Methodological reflections on the evaluation of the implementation and adoption of national electronic health record systems

Copyright @ 2012, International Journal of Integrated Care (IJIC). This work is licensed under a (http://creativecommons.org/licenses/by/3.0) Creative Commons Attribution 3.0 Unported License.Introduction/purpose of presentation: Far-reaching policy commitments to information technology-centered transformations of healthcare systems have now been made in many countries. There is as yet little empirical evidence to justify such decisions, hence the need for rigorous independent evaluation of current implementation efforts. Such evaluations however pose a number of important challenges. This presentation has been designed as a part of a Panel based on our experience of evaluating the National Health Service’s (NHS) implementation of electronic health records (EHR) systems in hospitals throughout England. We discuss the methodological challenges encountered in planning and undertaking an evaluation of a program of this scale and reflect on why and how we adapted our evaluation approach—both conceptually and methodologically—in response to these challenges. Study design/population studied: Critical reflections on a multi-disciplinary and multi-facet independent evaluation of a national program to implement electronic health record systems into 12 ‘early wave’ NHS hospitals in England. Findings: Our initial plan was to employ a mixed methods longitudinal ‘before-during-after’ study design. We however found this unsustainable in the light of fluxes in policy, contractual issues and over-optimistic schedules for EHR deployments. More importantly, this research design failed adequately to address the core of multi-faceted evolving EHRs as understood by key stakeholders and as worked out in their distinct work settings. Thus conventional outcomes-centric evaluations may not easily scale-up when evaluating transformational programs and may indeed prove misleading. New assumptions concerning the implementation process of EHR need to be developed that recognize the constantly changing milieu of policy, product, projects and professions that are inherent to such national implementations. The approaches we subsequently developed substitute the positivist view that EHR initiatives are self-evident and self-contained interventions, which are amenable to traditional quantitative evaluations, to one that focuses on how they are understood by various stakeholders and made to work in specific contexts. These assumptions recast the role of evaluation towards an approach that explores and interprets processes of socio-technical change that surround EHR implementation and adoption as seen by multiple stakeholders. Conclusions and policy implications: There is likely to be an increase in politically-driven national programs of reform of healthcare based on information and communication technologies. Programs on such a scale are inherently complex with extended temporalities and extensive and dynamic sets of stakeholders. They are, in short, different and pose new evaluation challenges that previously formulated evaluation methods for health information systems cannot easily address. This calls for methodological innovation amongst research teams and their supporting bodies. We argue that evaluation of such system-wide transformation programs are likely to demand both breadth and depth of experience within a multidisciplinary research team, constant questioning of what is and what can be evaluated and how, and a particular way of working that emphasizes continuous dialogue and reflexivity. Making this transition is essential to enable evaluations that can usefully inform policy-making. Health policy experts urgently need to reassess the evaluation strategies they employ as they come to address national policies for system-wide transformation based on new electronic health infrastructures

Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review

OBJECTIVE: To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.METHODS: MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.FINDINGS: Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.CONCLUSION: The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.<br/

Post-Implementation Evidence-Based Decision Making: The Telehealth Assessment Tool For Health (TeATH)

Few telehealth implementations survive the initial pilot phase, and any anticipated Return on Investment seldom materialises. Within South Africa a reason is the lack of post-implementation monitoring and assessment. To address this practice gap we developed a simple and practical tool to allow decision- and policy-makers to assess the post-implementation state of current telehealth applications. Recognised management approaches were reviewed, and elements adopted or adapted to develop the new decision support tool. A systems-based approach, applying a revised People, Process, and Technology methodology (incorporating Infrastructure), and Balanced Score Card and e-Readiness principles, was applied. This allowed development of the Telehealth Assessment Tool for Health (TeATH), whose utility was demonstrated by assessing the current performance of existing teleradiology implementations in three Provincial hospitals in Mpumalanga Province. Expected results were achieved, with TeATH revealing fair performance in the Technology dimension, but poor performance across People, Process, and Infrastructure for all three hospitals. TeATH is a simple and generic tool that provides decision support and guidance to health planners, differentiating weak or lagging implementations for which remedial action can be introduced. The tool has been adopted by the Provincial Department of Health, and has already influenced recent policy decisions. Broad application of TeATH would reduce wasteful expenditure, and facilitate implementation and uptake of telehealth in South Africa and elsewhere

Case of the Veterans Health Administration Telehealth Expansion

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, 2013.This thesis was scanned as part of an electronic thesis pilot project.Cataloged from PDF version of thesisIncludes bibliographical references (p. 164-169).This research applies an implementation framework derived from enterprise systems thinking to the Veterans Health Administration (VHA) Telehealth Expansion in order to characterize and evaluate the implementation methods used to expand Telehealth nation-wide. An in-depth, multi-disciplinary literature review was conducted to identify how enterprise-wide implementations are characterized in the literature and then was used to inform the development of a baseline enterprise implementation framework, the Timeline Implementation Framework. Said framework aims to characterize enterprise-wide implementations over time, from conceptualization to evaluation and sustainment, by breaking down an implementation into four phases (Enterprise Analysis, Implementation Planning, Implementation Execution and Innovation Evaluation) based on the nature of the activities and concepts that occur during each phase. The Timeline Implementation Framework was then applied to the VHA Telehealth Expansion. The framework guided study methods and facilitated analysis of a Clinical Video Telehealth clinic implementation. Further analysis was conducted in order to understand the VHA Telehealth expansion by considering an enterprise perspective of Telehealth's impact on VHA, and vice versa. Data collection included qualitative and quantitative evidence sources (e.g., interviews, observation, internal documents, and archival records) in order to gather information required to populate the developed framework. Fifteen interviews were conducted with VHA employees to allow for various perspectives emerging from multiple stakeholders with different roles across the enterprise. Conclusions aim to improve VHA implementation strategies in three key ways. First, by applying the framework to a Telehealth clinic, study findings help depict Telehealth expansion at a facility level. Second, results are used to provide constructive recommendations regarding implementation strategies throughout VHA. Third, this study tests the generalizability of the framework before applying it in further implementations.by Julie C. Andren.S.M

Webinars as a Knowledge Sharing Platform for eHealth in South and Southeast Asia

Setting up fully functional national eHealth systems is a challenge. Developing eHealth capacities in Asia can be achieved through distance learning such as webinars. The Asia eHealth Information Network (AeHIN) is a community of about 900 professionals in South and Southeast Asia, convened as a peer group dedicated to strengthening local health systems through the use of information and communications technology. It organised the AeHIN Hour held twice monthly as a venue for knowledge sharing. This paper will describe and analyse the context, inputs, processes and products of the AeHIN Hour webinars implemented over 47 months. Data is analysed through review of literature and AeHIN Hour technical reports. Analysis revealed that the AeHIN Hour provides individuals with a platform to learn and establish connections with other experts and like-minded individuals who could assist them in their current health system strengthening efforts. AeHIN paves the way for countries to recognise challenges and issues they face which are important for substantiating existing technical assistance. Shared interests among stakeholders sustain the activity. Management of the AeHIN Hour should be strengthened in order to maximise its value in building capacities among country-level actors who would shape the course of health systems strengthening

Success and failure in eHealth

Introduction In the field of eHealth, there seems to be a gap between promising research and clinical reality. This master thesis aims to give insight in patterns that can be found regarding the possible outcome in terms of success and/or failure. An in-depth review of workflow will be done, to get an understanding of the implications of eHealth on workflow. Methods Using a systematic article search, papers have been collected regarding the subject of this thesis. Through multiple search strategies, one final search string has been formulated. This final search string led to 903 papers. These papers have been assessed on relevance using qualitative methods. This resulted in 258 papers, which have been categorised by topic, entity and success or failure. After categorisation, the topic of workflow has been selected for an additional in-depth full-text review. Results The categorisation led to 27 categories. The categories are separated among the following entities: patient, health professional, health system and all. The first three have been separated in terms of success and failure as well. This led to a quantitative overview of different categories, for different actors in terms of success and failure. Workflow appeared to be essential for the possible success or failure of eHealth implementations. It is important to include workflow in the design of the tool as well. Conclusion Different categories show a unique combination in success and failure, and to what entity they belong. The category costs appeared to be mostly based on the health system and is attributed to failure. Therefore it is a pre-requisite for the implementation of eHealth. Other categories like quality healthcare and user expectations seem to target on success. The category legal was smaller than anticipated, which could have been caused by categories that are closely linked to each other

N.C. Medicaid Reform: A Bipartisan Path Forward

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race. The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers. This report is submitted to North Carolina’s policymakers and citizens. It assesses the current Medicaid landscape in North Carolina, and it offers recommendations to North Carolina policymakers concerning: (1) the construction of Medicaid Managed Care markets, (2) the potential and dangers of instituting consumer-driven financial incentives in Medicaid benefits, (3) special hotspotting strategies to address the needs and escalating costs of Medicaid\u27s high-utilizers and dual-eligibles, (4) the emerging benefits of pursuing telemedicine and associated reforms to reimbursement, regulation, and Graduate Medical Education programs that could fuel telemedicine solutions to improve access and delivery. The NC Medicaid Reform Advisory Team includes: Deanna Befus, Duke School of Nursing, PhD ‘17Madhulika Vulimiri, Duke Sanford School of Public Policy, MPP ‘18Patrick O’Shea, UNC School of Medicine/Fuqua School of Business, MD/MBA \u2717Shanna Rifkin, Duke Law School, JD ‘17Trey Sinyard, Duke School of Medicine/Fuqua School of Business, MD/MBA \u2717Brandon Yan, Duke Public Policy, BA \u2718Brooke Bekoff, UNC Political Science, BA \u2719Graeme Peterson, Duke Public Policy, BA ‘17Haley Hedrick, Duke Psychology, BS ‘19Jackie Lin, Duke Biology, BS \u2718Kushal Kadakia, Duke Biology and Public Policy, BS ‘19Leah Yao, Duke Psychology, BS ‘19Shivani Shah, Duke Biology and Public Policy, BS ‘18Sonia Hernandez, Duke Economics, BS \u2719Riley Herrmann, Duke Public Policy, BA \u271

THE AMERICAN CORRECTIONAL HEALTHCARE SYSTEM IS AILING: TECHNOLOGY INNOVATION AS A PRESCRIPTION FOR PENAL SYSTEM HEALTHCARE DELIVERY

The U.S. corrections industry has a history of poor inmate healthcare delivery, with penal-system reform advocates and other stakeholders highlighting these failures. Inmates receiving poor medical and psychiatric care behind jail walls experience greater difficulty becoming self-sufficient, and this situation contributes to the nation’s recidivism problem. Caring for inmates is often a neglected proposition and because of this, the U.S. courts impose legal requirements that inmates receive healthcare. Access to quality healthcare specialists for inmates led the penal system to investigate and implement use of telehealth during the 1990s. This thesis investigates how the evolving field of telehealth and emerging technologies may contribute to improved inmate healthcare in the future. A myriad of factors discussed in the thesis pose as challenges to implementing innovations that could improve penal system healthcare. For all the challenges confronting corrections administrators and criminal reform advocates, the corrections system is at a crossroads, as there is potential to modernize jail facilities and use technology to improve the safety and healthcare of inmates, corrections officers and those who render care. Investing in technology infrastructure that supports emerging technologies could also facilitate simpler integration of future innovations that address suicide, mental illness and other medical health maladies that would otherwise go unaddressed.Civilian, Dallas Fire-Rescue DepartmentApproved for public release. Distribution is unlimited