OBJECTIVES: Electronic health records (EHRs) provide substantial resources for observational studies, yet present significant challenges in safeguarding patient privacy while maintaining research quality. Differential privacy (DP) offers a quantifiable privacy guarantee; however, its impact on observational studies remains underexplored. We empirically evaluated the effects of DP across varying values of its privacy parameter, epsilon, on case-control analysis outcomes using EHR data. This study aims to inform DP parameter selection and examines the influence of study characteristics on differentially private observational studies. MATERIALS AND METHODS: We assessed the effects of DP on a case-control study of 1-year asthma exacerbations, including 22 165 participants with a history of asthma from UK Biobank linked to EHR data. Odds ratios (ORs) for sociodemographic factors and comorbidities were analyzed using adjusted and propensity score-matched models across epsilon values. RESULTS: DP influenced the magnitude, direction, and statistical significance of ORs, occasionally resembling patterns of misclassification, residual confounding, and false-positive bias. Rare and imbalanced covariates showed greater OR variability, especially in matched studies. Epsilons smaller than ln(2) led to noticeable OR fluctuations. DISCUSSION: The impact of DP on ORs and selection of an optimal epsilon depends on sample size, covariate prevalence, confounders, case-to-control ratios in propensity score matching, mitigation of random seed p-hacking, and trust models. CONCLUSION: The effects of DP on ORs are highly context-dependent. In this study, epsilon values below ln(2) led to unstable ORs across random seeds. Averaging results or using predetermined seeds may help reduce variability and mitigate p-hacking.

BACKGROUND: The Global Digital Exemplar (GDE) Programme is a national initiative to promote digitally enabled transformation in English provider organizations. The Programme applied benefits realization management techniques to promote and demonstrate transformative outcomes. This work was part of an independent national evaluation of the GDE Programme. AIMS: We explored how benefits realization management was approached and conceptualized in the GDE Programme. METHODS: We conducted a series of 36 longitudinal case studies of provider organizations participating in the GDE Programme, 12 of which were in depth. Data collection included a combination of 628 interviews (with implementation staff in provider organizations, national programme management staff, and suppliers), 499 documents (of national and local implementation plans and lessons learned), and 190 nonparticipant observations (of national and local programme management meetings to develop insights into the broader context of benefits realization activities, tensions arising, and how these were negotiated). Data were coded drawing on a sociotechnical framework developed in related work and thematically analyzed, initially within and then across cases, with the help of NVivo 11 software. RESULTS: Most stakeholders broadly agreed with the rationale of benefits realization in the GDE Programme to show due diligence that public money was appropriately spent, and to develop an evidence base supporting the value of digitally enabled transformation. Differing national and local reporting purposes, however, created tensions. Central requirements, for progress reporting and tracking high-level benefits, had limited perceived local value and were seen to impose an unnecessary burden on provider organizations. This was accentuated by the lack of harmonization of reporting requirements to different stakeholders (which differed in content and timing). There were tensions between the desire for early evidence of outcomes and the slow processes of infrastructural change (which created problems of attribution of benefits to causes as benefits emerged gradually and over long timeframes), and also between reporting immediately visible local changes and showing how these flowed through to high level organization wide benefits (eg, in terms of health outcomes or cost savings/return on investment). The attempt to fulfill these diverging agendas and informational needs within a single reporting tool had limited success. These difficulties were mitigated by efforts to simplify reporting requirements and to support targeted collection of key national outcome measures. Although progress was hampered by an initial lack of benefits realization expertise in provider organizations, some providers subsequently retained these skills for their own change management purposes. CONCLUSIONS: There is a need to recognize the limitations and cost of benefits realization management practices in the context of healthcare digitalization where benefits may materialize over long timeframes and in unanticipated ways. Although diverse stakeholder information needs may create tensions, prior agreement about rationales for collecting information and a targeted approach to tracking local and high-level benefits may enhance local relevance, reduce perceived reporting burdens, and improve acceptance/effectiveness. A single integrated reporting mechanism is unlikely to fulfill both national and local requirements.

Asthma is a common chronic lung disease. National guidelines encourage a stepwise approach to pharmacotherapy, and as such, an individual’s current treatment step can be considered as a severity categorization proxy. BTS/SIGN steps can be estimated from electronic prescription records, however substantial data processing is required including extracting information from free-text drug descriptions and dose instructions. Almost 4.5 million asthma controller inhalers were prescribed for people in the Asthma Learning Health System (ALHS) Scottish cohort between 2009 and 2017. Asthma treatment regimens were identified and categorized by the combination of medications prescribed in the 120 days preceding prescribing events. 26% of prescriptions had no primary controller (inhaled corticosteroid) prescriptions in the previous 120 days and were thus assigned Step 0. 16% of prescriptions were assigned to BTS/SIGN Step 1, 7% to Step 2, 21% to Step 3, and 30% to Step 4. We developed a robust methodology enabling researchers to easily replicate BTS/SIGN asthma treatment step estimates, to both describe the severity of asthma in a population and to demonstrate changes over time. This can provide valuable insights into population and patient-specific trajectories, to improve understanding and management of symptoms.

OBJECTIVE: The study sought to develop an in-depth understanding of how hospitals with a long history of health information technology (HIT) use have responded to the COVID-19 (coronavirus disease 2019) pandemic from an HIT perspective. MATERIALS AND METHODS: We undertook interviews with 44 healthcare professionals with a background in informatics from 6 hospitals internationally. Interviews were informed by a topic guide and were conducted via videoconferencing software. Thematic analysis was employed to develop a coding framework and identify emerging themes. RESULTS: Three themes and 6 subthemes were identified. HITs were employed to manage time and resources during a surge in patient numbers through fast-tracked governance procedures, and the creation of real-time bed capacity tracking within electronic health records. Improving the integration of different hospital systems was identified as important across sites. The use of hard-stop alerts and order sets were perceived as being effective at helping to respond to potential medication shortages and selecting available drug treatments. Utilizing information from multiple data sources to develop alerts facilitated treatment. Finally, the upscaling/optimization of telehealth and remote working capabilities was used to reduce the risk of nosocomial infection within hospitals. DISCUSSION: A number of the HIT-related changes implemented at these sites were perceived to have facilitated more effective patient treatment and management of resources. Informaticians generally felt more valued by hospital management as a result. CONCLUSIONS: Improving integration between data systems, utilizing specialized alerts, and expanding telehealth represent strategies that hospitals should consider when using HIT for delivering hospital care in the context of the COVID-19 pandemic.

OBJECTIVE: The Global Digital Exemplar (GDE) Program is a national attempt to accelerate digital maturity in healthcare providers through promoting knowledge transfer across the English National Health Service (NHS). "Blueprints"-documents capturing implementation experience-were intended to facilitate this knowledge transfer. Here we explore how Blueprints have been conceptualized, produced, and used to promote interorganizational knowledge transfer across the NHS. MATERIALS AND METHODS: We undertook an independent national qualitative evaluation of the GDE Program. This involved collecting data using semistructured interviews with implementation staff and clinical leaders in provider organizations, nonparticipant observation of meetings, and key documents. We also attended a range of national meetings and conferences, interviewed national program managers, and analyzed a range of policy documents. Our analysis drew on sociotechnical principles, combining deductive and inductive methods. RESULTS: Data comprised 508 interviews, 163 observed meetings, and analysis of 325 documents. We found little evidence of Blueprints being adopted in the manner originally conceived by national program managers. However, they proved effective in different ways to those planned. As well as providing a helpful initial guide to a topic, we found that Blueprints served as a method of identifying relevant expertise that paved the way for subsequent discussions and richer knowledge transfers amongst provider organizations. The primary value of Blueprinting, therefore, seemed to be its role as a networking tool. Members of different organizations came together in developing, applying, and sustaining Blueprints through bilateral conversations-in some circumstances also fostering informal communities of practice. CONCLUSIONS: Blueprints may be effective in facilitating knowledge transfer among healthcare organizations, but need to be accompanied by other evolving methods, such as site visits and other networking activities, to iteratively transfer knowledge and experience.

The novel coronavirus disease 2019 (COVID-19) pandemic has led to a worldwide crisis in public health. It is crucial we understand the epidemiological trends and impact of non-pharmacological interventions (NPIs), such as lockdowns for effective management of the disease and control of its spread. We develop and validate a novel intelligent computational model to predict epidemiological trends of COVID-19, with the model parameters enabling an evaluation of the impact of NPIs. By representing the number of daily confirmed cases (NDCC) as a time-series, we assume that, with or without NPIs, the pattern of the pandemic satisfies a series of Gaussian distributions according to the central limit theorem. The underlying pandemic trend is first extracted using a singular spectral analysis (SSA) technique, which decomposes the NDCC time series into the sum of a small number of independent and interpretable components such as a slow varying trend, oscillatory components and structureless noise. We then use a mixture of Gaussian fitting (GF) to derive a novel predictive model for the SSA extracted NDCC incidence trend, with the overall model termed SSA-GF. Our proposed model is shown to accurately predict the NDCC trend, peak daily cases, the length of the pandemic period, the total confirmed cases and the associated dates of the turning points on the cumulated NDCC curve. Further, the three key model parameters, specifically, the amplitude (alpha), mean (mu), and standard deviation (sigma) are linked to the underlying pandemic patterns, and enable a directly interpretable evaluation of the impact of NPIs, such as strict lockdowns and travel restrictions. The predictive model is validated using available data from China and South Korea, and new predictions are made, partially requiring future validation, for the cases of Italy, Spain, the UK and the USA. Comparative results demonstrate that the introduction of consistent control measures across countries can lead to development of similar parametric models, reflected in particular by relative variations in their underlying sigma, alpha and mu values. The paper concludes with a number of open questions and outlines future research directions.

Medication non-adherence is strongly associated with poor asthma control and outcomes. Many studies use an aggregate measure of adherence, such as the percentage of prescribed doses that were taken, however this conceals variation between patients' medication-taking routines. Electronic monitoring devices, which precisely record the date and time of a dose being actuated from an inhaler, provide the means to objectively and remotely monitor adherence behavior patterns. This secondary analysis of a New Zealand audio-visual medication reminder intervention study visually explored the relationships, variation, and heterogeneity between multiple measures of adherence, in 211 children aged 6-15 years old who presented to an emergency department with an asthma attack. Our findings highlight the weakness of statistical relationships between measures of adherence, and the irregularity in patient medication-taking behavior. This demonstrates that a single aggregate adherence measure fails to detect asthma patients for whom their day-to-day medication taking (implementation) is inconsistent with their longitudinal medication taking (persistence).

Implementation and adoption of complex health information technology (HIT) is gaining momentum internationally. This is underpinned by the drive to improve the safety, quality, and efficiency of care. Although most of the benefits associated with HIT will only be realized through optimization of these systems, relatively few health care organizations currently have the expertise or experience needed to undertake this. It is extremely important to have systems working before embarking on HIT optimization, which, much like implementation, is an ongoing, difficult, and often expensive process. We discuss some key organization-level activities that are important in optimizing large-scale HIT systems. These include considerations relating to leadership, strategy, vision, and continuous cycles of improvement. Although these alone are not sufficient to fully optimize complex HIT, they provide a starting point for conceptualizing this important area.

OBJECTIVE: To understand the evolving market of commercial off-the-shelf Computerized Physician Order Entry (CPOE) and Computerized Decision Support (CDS) applications and its effects on their uptake and implementation in English hospitals. METHODS: Although CPOE and CDS vendors have been quick to enter the English market, uptake has been slow and uneven. To investigate this, the authors undertook qualitative ethnography of vendors and adopters of hospital CPOE/CDS systems in England. The authors collected data from semi-structured interviews with 11 individuals from 4 vendors, including the 2 most entrenched suppliers, and 6 adopter hospitals, and 21 h of ethnographic observation of 2 user groups, and 1 vendor event. The research and analysis was informed by insights from studies of the evolution of technology fields and the emergence of generic COTS enterprise solutions. RESULTS: Four key themes emerged: (1) adoption of systems that had been developed outside of England, (2) vendors' configuration and customization strategies, (3) localized adopter practices vs generic systems, and (4) unrealistic adopter demands. Evidence for our over-arching finding concerning the current immaturity of the market was derived from vendors' strategies, adopters' reactions to the technology, and policy makers' incomplete insights. CONCLUSIONS: The CPOE/CDS market in England is still in an emergent phase. The rapid entrance of diverse products, triggered by federal policy initiatives, has resulted in premature adoption of systems that do not yet adequately meet the needs of hospitals. Vendors and adopters lacked understanding of how to design and implement generic solutions to meet diverse user needs.

OBJECTIVE: To investigate experiences with leveraging health information technology (HIT) to improve patient care and population health, and reduce healthcare expenditures. MATERIALS AND METHODS: In-depth qualitative interviews with federal government employees, health policy, HIT and medico-legal experts, health providers, physicians, purchasers, payers, patient advocates, and vendors from across the United States. RESULTS: The authors undertook 47 interviews. There was a widely shared belief that Health Information Technology for Economic and Clinical Health (HITECH) had catalyzed the creation of a digital infrastructure, which was being used in innovative ways to improve quality of care and curtail costs. There were however major concerns about the poor usability of electronic health records (EHRs), their limited ability to support multi-disciplinary care, and major difficulties with health information exchange, which undermined efforts to deliver integrated patient-centered care. Proposed strategies for enhancing the benefits of HIT included federal stimulation of competition by mandating vendors to open-up their application program interfaces, incenting development of low-cost consumer informatics tools, and promoting Congressional review of the The Health Insurance Portability and Accountability Act (HIPPA) to optimize the balance between data privacy and reuse. Many underscored the need to "kick the legs from underneath the fee-for-service model" and replace it with a data-driven reimbursement system that rewards high quality care. CONCLUSIONS: The HITECH Act has stimulated unprecedented, multi-stakeholder interest in HIT. Early experiences indicate that the resulting digital infrastructure is being used to improve quality of care and curtail costs. Reform efforts are however severely limited by problems with usability, limited interoperability and the persistence of the fee-for-service paradigm-addressing these issues therefore needs to be the federal government's main policy target.

OBJECTIVE: We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). MATERIALS AND METHODS: Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. RESULTS: Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. CONCLUSIONS: The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.