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

Abstract

BackgroundEvidence 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.MethodsWe 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.ResultsThe 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.ConclusionsThis 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.

Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care

“…We define a workaround as a behavior adopted by a user to overcome a perceived limitation in a technical system. 22 Although not all workarounds are inherently bad, [23][24][25][26][27][28][29][30][31] they point to mismatches between capabilities of existing HIT systems and the clinical tasks practices need to perform.…”

Rethinking resistance to ‘big IT’: a sociological study of why and when healthcare staff do not use nationally mandated information and communication technologies

“…[8][9][10][11] Similar findings were documented by the evaluators of the implementation of hospital records within the NPfIT. 3,[12][13][14] At the time of writing, most of the technologies in the NPfIT (including hospital-based records and HealthSpace) had been withdrawn because of delays in supply and/or non-uptake by clinicians, and a new policy emphasising local development and/or procurement introduced. 15 The SCR was still Department of Health policy but its use in clinical practice remained limited.…”

Ordo ab Chao: Framework for an Integrated Disease Report

“…An IDR could potentially reduce errors 7,75,76 and improve patient safety by decreasing the risk that important data may inadvertently fail to come to the attention of caregivers. 77 …”