The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders

Academic Health Science Centers and Health Disparities: A Qualitative Review of the Intervening Role of the Electronic Health Record and Social Determinants of Health

Literature on the magnitude of negative health outcomes from health disparities is voluminous. Defined as the health effects of racism, environmental injustice, forms of discrimination, biases in science, and sociological or socioeconomic predictors across populations, health disparities are part of an ongoing and complicated national problem that health equity programs are specifically designed to address. Academic Health Science Centers (AHC) institutions are a complex and unique educational-healthcare ecosystem that often serves as a safety net for patients in vulnerable and lower-income communities. These institutions are often viewed as one of the most uniquely positioned entities in the U.S. with an abundance of resources and networks to advance health equity as a high-impact goal and strategic imperative. Relatively little progress, however, has been made to better understand the potentially transformative nature of how digital health technologies (DHT)—such as mobile health apps, electronic health record (EHR) and electronic medical record (EMR) systems, smart ‘wearable’ devices, artificial intelligence, and machine learning—may be optimized to better capture and analyze social determinants of health (SDH) data elements in order to inform strategies to address health disparities. Even less has been explored about the challenging implementation of electronic SDH screening and data capture processes within AHCs and how they are used to better inform decisions for patient and community care. This research examines how AHC institutions, as complex education-healthcare bureaucracies, have prioritized this specific challenge amongst many other competing incentives and agendas in order to ultimately develop better evidence-based strategies to advance health equity. While there are clear moral, ethical, and clinical motives for improving health outcomes for vulnerable populations, when an AHC demonstrates that electronically screening and capturing SDH can improve the ability to understand the “upstream” factors impacting their patients\u27 health outcomes, this can inform and influence policy-level choices in government legislation directed at community-level factors. A qualitative thematic analysis of interview data from AHC administrators and leadership illustrates how AHCs have mobilized their EHR as a featured component of their healthcare delivery system to address health disparities, exposing other related, multifactorial dimensions of the Institution and region. Key findings indicated that: electronic SDH screening and updating workflow processes within an AHC’s clinical enterprise is a significant venture with multiple risks and the potential of failure. Universal adoption and awareness of SDH screening is hampered by notions of hesitancy, skepticism, and doubt as to an AHC’s ability to meaningfully extract and use the data for decision-support systems. Additional investment in resources and incentive structures for capturing SDH are needed for continued monitoring of patient health inequalities and community social factors. Data from this and future replicated studies can be used to inform AHC and government decisions around health and social protection, planning, and policy

On the Cusp of Change: Health Information Technology in the United States, 2009

Examines the state of electronic health records (EHR) adoption in U.S. hospitals generally and in safety-net hospitals, changes in state and federal policies, links between EHR adoption and quality metrics, and implications for healthcare disparities

Health Information Technology in the United States: On the Cusp of Change, 2009

In this report we use the data collected for ONCHIT to focus on EHR adoption in the inpatient setting. We report on several important policy issues. These include the rate of adoption of EHRs among U.S. hospitals generally and among safety-net hospitals, changes in both state and federal policy, and the potential of EHRs to change the quality measurement enterprise

E-health and e-welfare of Finland : Check Point 2022

The report provides an overview of progressive nationwide activities towards better e-services in Finland. The information system services of social welfare and health care are monitored by systematic gathering, analysis, and use of data, which allows the tracking of the progress of operations and the realisation of goals. In 2020 and 2021, six data collections were carried out to produce data for the monitoring of the Finnish ‘Information to support well-being and service renewal, eHealth and eSocial Strategy’. Some of the results presented in the report are also openly available in database cubes

Successful Strategies for Implementing EMR Systems in Hospitals

Some hospital leaders are ineffective in implementing the electronic medical record (EMR) systems in the hospitals. The purpose of this multiple case study was to explore strategies hospital leaders use to successfully implement EMR systems. The target population consisted of hospital leaders and healthcare professionals from two hospitals who have successfully implemented EMR systems. The conceptual framework of this research study was Kotter\u27s 8-stage process for leading change, building on the model of an effective change management method. Data were collected from 5 interviewed participants and company documents related to strategies regarding the EMR system implementation. The results of reviewing open-ended interview questions and archived documents were analyzed using codes and themes to facilitate triangulation. Three primary themes were developed from the coded data: (a) strategies hospital leaders use to implement the EMR system, (b) strategies hospital leaders use to achieve quality and best practice, and (c) strategies hospital leaders use to manage change and resistance to change. Results revealed 4 steps for successful implementation: (1) creating a vision, (2) communicating the vision, (3) establishing strong leadership, and (4) consolidating gains. Utilizing the successful strategies hospital leaders use to implement the EMR systems could produce quality patient care, efficiencies in hospital operations, and reduced organizational operation cost. The findings could effect positive social change through delivery of quality health and patient care that results in community cost benefits and healthier patient lifestyles

Implementation Plan for EMR and Beyond

Change is never easy for anyone, but how we implement change can make the difference in how an innovation is accepted. Over the last two years, a small community hospital in California has introduced a new electronic medical record (EMR) to meet the requirements of meaningful use mandated by the Centers for Medicare and Medicaid (CMS) for all hospitals across the United States. EMRs are expected to improve quality in many areas, especially to improve outcomes, while safely reducing costs (U.S. Department of Health & Human Services, 2012). Adoption of EMR’s is not optional, if facilities want to avoid penalties and continue operating. As a result, EMR’s have been implemented in numerous healthcare facilities over the last decade. However, implementation does not guarantee acceptance. Many organizations have tried to implement something new and failed. Healthcare facilities need to build implementation plans into their development of any new innovations. In particular, end users need to buy in and accept new system usability in order to improve compliance and employee satisfaction. Our EMR is being developed in stages, so our processes are constantly changing with requires fast transitions in the end user learning. We have moved through the first two stages and are moving into the third stage in the next few months. This project describes an implementation plan for an electronic medical record development that we have used during our first two stages. The project plan has a strategic focus on end user acceptance of meaningful use guidelines that is sustainable for continued growth. The elements of this plan can be applied to other types of innovative change in healthcare

eHealth Conversations : using information management, dialogue, and knowledge exchange to move toward universal

The publication of eHealth Conversations, developed with the support of the Spanish Agency for International Development Cooperation (AECID), represents a major step forward for the PAHO/WHO Strategy, since it explores ways of implementing regional mechanisms with free and equitable access to information and knowledge sharing. These initiatives aim to advance the goals of more informed, equitable, competitive, and democratic societies, where access to health information is considered a basic right. This publication is one of the instruments used by PAHO/WHO to develop the initiatives outlined in the Strategy, which coincides with the global eHealth strategy. One of the fundamental needs for the improvement of eHealth is the dissemination of information, and PAHO/WHO is assuming a leading role in this effort. The development of this new electronic publication is a key step in disseminating information that will be useful for decision makers on applying these technologies for the health of the Americas. This electronic book is one of the products of PAHO/WHO’s project: “eHealth Conversations: Using Information Management, Dialogue, and Knowledge Exchange to Move Toward Universal Access to Health.” Participants in these conversations included experts on electronic health and other specialties. Through virtual dialogues, the experts contributed with knowledge and reflections on the present and the future of eHealth in the Americas, analyzed the situation, and made recommendations for the implementation of electronic health initiatives. These recommendations are not only intended for PAHO/ WHO, but also for governments and the private sector. The aim of the project is to guarantee the convergence of local, national, and regional initiatives regarding the adoption and application of ICTs for public health, with special attention on critical issues in this field. It also intends to strengthen individual and collective capacities of health workers and institutions, connecting them in a network of on-line health networks, as well as to reinforce the PAHO/WHO eHealth program.Acknowledge the Spanish Agency for International Development Cooperation (AECID) for its financial support in preparing this publication and developing the project titled “eHealth Conversations: Using Information Management, Dialogue, and Knowledge Exchange to Move Toward Universal Access to Health;

An Integrative Review of the Literature on Technology Transformation in Healthcare

Healthcare transformation through technology is a core objective of health reform. It is important for decision makers to understand the likelihood that reform policies will in fact transform. This study evaluates evidence of technology transformation in healthcare through an integrative review of the healthcare and business literature, guided by the theory of punctuated equilibrium (TPE). TPE describes the process of transformation within organizations, markets, and groups. The theory explains transformation as a pattern of long periods of incremental change (equilibrium) punctuated by short periods of dramatic change (revolution). An underlying deep structure defines the environment of the organization, market, or group. Radical change in the deep structure of the environment is necessary for transformational change. This integrative review covered the period January 2004 through April 2012. The inclusion criteria required that the article or study address both the implementation of health information technology in the United States and describe one of the three components of TPE. Five hundred twenty articles focusing on transformational change were identified through structured database searches of MedLine/PubMed, Business Source Complete, Social Science Research Network, and others. The articles were reviewed, and coded using the three elements of TPE. A directed content analysis of the coded data produced 10 themes describing the three TPE elements: variations in the environment, market complexity, regulation, flawed risk and reward, theories of technology acceptance, barriers, ethical considerations, competition and sustainability, environmental elements of revolution, and internal elements of revolution. The results describe a healthcare market exhibiting strong equilibrium and substantial resistance to change from HIT. Minimal descriptions of the revolutionary element of TPE were evident. The deep structure of healthcare indicates that the historical provider and hospital-centered market prevails. Conditions that might encourage alteration of this deep structure were: empowering and engaging patients; updating care delivery models; and reducing market uncertainty. The revolutionary changes seen in other complex markets from banking to travel to manufacturing relied heavily on the power of the consumer to alter deep structure. Although the concept of patient centeredness was present in the literature there was little clarity regarding the patient as an agent of structural change. To our knowledge this is the first application of TPE to investigate technology transformation in healthcare. Others have demonstrated TPE as a viable model for explaining transformational change in other markets. The study is limited by the study timeframe and the absence of newer literature reflecting the impact of recent policy changes. Despite this limitation the findings suggest that TPE presents a potentially valuable framework to guide evaluation of the progress of policies that encourage transformation from technology. Some propose that altering the complex deep structure of healthcare may require a complete destruction of existing processes before new processes, innovations, and technologies can emerge. The Affordable Care Act (2010) and the meaningful use provisions of the HITECH Act (2009) are moving healthcare toward new patient centered models of care. Uncertainty around the future of reform policies from possible repeal or amendment likely contributes to resistance to transformational change. This may perpetuate the historical rational and incremental pattern of HIT advancement. Patients as consumers have the potential to influence change given the appropriate tools. The importance of consumers to the transformation process suggests that policies fostering technologies that integrate patients into new care delivery models are likely paramount to realizing technological transformation