Takian, A. Petrakaki, D., Cornford, T., Sheikh, A. & Barber, N. (2012) ‘Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems’, BMC Health Services Research, vol.12, no.105. (original) (raw)
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BMC Health Services Research, 2012
Background: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. Methods: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS). Results/discussion: We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations ! intervention ! changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. Summary: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.
Lessons learned from England's national electronic health record implementation
Proceedings of the 2nd ACM SIGHIT symposium on International health informatics - IHI '12, 2012
Background: National electronic health record (EHR) programs are increasingly being pursued across the world with the aim of improving the safety, quality and efficiency of healthcare. Despite significant international investments, and particularly in the light of reported "failures", there is surprisingly little evidence on the specific and potentially transferable factors associated with the planning and execution of large-scale EHR implementations. England embarked on a National Program in 2002, characterized by "top-down", central procurement of a few, standardized EHR systems. Objectives: To evaluate the national implementation and adoption of EHRs in English hospitals and derive lessons for this and other national EHR programs. Design: We conducted a qualitative case study-based longitudinal evaluation drawing on sociotechnical principles. Setting: Data were collected from 12 "early adopter" hospitals across England. Data sources: Our dataset consisted of 431 semi-structured interviews; 590 hours of observations; 334 sets of notes from observations, researcher field notes and notes from conferences; 809 hospital documents; and 58 national and regional documents. Results: A range of factors emerged as important. These included software characteristics and user involvement in shaping technology; realistic timelines, balancing the national EHR vision and stakeholder expectations; relationship building and communication; balancing national progress with allowing local accommodation; and maintaining central direction whilst permitting degrees of local autonomy. Conclusions: It is not possible to be prescriptive for achieving "successful" national EHR implementations. Nonetheless, we identify dimensions likely to be of greater significance than others, in a range of national contexts. We argue that design, based on users' requirements, and accommodation of the technology in the healthcare setting need to occur on a small-scale first before building out to satisfy organizational, local health economy and national needs, and that this needs time. Our results will we hope offer evidence to inform national strategies for large-scale and expensive EHR ventures.
Studies in health technology and informatics, 2012
The historical National Programme for Information Technology (NPfIT) in England was the most expensive (~$20billion) and ambitious politically-driven IT-based transformations of public services ever undertaken. Nationwide implementation of integrated electronic health record (EHR) systems in hospitals was at the heart of the NPfIT (~$10billion). We conducted the first longitudinal, prospective, and sociotechnical case study-based evaluations of the implementation and adoption of national EHRs implementations in 12 'early adopter' hospitals across England. This paper reports the arrival, implementation process, and stakeholders' experiences of one EHR software (Millennium) at a National Health Service's (NHS) general hospital participating in NPfIT, hereafter called Alpha. From the outset, Alpha envisioned the implementation of EHR as a practice of change management to improve its performance. This vision attributed to the establishment of a 'design authority' at Alpha, including users from various capacities and levels. The 'design authority' was perceived a key contributor to appropriate (compared to other hospitals we studied) clinical engagement and bottom-up approach to deploying EHR. Through conducting several hundreds of group and individual workflow familiarization, Alpha adopted a novel approach to training staff on EHR software. This led to greater local configuration and high sense of ownership among users, which transformed work practices towards overall better performance of the hospital. Contrary to painful and turbulent experiences of EHR implementation via NPfIT route in the English hospitals, this in-depth case study revealed the importance of vision (change management) and insightful leadership in 'working out' EHR. We advocate envisioning EHRs as change management endeavors to enhance their complex, multi-dimensional, and sociotechnical adoption in healthcare settings.
BMJ, 2011
Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. Design A mixed methods, longitudinal, multisite, sociotechnical case study. Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a sociotechnical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the topdown, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a "middle-out" approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities.
BMJ: British Medical …, 2010
Objectives: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. Design: A mixed methods, longitudinal, multisite, sociotechnical case study. Setting: Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a sociotechnical coding matrix, combined with additional themes that emerged from the data. Main result: Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the topdown, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. Conclusions: Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.
Background: In 2002, the National Health Service (NHS) in England embarked on a major technology-based transformation of healthcare. Central to this National Programme for Information Technology (NPfIT) was the creation of a comprehensive “cradle-to-grave” electronic health record (EHR) – the NHS Care Records Service (NHS CRS) – that could be shared across a range of NHS providers for all 50 million residents of England. Aims: To undertake an evaluation of the implementation and adoption of the NHS CRS in secondary care sites in England, across the three clusters: North-Midlands and East; South; and London. Methods: A mixed methods case study-based longitudinal evaluation undertaken in 12 ‘early adopter’ sites across the three geographical implementation clusters. Sites were opportunistically sampled according to their current or planned stage of implementation, and to provide a variety with respect to: location, size, type of care provided, Foundation and teaching status, and NHS CRS software system. Fieldwork was undertaken in six complimentary work-packages in which we sought to understand how the participating trusts made the NHS CRS work (or not) in their organisations; to identify local consequences of implementing the new systems, the costs incurred and to assess whether the new systems resulted in a reduction in missing information in outpatient clinics. Main findings: Implementation of the NHS CRS software systems has proceeded much more slowly and with, as yet, substantially less functionality than was originally planned. The delays have related, at least in part, to ambitious expectations about: the nature of EHR systems; the time needed to build, configure and customise the software; the work needed to ensure that these systems were supporting rather than hindering care provision; and the training and support needs of end-users. Other factors affecting the rate of implementation included: the constantly changing milieu of NHS policy and priorities; the different stages of development of the different NHS CRS systems; and a complex and multilayered communication process between organisational structures, along with contractual arrangements which largely excluded NHS providers and were perceived by users as a major source of frustration that slowed implementation. As a result of commercial and other sensitivities about cost and consequences of implementation a full economic analysis could not be undertaken; however we have identified the main cost categories that need to be considered in the context of implementing complex EHR systems. At one site, in which a NHS CRS system of limited functionality had been implemented, there was no improvement in the amount of missing patient information in outpatient clinics. More broadly, however, there was some evidence that these early experiences of deploying the NHS CRS have resulted in important organisational learning and development of relevant competencies within and amongst NHS Trusts and NHS Connecting for Health (NHS CFH). Conclusions: This evaluation has found that implementation of the selected NHS CRS software packages has proved time consuming and challenging, with limited discernible short-term benefits for clinicians or patients, although we began to see the application of new approaches to managing information at some sites as systems matured. These findings do not preclude the possibility of longer-term benefits, which have been achieved in some hospitals in other countries, but these do often take years to realise. Nonetheless, there remains considerable buy-in into the vision and potential offered by the NHS CRS. In a future in which hospitals may have to function as business entities in order to survive, there is very likely to be a need to capture and quantify many aspects of business processes using some form of the NHS CRS. The recent move away from a centralised top-down delivery model to one in which there is greater local autonomy and choice is an overall welcome development. However, this needs to be accompanied by NHS-wide standards and incentive setting mechanisms in order to ensure continuing progress both locally and nationally, towards integrated, joined-up care systems.
BMC Health Services Research, 2012
Background: 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. Methods: Longitudinal, real-time, case study-based evaluation of the implementation and adoption of an EHR software (RiO) into an English mental health hospital known here as Beta. We conducted 48 in-depth interviews with a wide range of internal and external stakeholders, undertook 26 hours of on-site observations, and obtained 65 sets of relevant documents from various types relating to Beta. Analysis was both inductive and deductive, the latter being informed by the 'sociotechnical changing' theoretical framework.
The policy‐practice nexus of electronic health records adoption in the UK NHS
Journal of Enterprise Information Management, 2011
PurposeThis paper seeks to report the findings from a seven‐year study on the UK National Health Service on the introduction of an electronic health record for 50 million citizens. It explores the relationship between policy and practice in the introduction of a large‐scale national ICT programme at an estimated value of £12.4bn.Design/methodology/approachUsing a longitudinal research method, data are collected on the policy‐practice nexus. The paper applies institutional theory using a conceptual model by Tolbert and Zucker on the component processes of institutionalisation.FindingsThe findings suggest that institutional forces act as a driver and an inhibitor to introducing enabling technologies in the health‐care environment. A process analysis shows that, as electronic health records force disruptive change on clinicians, healthcare managers and patients, culturally embedded norms, values and behavioural patterns serve to impede the implementation process.Research limitations/im...
The Early Adoption of Electronic Health Record in UK: Standardisation versus Localisation
Electronic Health Record System (EHRs) attracts the increasing concerns of many governments, being considered as the essential digital infrastructure to enhance the quality of healthcare via the availability of patients' data and hospital performance audit. NHS Care Record Services (NCRS), the EHRs in UK is distinguished from other countries when pursuing the top-down strategy and proceeding in substantial scale. However, the early diffusion of this innovation faced serious problems, mainly due to the unexpected local consequences of central strategy. The case study of EHRs in UK would provide meaningful insights for the implementation of EHRs. In the scope of this essay, the early stage of EHRs adoption in UK would be focused. Based on the framework about technological diffusion, the determinants of adopting would be analysed to shed the light on the conflict between standardisation and localisation. The recommendations would be proposed to expedite the implementation by balancing between central and local perspectives, reducing uncertainty and cost, and encouraging knowledge sharing among users.