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Background Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety. Objectives The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify 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; and (5) disseminate the findings to a range of audiences. Design Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews. Settings and participants Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated. Intervention An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region. Outcomes Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication. Results We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety. Limitations The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals. Conclusions There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks. Future work Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures. Study registration This study is registered as PROSPERO CRD42017073004. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

BackgroundThere have been concerns about the quality and safety of NHS hospital services since the turn of the millennium. This study investigated the progress that acute NHS hospital trusts have made in developing and using technology infrastructures to enable them to monitor quality and safety following the publication in 2013 of the second Francis report on the scandal at Mid Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Sir Robert Francis QC.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. HC 898. London: The Stationery Office; 2013).MethodsA telephone survey of 15 acute NHS trusts in the Yorkshire and the Humber region, and a review of board papers of all acute NHS trusts in England for January 2015, were undertaken. The telephone survey was used to identify trusts for a larger field study, which was undertaken in four acute NHS trusts between April 2015 and September 2016. The methods included the direct observation of the use of whiteboards and other technologies on two wards in each trust, an observation of board quality committees, semistructured interviews and an analysis of the quality and safety data in board papers. Published sources about national and local agencies were reviewed to identify the trust quality and safety data that these agencies accessed and used. An interview programme was also undertaken with those organisations. The Biography of Artefacts approach was used to analyse the data.FindingsThe data and technology infrastructures within trusts had developed over many years. The overall design had been substantially determined by national agencies, and was geared to data processing: capturing and validating data for submission to national agencies. Trust boards had taken advantage of these data and used them to provide assurance about quality and safety. Less positively, the infrastructures were fragmented, with different technologies used to handle different quality and safety data. Real-time management systems on wards, including electronic whiteboards and mobile devices, were used and valued by nurses and other staff. The systems support the proactive management of clinical risks. These developments have occurred within a broad context, with trusts focusing on improving the quality and safety of services and publishing far more data on their performance than they did just 3 years earlier. Trust-level data suggest that quality and safety improved at all four trusts between 2013 and 2016. Our findings indicate that the technology infrastructures contributed to these improvements. There remains considerable scope to rationalise those infrastructures.LimitationsThe four trusts in the main study were, in part, purposively selected, and deliberately biased towards sites that had made progress with designing and deploying real-time ward management systems. This limits the generalisability of the study. The study focused more on the work of nurses and nurse managers, and has relatively little to say about the experiences of doctors or allied health professionals.Future workFuture research might focus on the effects of mobile technologies and electronic whiteboards on acute wards, the value of current national data returns, and the uses and value of trust data warehouses.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Healthcare systems worldwide are investing in networked health IT systems that link healthcare providers across multiple organisations. Much of the policy arguments in favour of such investment rely on the assumption that networked health IT will lead to improved patient safety. As part of the first stage of a realist review to determine how and in what contexts networked, inter-organisational health IT does lead to improved patient safety, we elicited stakeholders' theories from the literature that reveal possible answers to this question. A key mechanism appears to be that the information provided supports improved decision making. Greatest benefits are likely to be found in relation to medication information, in scenarios where the patient is less able to provide accurate information about their medications themselves. However, access and use of this information depends on ease of access, clinicians' perception of the likelihood that the desired information will be available, and clinicians' trust in the information.

Policy makers and health system managers in many countries are advocating the deployment of inter-operable health information technology systems, spanning organisations in a health economy, believing that they will be clinically effective. The case for investments has not, however, been made to date. This paper presents early results from a systematic review of the effects of inter-operable systems on patient safety. The review uses the realist synthesis method, which focuses on evidence about the decisions and actions that link interventions and outcomes, as well as the evidence about those outcomes. The evidence base is sufficient to identify plausible arguments for investments in inter-operable systems. This said, there is limited empirical evidence about each of the steps in the sequences of events. We comment on implications for the design of sustainable socio-technical solutions. We suggest that current gaps in the evidence base are in areas where informatics field methods can make a valuable contribution to our understanding of the role of inter-operable systems in patient safety.