Integration of a nationally procured electronic health record system into user work practices

BACKGROUND: Evidence suggests that many small- and medium-scale Electronic Health Record (EHR) implementations encounter problems, these often stemming from users' difficulties in accommodating the new technology into their work practices. There is the possibility that these challenges may be exacerbated in the context of the larger-scale, more standardised, implementation strategies now being pursued as part of major national modernisation initiatives. We sought to understand how England's centrally procured and delivered EHR software was integrated within the work practices of users in selected secondary and specialist care settings. METHODS: We conducted a qualitative longitudinal case study-based investigation drawing on sociotechnical theory in three purposefully selected sites implementing early functionality of a nationally procured EHR system. The complete dataset comprised semi-structured interview data from a total of 66 different participants, 38.5 hours of non-participant observation of use of the software in context, accompanying researcher field notes, and hospital documents (including project initiation and lessons learnt reports). Transcribed data were analysed thematically using a combination of deductive and inductive approaches, and drawing on NVivo8 software to facilitate coding. RESULTS: The nationally led "top-down" implementation and the associated focus on interoperability limited the opportunity to customise software to local needs. Lack of system usability led users to employ a range of workarounds unanticipated by management to compensate for the perceived shortcomings of the system. These had a number of knock-on effects relating to the nature of collaborative work, patterns of communication, the timeliness and availability of records (including paper) and the ability for hospital management to monitor organisational performance. CONCLUSIONS: This work has highlighted the importance of addressing potentially adverse unintended consequences of workarounds associated with the introduction of EHRs. This can be achieved with customisation, which is inevitably somewhat restricted in the context of attempts to implement national solutions. The tensions and potential trade-offs between achieving large-scale interoperability and local requirements is likely to be the subject of continuous debate in England and beyond with no easy answers in sight

We are bitter, but we are better off: Case study of the implementation of an electronic health record system into a mental health hospital in England

In contrast to the acute hospital sector, there have been relatively few implementations of integrated electronic health record (EHR) systems into specialist mental health settings. The National Programme for Information Technology (NPfIT) in England was the most expensive IT-based transformation of public services ever undertaken, which aimed amongst other things, to implement integrated EHR systems into mental health hospitals. This paper describes the arrival, the process of implementation, stakeholders' experiences and the local consequences of the implementation of an EHR system into a mental health hospital

Machines and machinations: The integrated care record service in the UK national health service

This paper examines the use of Actor Network Theory (ANT) as a lens to get a better understanding of the implementation of the Integrated Care Record Service (ICRS) in the UK National Health Service (NHS). Actor Network Theory has been deployed in various environments to achieve a better understanding of the roles of not only the humans but also the artifacts that constitute, in this case, healthcare networks of services and organisations. The theory is used as a means of supporting real world interventions, providing a richer understanding of complexities involved and thereby helps management to make better decisions. This study also explores Latour’s concept of machines as machinations, whose role is to translate other actors into the network. We propose ICRS as a fruitful empirical context for the use of ANT to support decision making for actors in health care provision. Actor Network Theory (ANT) is well-suited for use in the socio-technical evaluation of IS into the ICRS project because this approach treats human and non-human actors symmetrically. This approach facilitates a more thorough examination of the ways in which information technology is enabled or restricted in social processes

Knowledge management and organizational culture

This paper explores the relationship between organisational knowledge, organisational culture, and Process Based Systems (PBS), in the U.K. National Health Service (NHS). Links between PBS and organisational culture have been observed before(Perry, 2003); the contribution made by PBS to organisational knowledge has also been suggested (Perry, 2004). However, links between organisational knowledge and organisational culture in the NHS have not been widely studied. A qualitative study of these links across clinical functions has been used in conjunction with a literature review to consider in particular the use of tacit knowledge and the role that might be played by PBS in mediating and sharing this "embedded" or experiential form of knowledge. While there may be some opportunity for "externalisation" (Nonaka, 1994) - the conversion of tacit to explicit knowledge, this paper argues that PBS may also contribute to "socialisation" - the direct generation of tacit knowledge by tacit knowledge.Process Based Systems, knowledge management, organisational culture

Implementation and adoption of the first national electronic health record: a qualitative exploration of the perspectives of key stakeholders in selected English care settings drawing on sociotechnical principles

Introduction: Internationally, there is increasing interest in the potential of information technology to enhance the quality and efficiency of healthcare. Many countries are currently actively pursuing electronic health record implementations. However, the introduction of such systems often has significant consequences for users’ work practices and organisational functioning due to the complex processes involved in implementing and adopting new technology. Problems may be exacerbated in a national implementation context if users feel that systems are imposed and offer insufficient customisability due to a focus on achieving widespread interoperability. England has embarked on a large-scale national implementation of electronic health records. One of the procured systems was Lorenzo, which was to be built while it was being implemented. Investigating the implementation and adoption of Lorenzo is of particular interest as, in theory, the approach of “co-creating” a system in collaboration with the National Health Service (NHS) should help to increase software usability and thereby facilitate integration with work practices. I sought to understand the views and experiences of users as well as organisational consequences of introducing Lorenzo, and how these evolved over time in the complex environment of a national electronic health record implementation. Methodology and methods: I conducted a qualitative longitudinal investigation in purposefully selected secondary and community care settings which were implementing early Lorenzo functionality. I conceptualised the settings as case studies. Data collection was theory-driven in that it utilised a methodological framework, which was developed specifically for the purposes of my study and based on the existing theoretical and empirical literature. Using this framework with multi-sited ethnography helped me to examine the immediate environment in which Lorenzo was implemented without neglecting the organisational and political context in which local developments were situated. Data collection consisted of interviews with Lorenzo users and managers in case study sites; interviews with external stakeholders (including policy makers, system developers, and independent sector representatives) from outside NHS Trusts; non-participant observation of staff meetings and use of the technology; as well as a combination of field notes, documents pertaining to Trusts and wider political developments, and press statements. Data collection and thematic analysis were informed by a sociotechnical Actor-Network Theory-based approach highlighting the interrelated nature of technical and social dimensions. The study also drew on other related theoretical frameworks that helped to address some of Actor-Network Theory’s theoretical and practical shortcomings. Most helpful in this respect were Strong Structuration Theory, the Social Shaping of Technology, and the Theory of the Diffusion of Innovations (theoretically); and multi-sited ethnography and case studies (practically). I employed inductive and deductive analytical techniques utilising thematic tables for organising and interpreting the data. Individual case studies were analysed first in order to examine local dynamics, before cross-case comparisons were made and findings were integrated with data obtained from outside case study sites. Results: I collected data between 2009 and 2011 in three case study sites. The complete dataset comprised interview data from a total of 66 different participants within Trusts, 14 interviews with stakeholders from outside case study sites, 38.5 hours of non-participant observation, 149 pages of press statements, 31 pages of field notes, and a range of national and local Trust documents. The three sites differed in demographics and local implementation strategies, and hence presented diverse stories of sociotechnical change unfolding over time within their complex individual contexts. However, there were also similarities, not least the fact that all were implementing the same system and that they were operating within constantly evolving political and economic contexts. Users found it difficult to integrate Lorenzo with their everyday work practices as the software was perceived to be not fit-for-purpose. Over time, these difficulties attenuated to some extent, particularly in the smaller-scale deployments in sites that had invested significant time and resources to adapt the software to fit with their everyday practices. Lorenzo implementation also had significant consequences for organisational functioning, which was often hampered by local restrictions in software customisability associated with national arrangements. Conclusion: I have developed a theoretically informed methodological framework and applied this to explore sociotechnical processes involved in the implementation and adoption of Lorenzo. In doing so, I identified potentially transferable theoretical insights into local and national developments over time and based on these proposed mechanisms involved in the implementation and adoption process. Overall, my findings help to explain why the adoption of Lorenzo was much slower and on a smaller scale than originally anticipated. The interplay between social (political, individual and organisational) and technical factors was central to implementation progress. At the root of many problems encountered were difficulties with integrating systems with work practices of users and more general organisational functioning. In relation to Lorenzo, co-creating national software with strong user involvement was hampered due to different requirements in individual settings and wider, political and economic constraints. Based on the English experience, there may be some important transferable lessons for similar ventures in other countries. Most importantly, national implementations need to build on a solid basis of local technology adoption by allocating sufficient time for individual users and organisations to adjust to the complex changes that often accompany such service redesign initiatives

Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems:England, the USA and Australia

As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera's typology of national programmes - ‘top-down’, ‘bottom-up’ and ‘middle-out’ - to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy

The effect of Electronic Health Records on the medical professional identity of physicians:a systematic literature review

Electronic Health Records (EHR) have become standard practice and have altered the way physicians work and communicate with their patients. This changing work environment may subsequently influence the perceived professional identity of physicians. In this study, we aim to understand the impact of EHR use on the medical professional identity of physicians. We conducted a systematic literature review which resulted in the analysis of 34 papers that met inclusion quality criteria. The literature suggests that EHRs make the interaction between patients and physicians more formal and standardized. In addition, physicians experience a decrease in their autonomy which negatively influences their experienced professional identity. Based on these findings, we recommend examining how EHRs can allow physicians to focus more on medical work and communication with their patients and be less distracted by EHR requirements so that their medical professional identity can be restored or enhanced

Understanding the implementation and adoption of an information technology intervention to support medicine optimisation in primary care: qualitative study using strong structuration theory

Objectives: Using strong structuration theory, we aimed to understand the adoption and implementation of an electronic clinical audit and feedback tool to support medicine optimisation for patients in primary care. Design: This is a qualitative study informed by strong structuration theory. The analysis was thematic, using a template approach. An a priori set of thematic codes, based on strong structuration theory, was developed from the literature and applied to the transcripts. The coding template was then modified through successive readings of the data. Setting: Clinical commissioning group in the south of England. Participants: Four focus groups and five semi-structured interviews were conducted with 18 participants purposively sampled from a range of stakeholder groups (general practitioners, pharmacists, patients and commissioners). Results: Using the system could lead to improved medication safety, but use was determined by broad institutional contexts; by the perceptions, dispositions and skills of users; and by the structures embedded within the technology. These included perceptions of the system as new and requiring technical competence and skill; the adoption of the system for information gathering; and interactions and relationships that involved individual, shared or collective use. The dynamics between these external, internal and technological structures affected the adoption and implementation of the system. Conclusions: Successful implementation of information technology interventions for medicine optimisation will depend on a combination of the infrastructure within primary care, social structures embedded in the technology and the conventions, norms and dispositions of those utilising it. Future interventions, using electronic audit and feedback tools to improve medication safety, should consider the complexity of the social and organisational contexts and how internal and external structures can affect the use of the technology in order to support effective implementation