149 research outputs found
"There are too many, but never enough": qualitative case study investigating routine coding of clinical information in depression.
We sought to understand how clinical information relating to the management of depression is routinely coded in different clinical settings and the perspectives of and implications for different stakeholders with a view to understanding how these may be aligned
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
usersâ 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 âco-creatingâ 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 Theoryâs 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
- âŠ