be purposefully developed ehealth tools or services.14 ,15 Only readily accessible, full articles published in English language from 1 January 2005 to 28 February 2011 were included. The date limits were based on the need for currency of the technology reported and publication of the key text.16 Due to the paucity of articles retrieved, no studies were excluded on the basis of design or quality.
Information sources and search strategy
Each of the databases selected (ASLIB, EBSCO Host, Cochrane Library including the Database of Abstracts of Reviews of Effects (DARE) and Effective Practice and Organisation of Care (EPOC), Informa Healthcare, PsycNet, Sciverse Scopus, Zetoc) showed multiple results on the preliminary scoping search term (health* AND technolog*) providing worldwide coverage of health technology research. This also guided refinement of search terms through team negotiation to identify published, peer reviewed articles maintaining the review focus on shared care. Grey literature, in the form of policy documents, consultations and reports, were sourced from government and NHS websites, and experts in the field, to provide context throughout this review.
An incremental search string (table 1) was applied with results and exceptions recorded for each research database at each level of refinement using an adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.52 Titles were independently screened by two researchers (KM, DS) with abstracts followed by full papers reviewed where any doubt remained. Consensus on final inclusions was negotiated.
Data extraction, appraisal and analysis
Data from the selected studies were tabulated mapping ‘5 Ws and H’ (Who, What, Why, Where, When and How) to corresponding PICOS terms (Population, Intervention, Comparator, Outcome, Study design). Variables extracted included participants, elements, aims, geographical and practice settings, timelines and backgrounds, methods and response rates along with definitions of ehealth and authors’ conclusions. Critical appraisal tools geared to each study design type49–51 were applied independently by two researchers (KM, DS). Reviewer notes were added to complete the mapping and appraisal overview. The overall quality of evidence was assessed and risk of publication and selective reporting bias considered.
Meta-narrative review approach, which ‘treats conflicting findings as higher order data,16 was followed in comparing commonalities while contesting differences in the findings of the included studies.
Screening reduced the initial 327 papers identified to 12 (figure 1). Reasons for excluding papers, other than duplication or non-English language, were their focus: on non-ehealth specific applications, such as online searching for medicines or other information; or email exchange with or without attachments; on technical aspects of systems development or implementation; or views expressed were those of patients, hospital management or systems developers; or that they did not focus on the views of healthcare professionals, working collaboratively, supported by ehealth. Ten papers were selected for inclusion from the electronic database searches with a further two added through reference tracking.
Study characteristics and results
The mapping and appraisal overview (see online supplementary table) included three reviews (systematic, meta-narrative, realist), four qualitative, two mixed methods and three quantitative (questionnaire based) studies. The primary research studies used combinations of questionnaires, case study, group and individual interviews, observation and extraction of data from records to collect data which were then analysed using thematic, interpretive, analytic induction/constant comparative and statistical analysis methods. Practice settings were rural or urban featuring primary care, secondary care or both. Geographical settings ranged from single country, including Canada, USA, Denmark, Sweden, Australia, New Zealand, Crete, Norway, England, Scotland, to Europe and worldwide. The focus was on electronic records (7), telemedicine (2) or general ehealth implementation (3) from the perspective of doctors, nurses, IT developers, policy makers, managers and one hospital pharmacist.
Definitions of ehealth and shared care
Ehealth definitions were highlighted in this review (see online supplementary table) as they have yet to find consensus.53 ,54 Of the 12 articles reviewed, five gave an explicit or implicit definition of ehealth similar to WHO14 and ECIS,15 ,22 ,28 ,55–57 one provided a list of functionality and resource requirements58 while six defined a specific ehealth application but not ehealth itself.26 ,30 ,59–62 Although shared care is the basis for inclusion, only one paper included a definition: ‘establishing coherent treatment of the patient through close coordination and cooperation across care sector boundaries’60 while Melby et al61 offered ‘integrated’ or ‘seamless’ care as alternative terms.
Quality of evidence
The review team applied a modified form of the GRADE (Grading of Recommendations, Assessments, Developments and Evaluation) tool.63 added to the critical appraisal findings (tables 2⇑⇑–5). The ‘quality of evidence’ was based initially on the study design but adjusted for rigour of application to a rating of ‘high’, ‘moderate’, ‘low’ or ‘very low’. A further rating, termed ‘magnitude of effect,’ was added based on applicability of the review article findings to the current research.
What ehealth shared care research has been conducted by whom?
Three ehealth research themes were identified with a shared care focus:
Why, how, when and where did they conduct their research?
Reasons given for conducting the research include exploring (or identifying or evaluating) the impact (or attitudes or perceptions or factors or influences or context or processes) of ehealth implementations on individuals (system users or healthcare professionals or patients) to inform (or contextualise or understand or make sense of or influence) future ehealth outcomes.
What was the methodological quality of the research?
Appropriate methodologies were adopted for all studies but, following GRADE63 criteria for assessment, the consistency, precision and rigour with which they were applied in some papers raised questions over the validity and robustness of some findings22 ,28 ,55 (tables 2⇑⇑–5).
What were the key findings?
From the earliest58 to the most recent study57 included in this review, findings around the impact of technology on shared care are explicitly26 ,28 ,30 ,62 or implicitly22 ,55 ,57–61 ,64 expressed as organisational, social or technical with additional external factors. Several expressed findings in terms of barriers or challenges and facilitators or benefits.55 ,58–60 ,64
Social factors around the impact of ehealth on shared care
Social factors are the most frequently raised. Issues include positive and negative aspects of the impact of ehealth technologies on the patient consultation,26 ,57 ,58 ,62 ,64 the extra workload,26 ,55 ,58 ,62 ,64 need for training,28 ,58 ,59 variation in IT literacy levels,22 ,28 ,55 usability,26 ,28 ,59 patient privacy28 ,58 ,62 and the professional's role in ehealth supported shared care.22 ,26 ,62 There is evidence of contradictory findings between articles: extra workload but time saving59; quality of care affected62 but also unaffected28; patient safety unaffected28 ,62 but prevents medication errors.62 While the professional networking opportunities offered by ehealth are seen as positively promoting shared care61 there is evidence of discrepancy in identifying the need for shared care.60 Concerns are expressed about ehealth facilitated roles in shared care but medical practitioners’ confidence appears raised by access to ehealth technologies62 with data seen as incomplete/inaccurate62 but communication between healthcare professionals more legible.61 It is not clear whether these contradictory findings are due to differences in study quality, scope, setting or other factors.
Organisational factors around the impact of ehealth on shared care
Organisational factors focus strongly on resources22 ,28 ,55 ,58 ,59 ,64 and the time implications30 ,55 ,59 of using ehealth and also the culture of the workplace22 ,26 ,28 and change management requirements26 ,30 ,62 ,64 for successful implementation. Efficiency28 and cost effectiveness22 ,57 are seen as unproven with concerns raised around data security22 ,28 and liability risks28 although access to an audit trail26 ,59 was viewed as a benefit of ehealth supported shared care.
Technical factors around the impact of ehealth on shared care
Few technical factors were raised with the emphasis placed on systems incompatibility,22 ,26 ,60 ,62 technological inadequacies22 ,59 ,62 and the need for shared ehealth definition and terminology.26 ,28 ,30
External factors around the impact of ehealth on shared care
What gaps in research were identified?
Limited research was identified which explored the impact of ehealth on non-medical practitioners’ expanding role in shared care. Granlien et al60 had ‘not found any studies concerning the users roles in adopting technological infrastructures supporting shared care’ and only 1 of the 12 studies included the views of one hospital pharmacist.62 Granlien et al60 also noted that ‘there is very little qualitative research exploring the practical barriers to the adoption of such systems in the primary care sector.’ Pagliari et al59 had also reported that ‘evaluations of healthcare IT initiatives remain poorly documented’ which was more recently confirmed by Ekeland et al.57 Greenhalgh et al26 make extensive recommendations for further research including exploring ‘how staff contextualise and prioritise knowledge for shared use,’ recommending more ‘technically orientated review by an interdisciplinary team’ with the aim of ‘telling it like it is.’
Why not ask the pharmacist?
This systematic review identified organisational, social, technical and external themes highlighting issues to be addressed within each. At an organisational level, the main influences are resource and time implications, culture of the workplace and change management requirements. Social concerns focused on the impact on patient consultations, extra workload, need for training suited to varying levels of IT literacy, usability, patient privacy and the practitioners’ role. Technical aspects included systems incompatibility, technological inadequacies, need for shared definition and terminology while external factors highlighted the interplay between national policy and strategy and regional autonomy.
Acceptance of ehealth to support medical and non-medical practitioner provided shared care is reported but evidence of quality, safety and efficiency benefits, as well as resource and training implications, remains limited and inconclusive. Pharmacy practice research is notable by its absence. Since this review was conducted, a European Commission survey-based project aimed at ‘assessing the perspective of the main end users’ which does include pharmacists as well as patients, doctors and nurses, has commenced.65 It is specific to the telehealth field and includes one question about ‘cooperation among health professionals’. NHS Scotland is developing a Citizen eHealth Strategy, as part of its overall eHealth Strategy, aimed at helping individuals to improve their own health by engaging with ehealth services. An online survey was open to the general public as part of the development and consultation process until the end of 2011.66 Findings from a more recent electronic health record study in England by Sheikh et al67 reinforce those highlighted by this review: delays in implementation; need to focus on the staff/technology interaction; individual and organisation learning. Audit Scotland's 2010 review urges the Scottish Government and NHS boards to ‘consider the long term clinical, organisational and cost benefits’ of telehealth68 but, given the limited number of papers published in this area, it is still unclear what ehealth applications are perceived to have worked and how in supporting shared care of patients. However, the similarities to non-healthcare IT implementation issues69–71 and adoption of innovation theory72 are noteworthy with further research into IT implementation failures in progress.73 Recent press releases from the Royal College of General Practitioners,45 ,74 the Royal Pharmaceutical Society45 ,75 and the Scottish Government76 ,77 focus on joint working and integration between doctors and pharmacists, all underpinned by ehealth, which in turn resonate with the findings of the Christie Commission and the Wilson Report into the provision of pharmaceutical care.78 ,79 All point to increasing reliance on ehealth to support shared or integrated care but, as this review demonstrates, there remains a lack of quality evidence to support strategic decision making in healthcare generally and specifically around the role of the pharmacist.
Strengths and weaknesses
The main strengths of this systematic review are the methodological rigour and application of established tools by a multidisciplinary team with independent review and input from external advisors. These strengths reduce the potential for publication and selection bias. Limitations and weaknesses are the potential bias inherent in snowballing techniques. With a limited number of quality studies identified for review, results may only be generalisable where contexts are similar.
Evidence of medical and non-medical practitioners’ views of the impact of ehealth on shared care remains limited, with pharmacists particularly under-represented in ehealth research. Organisational development and training for core and optional ehealth services remain key in keeping people at the heart of integrated ehealth strategies across the UK.8–11 ,76 ,77 ,79
Based on these findings, and taking into account the ‘Pathways to Impact’ identified by Research Councils UK,80 we recommend that the research agenda for future work prioritises the:
Organisational resource and time implications, culture of the workplace and change management requirements: is organisational culture and practice changing effectively and sustainably to meet the needs and expectations of patients and shared care providers?
Social impact on patient consultation, extra workload, need for training suited to varying levels of IT literacy, usability, patient privacy and the practitioner's role: has ehealth changed the personal interaction between patient and provider or between members of the healthcare team to the benefit of health, well-being or quality of life?
Technical systems incompatibility, technological inadequacies, need for shared definition and terminology: exploring opportunities for ehealth innovation and acceptance through research engagement with patients and healthcare professionals.
Finally, it is evident that research into the role of the pharmacist within the shared care team should be prioritised. Policy and practice are embedded yet the evidence base for effective, sustainable role development is lacking.
What this paper adds
What is already known on this subject
Evidence of medical and non-medical practitioners’ views of the impact of ehealth on shared care remains limited.
Pharmacists in particular are under-represented in ehealth research despite their increasing role in shared care.
Organisational development and training for core and optional ehealth services remain key in keeping people at the heart of integrated ehealth strategies across the UK.
What this study adds
This review demonstrates the need for further targeted research aimed at understanding the impact of ehealth on patient consultations, and the associated resource, training and support needs of all shared care providers.
The authors gratefully acknowledge and thank Professor Sir Lewis Ritchie and the late Dr Yashodharan Kumarasamy for their time and expertise in providing feedback throughout the review. Also Dr Lorna McHattie who was involved in the early stages.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online table
Contributors All of the authors were involved in the conception and design of the study. KM and DS conducted the data collection and analysis with interpretation discussed as a team. KM and DS drafted the article which was reviewed and approved by AS.
Funding No dedicated funding was received for this research but it is part of a larger research programme funded by NHS Education for Scotland. The authors gratefully acknowledge their support.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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