Title: Do Networked Information Technologies Improve Patient Safety? A Realist Synthesis
Funder: Department of Health and Social Care

Abstract: The aim of this study is to establish how and why networked, inter-organisational Health Information Technology (HIT) services improve patient safety, do not do so, or increase safety risks. The objectives of the study are to: 1. Identify initial programme theories, and prioritise theories to review; 2. Search systematically for evidence to test the theories; 3. Undertake quality appraisal, and use included texts to support, refine or reject programme theories; 4. Synthesise the findings; 5. Disseminate the findings to a range of audiences. We will undertake a realist synthesis, in 5 Stages, corresponding to the objectives. Stage 1 focuses on the identification of programme theories. Searches will be designed and conducted to identify relevant government policies and official reports, and articles by opinion leaders. Documents will be reviewed, to identify relevant statements about HITs and patient safety. Leading theories (in key texts) of patient safety will be identified, and statements relevant to the review identified. The findings will be summarised, for presentation to 4 nominal groups - policy makers, NHS implementation leads, frontline clinicians, and our patient and public involvement group. The groups will meet separately, in the order listed. The meetings will be structured, so as to identify leading programme theories for detailed evaluation. Following the first meeting, each subsequent meeting will also be presented with the outputs of the preceding group(s). Stages 2 and 3 involve a series of literature searches, designed to identify and assess evidence for each link (or a series of links) in a chain of reasoning in the programme theories. We will design searches for Ovid databases, including Medline, Embase and HMIC, and also ASSIA, Sociological Abstracts and IEEE Explore. Evidence will be assessed for rigour and relevance, and then used to evaluate the selected programme theories. The theories will be supported, refined or rejected. We will also identify evidence that sheds light on the reasons why the intended effects of programme theories are - or are not - realised in practice. The nominal groups will be re-convened (by email or web-based service) towards the end of Stage 3, to comment on the emerging findings. The groups may lead us to conduct further literature searches. Stage 4 is the synthesis phase of the review, where the findings are interpreted. The nominal groups will be convened again, by email or web-based service, at the end of this Stage, and will comment on our interpretations and provide their own. In Stage 5 we will prepare a number of outputs for dissemination. The review will add value in two ways. First, the underlying mechanisms that link HITs and patient safety are poorly understood. Identifying the chains of reasoning will help us – and practitioners and policy makers - to understand the underlying logic linking the implementation of networked, inter-organisational HITs and their subsequent effects. We will also identify cultural, economic and other reasons why intended effects – represented by the chains of reasoning - are not achieved in practice. Second, we will produce evidence-based guidance for NHS organisations. We will ensure that the guidance is useful to practitioners. Policy makers and practitioners will be involved in the review and will also be involved in the development of the guidance.

Lay abstract: The NHS has committed considerable resources to improving patient safety in the last decade. There have been improvements in some important areas, such as reductions in the incidence of infections that are acquired in hospital. Overall, though, the number of errors made in the course of patients' treatment remains high, and it is widely accepted that NHS patient care can and should be safer. Many people have argued that information technology (IT) systems improve patient safety. There have been more than 30 reviews of experimental evidence of the effects of other IT services on aspects of patient safety. Most of them focus either on hospital IT systems or on telehealth systems, which are designed to support patients in their own homes. There have not, in contrast, been any systematic reviews of the effects of networked IT systems that link GPs, community-based NHS services, hospitals and social services. These systems allow professionals to see one another's patient records, and to communicate more easily with one another. We will undertake a systematic literature review of these IT networks. NHS organisations have been devoting considerable money and effort to implementing these systems in the last five years. The review is needed now because the Secretary of State for Health has announced £4.2bn. additional funding for IT investments in the NHS in England over the next 4 years. A significant proportion of the total will be used to develop and implement this type of IT service. Yet we do not know whether these investments are justified, on the basis of the available evidence. If they are, NHS organisations need to know what types of systems to design (or buy) and implement, so that they can ensure that money is well spent. We will use a literature review using a method called realist synthesis. The first step involves identifying ‘programme theories’. We will obtain the views of knowledgeable people, such as people who have implemented similar IT systems, about the ways in which they think that they improve the safety of patient care. It is important to note that there is suggestive evidence that they can sometimes increase safety risks, and we will also capture views about how these arise. The next step in the review is to search for evidence about these theories. We expect to find that there is good evidence for some theories, and also evidence suggests that some theories are wrong. We will be able to say which functions are most likely to lead to improvements - for example, it is possible that better sharing of information about patients' medications leads to safer care - and which patient groups are most likely to benefit. Sometimes negative evidence is important: we may find that widely held assumptions about the best type of IT networks are not supported by good evidence, and poor value investments can be avoided. We will also identify reasons why the benefits that IT advocates hope for are not realised in practice. The review will identify cultural, economic and other reasons why intended effects are not achieved in practice. This will allow us to consider ways in which these issues might be tackled in practice, and better results achieved. Working with policy makers and practitioners, we will make evidence-based recommendations for NHS organisations purchasing and implementing these IT networks.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE