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 (original) (raw)
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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.
BMC medical informatics and decision making, 2015
Our aim was to explore the approaches to and the challenges and benefits of implementing Electronic Patient Record systems (EPRs) into NHS acute, mental health and community care hospitals throughout England. A mixed methods approach was adopted that comprised an online survey (n = 59) and semi-structured telephone interviews (n = 8) with chief information officers (or heads of EPR projects) at NHS trusts throughout England. Survey analysis was descriptive, whilst the qualitative interviews were analysed thematically. A range of devices and approaches to implementing EPRs were described with 32 % of survey respondents utilising a best of breed approach. Interviewees' perceived and expected benefits of implementing an EPR included efficiency, availability and accessibility of clinical information, and patient safety. Key challenges to EPR implementation were securing clinician involvement, difficulties posed by government and national policy and limited availability of financial ...
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.
BMC health services …, 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).
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.
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.
American Journal of Applied Sciences, 2015
This study is concerned with the aspect of revealing the factors that affect the adoption of IT programs in the health sector in the NHS in UK. It focuses on the identification of the factors that influence significantly the adoption of LORENZO, the Electronic Health Record system that is being implemented in the Strategic Health Authorities (SHAs) in the North, Midlands and East of England (NME) region as part of the National Program for Information Technology (NPfIT) in the NHS. This study is based on the Technology Acceptance Model (TAM). A qualitative research methodology was used to approach this area unlike the quantitative approach usually associated with the TAM. The data was obtained by conducting face-to-face semi-structured interviews with people who represented the end users in the NHS and the designing company (the LSP). By contrast with most academic studies, the research, therefore, studied the NPfIT from the bottom up (i.e., the end user perspective). The main tool used to aid the analysis of the interview data is NVivo. This analysis was used to develop an extended TAM model and to suggest a theoretical model of the relationship between LORENZO development methodology and users' acceptance. The study suggests some factors, apart from usefulness, which LORENZO's designers, the NHS should take into account when it comes to enhance users' usage of IT adoption. These factors are clinical safety, security, integration and information sharing.
eHealth and Organizational Change in Hospital Setting a Case Study on Electronic Health Records
2018
This chapter introduces a socio-technical organizational perspective on a EHR implementation in hospital setting through a qualitative a case study from one of the major hospital facilities in Portugal: the Hospital Doutor Fernando Fonseca in Amadora, Portugal. Through the account of eight key representatives pertaining to the main professional categories of the hospital, the researchers pinpointed the core organizational adjustments, strategic choices and relative challenges that anticipated, accompanied and followed the EHR implementation as perceived by key professionals, further capturing expectations concerning adjustments estimated but not yet realized. The study’s main contributions are identified in deepening the link between qualitative organizational studies and EHRs, offering an empirical case study portraying a change management experience that could be replicated in similar framesets, and furnishing practical recommendations and insights on what adjustments are to be en...