Table 3 Summary of Themes and Subthemes Representing Factors Influencing Data Quality in iCare and CareLink+

1. Staff related challenges

1.1. Staff behaviour and practices

Staff non-compliance and attitudes toward documentation practices, and missing details in second hand documentation (e.g. documenting on behalf of other staff)

‘Some staff just don’t care [about documenting properly]’ (1).

‘I request others to document on my behalf. So, I write only brief observation on a paper’ (16).

Verbal communication of client information between staff

‘[A] client passing away is currently communicated verbally’ (66).

‘I wish everything was [documented] in iCare for us, as things get forgotten at handover’ (66).

Unintentional human error in documentation

‘We have a lot of documents to upload (GP or hospitals), the timeliness of info going into iCare….Transfer of information from admission documents – human error that can happen sometimes.’ (72).

‘If it is incorrect, it means that somebody has made the wrong entry’ (77).

‘Entering a note for the wrong client is an easy mistake to make on CareLink+’ (86).

1.2. Cultural diversity

Staff English language skills impact clear and accurate documentation

‘There are so many free text fields where quality of notes largely depends on the level of English of staff completing those fields’ (84).

1.3. Diversity in technical skills

Staff literacy skills and computer skills impact use of clinical systems for documentation purpose

‘It doesn’t appropriately engage the user at their level of literacy/English fluency/clinical knowledge’ (32).

‘A lot of us were not used to computers. We learned from bits and pieces and picking other people’s brain’ (64).

1.4. Diversity in clinical knowledge

Staff level of clinical knowledge impact on data input and interpretation

‘As I don’t have clinical background, [it is] sometimes not easy to understand clinical terms’ (57).

‘[A lot of] Information is entered in the system which are summary text with acronyms and short-form [and] are difficult to understand. Information should be entered in a language that can be understood by other users’ (81).

2. Education and training

2.1. Role specific training

Staff do not receive training to understand the specific requirements of their role

‘People understanding their roles and responsibilities [impact how up to date data and documentation are]’ (25).

‘Difficult to understand some forms and charts that are not required to be completed daily and that are not explained to us. For example, pain chart and forms’ (44).

2.2. Formal training in system use

Staff receive minimal/no training on system use and expectations

‘There is no specific training. So, usually, the person who is new…is shown how to use iCare through someone on site’ (26).

‘We were only educated on progress notes and charts. The rest, we were not shown. When I was on the floor, I didn’t know what they were for. It wasn’t until I was thrown into this role that I just clicked on everything’ (63).

3. External barriers

3.1. Governance of external providers

There is no onus on external providers to enter client data into systems, relying on verbal handover

‘What people enjoy or how they reacted to an event. NDIS providers have their own book for notes. All social activities are [provided by] external providers, so we don’t know what happens’ (41).

3.2. Errors in health/medical documentation

There are often errors in discharge information provided by hospitals and other external providers, which are transferred to clinical systems

‘[There are] incorrect information from hospital and [we] need to redo assessment’ (5).

3.3. Families as information source

Families are contacted for background client information, but don’t always understand what is being asked of them or are unable to provide accurate information

‘Sometimes family members don’t understand what we are trying to get out of them as admission information, which goes into better supporting clients, [so this information is missing]’ (54).

3.4. Sector-wide staff shortages

Sector-wide staff shortages create greater time constraints and more need for agency staff who aren’t familiar with systems or business procedures

‘Short [of] staff and therefore time is an issue’ (1).

‘There are chances some people won’t write it straight away, so it’s not always entered…. or they are in a hurry, shortage of staff, clients need attention’ (40).

4. Operational guidelines and procedures

4.1. Data and documentation requirements

Lack of clarity of data and documentation requirement, timeline for updating client information, and standard practices when documenting client progress

‘There are no guidelines as to what to collect or a checklist’ (34).

‘This is not just a systems problem; Brightwater needs to know requirements clearly to make system only provides what is needed instead of [collecting] all unnecessary details. Brightwater is the culprit’ (29).

‘[There is] Low clarity around expected format of notes - some clinicians document more in-depth than others’ (89).

4.2. Staff roles and responsibilities for data collection

Lack of clarity of staff roles for data collection (including rushed data collection on client admission)

‘Everyone’s responsible so no one’s responsible’ (60).

‘Expectations for demographic data and accountability for roles [are] not clearly outlined or monitored’ (32).

4.3. Staff roles and responsibilities for monitoring data collection

Lack of clarity of staff roles for monitoring data collection and checking data quality

‘No one is monitoring update of information [to ensure data is up to date and that the information collected is of high quality]’ (63)

‘Who would monitor it anyway, who would start it, and who does training on it’ (34).

5. Organizational practice and culture

5.1. ‘One size fit all’ approach

Business uses two clinical systems (Clinical Manager and CareLink+) to service multiple business areas with unique data and reporting requirements

‘[iCare] may be working well for RAC but not for TCP’ (1).

‘iCare is RAC focused, the care plans populate automatically in a way that is not appropriate for disability’ (71).

‘There is no social worker assessment for [our site] with the right details – we have to use a word document and upload it’ (35).

‘Actualise function is not suitable for Capacity Building’ (90).

5.2. Burden of documentation

Staff are busy and documentation is often not prioritised as a result

‘If you have to write too many things, people copy and paste and it’s not always right (40)”.

‘Incident form gets completed at the end of the shift as we are busy during shift hours. Often incident is forgotten at the end of the shift’ (50).

‘I often need to back date notes due to being too busy on the day’ (35).

‘[There are] hundreds of progress notes… [It’s] too much to look at start of the shift’ (59).

5.3. Communication of system or procedure change to workforce

Changes to systems and processes not communicated adequately

‘[Brightwater] don’t communicate changes when they make changes to processes’ (56).

‘Don’t put information in a big letter to inform changes. Short SMS will be more effective to inform changes, I can’t be bothered reading through the long emails from IT’ (56).

5.4. Duplication of effort

Multiple forms duplicate information, and staff are still using paper-based forms which need to be uploaded

‘Forms doesn’t speak to each other and thus, creating duplication’ (28).

‘Some staff still uses paper-based forms which takes time to be entered into iCare’ (82).

‘[staff] saving [documents] to F-Drive for easy retrieval’ (37).

6. Technological infrastructure challenges

6.1. System speed, connectivity, and reliability

Internet speed, Wi-Fi connectivity, and computer and clinical system performance impact on staff ability to complete data entry

‘The system is slow. It plays a big part in me putting information into the system, and there is a lag during busy times’ (41).

‘The system will time out. It will log out in the middle of a note if you move away’ (35).

‘Last time I used CareLink + was Monday afternoon and it crashed. It’s been crashing a lot lately’ (78).

6.2. Technological support

Unclear procedure to feedback on bugs found in the system

‘Don’t know who to contact to fix bugs [in iCare]’ (41).

6.3. Equipment and Resources

Not enough computers at sites to support uninterrupted documentation at the point-of-care

‘Staff queue at the end of shift to document notes’ (31).

‘IT has been the biggest issue, with the constant glitches, one day iPads aren’t working [but] desktops are working, but there are not enough computers’ (81).

7. Systems design limitations

7.1. Data extraction and reporting

Difficult to extract data for reporting

‘Functions to pull out data is difficult, and it is difficult to work with reports’ (49).

‘Reporting does not work. It does not pull correct data in the reporting, or it is not complete’ (52).

‘From a backend perspective, the modelling of the data and tables at the backend makes it difficult to pull data out for reporting purposes’ (79).

‘I think when these systems were created, they looked at it from function, rather than reporting and didn’t think about pulling data out for reporting’ (79).

7.2. Search and filter

Lack of search and filter function impact locating data and information

‘There is no search function to look for documents by keyword’ (30).

7.3. Single view of information

Lack of single view of crucial client information

‘[The System] should make everything available in one place rather than having to navigate through many places’ (49).

7.4. Change history

Lack of timestamps and detailed change history

‘There is no visible history of data being up to date’ (31)

‘I don’t think it’s possible to tell which field was updated by which person on this date’ (81).

‘Can’t tell [if information has been updated] as there is no timestamp. Also, it’s hard to tell who edited the information as it doesn’t show the name of the person who edit data’ (49).

8. Systems configuration

8.1. Dropdown Values

Generic dropdown values which do not capture sufficient clinical detail

‘Not everything fits into the dropdown’ (7).

‘[The client is] Blind in the right eye for example – iCare dropdown only has sight/vision [issue]. Dropdown [values] limits and prevents person-centred care’ (4).

‘Yes, staff often find it difficult to understand what to choose from dropdown list. E.g., Client incident form’ (31).

‘The dropdown is good for quickly getting things done but there is no point as all clients have generalised points but certainly not specific to person’ (6).

8.2. System configuration for free text fields

Overreliance on unstructured free-text fields

‘There are so many free text fields where quality of notes largely depends on the level of English of staff completing those fields’ (84).

‘Carer documentation is very freehand and so quality isn’t amazing’ (25).

‘Information is put into free text fields, hard to be able to pull information out’ (26).

‘It’s unclear on what to write in the free text fields’ (28).

8.3. System configuration for information mapping

Inadequate information mapping and errors in automation

“I tell staff to pretend it’s Fifty First Date and start from scratch each time” (29).

‘Assessments don’t create alerts automatically and that’s why the reviews [are] forgotten when [staff] are busy’ (2).

‘Second wound entry overwrites active wound reminder’ (60).

‘Cognition assessment that are mapped to care plan can’t be updated in care plan (for small changes). We need to go to the cognitive assessment to add small changes…. Interventions are not going to care plan.’ (9)

8.4. System configuration for unused capabilities

Underutilisation of system capabilities

‘There are more features that we don’t know of’ (47).

‘There are more data in iCare that we could use but we don’t have training to be able to use all of its features’ (51).

‘It’s a waste if we are not using it properly’ (33).

8.5. Integration of multiple systems and information transfer

Internal data systems do not facilitate the effective two-way flow of information

‘I understand there are still glitches between e10 and iCare. So, sometimes it doesn’t transfer across very well. Sometimes Admin will enter data that disappears in the next update.’ (71).

‘If we document client contact details in iCare’, it disappears, but if we update in e10, it will populate in iCare’ (80)

‘Two different systems created by two different vendors, one is predominantly a finance system and the other is a clinical system. Those two vendors don’t talk to each other’ (79).

Lack of integration with external systems (e.g. My Health Record, government health system) for sharing information with hospital

‘Link with government health system will help sharing information with doctors and hospitals’ (29).

‘Integration to hospital systems so that there is automatic generation of task that can be checked off’ (3)