Dimitra Petrakaki

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals

Objectives To evaluate the implementation and adoption of the NHS detailed care records service in “early adopter” hospitals in England. Design Theoretically informed, longitudinal qualitative evaluation based on case studies. Setting 12 “early adopter” NHS acute hospitals and specialist care settings studied over two and a half years. Data sources Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers’ field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. Results Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. Conclusions Implementation of the NHS Care Records Service in “early adopter” sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

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, socio-technical 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 socio-technical 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 top-down, 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.

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems

BackgroundA 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.MethodsCritical 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/discussionWe 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.SummaryNew 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.

The possibilities of technology in shaping healthcare professionals : (Re/De-)Professionalisation of pharmacists in England

The paper discusses the possibilities technology provides for (re-)shaping healthcare professionals. Drawing upon critical studies of technology and the sociology of professionals, we present findings from a longitudinal study into the introduction of the Electronic Prescription Service (EPS) in Community Pharmacies in England conducted between June 2009 and July 2011. Our case illustrates the conditions that allow technology to shape healthcare professionals and the potential consequences of such shaping. The data collected, which consisted of qualitative interviews and document analysis, and their analysis rests on predictions of future directions and developments of the pharmacy profession through EPS. Specifically, we show that technology has the potential to shape fundamental aspects of pharmacy work such as its nature and values, professional roles, the degree of power professionals can exercise, their jurisdictions and professional boundaries. Drawing upon these changes and on their implications, we argue that the introduction of technology in a healthcare setting does not determine consequences but opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously. Their implications for healthcare professionals in the future, remains an open, yet worth exploring, question for the present.

Changes in healthcare professional work afforded by technology: The introduction of a national electronic patient record in an English hospital

This article considers changes in healthcare professional work afforded by technology. It uses the sociology of professionals’ literature together with a theory of affordances to examine how and when technology allows change in healthcare professional work. The study draws from research into the introduction of a national electronic patient record in an English hospital. We argue that electronic patient record affords changes through its materiality as it interacts with healthcare professional practice. Its affordances entail some level of standardisation of healthcare professional conduct and practice, curtailment of professional autonomy, enlargement of nurses’ roles and redistribution of clinical work within and across professional boundaries. The article makes a contribution to the growing literature advocating a cultural approach to the study of technological affordances in organisations and to studies that explore healthcare professional practice in conjunction with the materiality of technology. Two main lines of argument are developed here. First, that technological affordances do not solely lie with the materiality of technology nor with individual perceptions, but are cultivated and nurtured within a broader cultural–institutional context, in our case a professional context of use. Second, that technological affordance of change is realised when healthcare professionals’ (individual and collective) perceptions of technology (and of its materiality) fit with their sense of (professional) self. In this respect, the article shows the extent to which the materiality of technology plays out with professional identity and frames the level and extent to which technology can and cannot afford restructuring of work and redistribution of power across professional groups.

The Working Out of Modernization in the Public Sector: The Case of an E-government Initiative in Greece

It has become common place for governments to initiate electronic-government projects in order to reform public administration. This paper seeks to explore the ways in which an e-government project, as a potential mode of reformation, is established and made to work, and then, further, to account for some of its consequences for conventional public administration. To do so we draw upon a detailed empirical study of a Greek e-government initiative, the establishment of Citizen Service Centres (CSCs). CSCs represent a significant part of Greeces e-government strategy, which has sought to modernize public administration and make the provision of public services more efficient, accessible and responsive to citizens. Drawing upon Foucaults work on power/knowledge we show that the e-government initiative is established through various technologies of power that intend to discipline public sector staff towards a particular mode of working. We also illustrate that the establishment of these modernization practices is the outcome of considerable negotiation, improvisation and enactment as different occupational groups seek to collaborate (or not) across professional and institutional boundaries. Finally, we show and argue that rather than reforming the provision of public services, such e-government based modernization projects are more likely to reproduce, in more complex ways, the long established public sector practices it sought to change.

Technological affordances of risk and blame: the case of the electronic prescription service in England

Information and communication technology (ICT) is often presented by health policymakers and software designers as a means for reducing clinical risk, leading to safer clinical practice. Studies have challenged this view, showing how technology can produce new or unanticipated risks. Although research seeks to objectively identify these risks, we recognise that technological risks are socially constructed through the interaction of technology and practice. The aim of this article is to explore how technology affords opportunities for the social construction and control of risk in health care settings. Drawing upon a study of the electronic prescription service introduced in the National Health Service in England, we make three arguments. Firstly, as technology interacts with social practice (for example, through policy and the design and use of ICT) it affords opportunities for the construction of risk through its interpretive flexibility, transformative capacity and materiality. Secondly, social actors interpret these risks within and across professional boundaries and cultures. Thirdly, the social construction of risk affords certain implications to policymakers, designers and users of health ICT, specifically a reordering of power and responsibility and a recasting of questions of blame. These, in turn, raise questions concerning the boundaries and bearers of responsibility.

Narrowing down accountability through performance monitoring technology : e-government in Greece.

Purpose - The purpose of this paper is to explore the relationship between performance monitoring technology and accountability in electronic government initiatives. Specifically, it aims to investigate how performance monitoring technologies are deployed in electronic government and the consequences that may arise from their implementation on public service accountability. Design/methodology/approach - The paper draws upon an in-depth empirical study of several Greek Citizens Service Centres (CSCs). CSCs are a central component of Greeces e-government strategy. Qualitative methods are deployed during fieldwork and data are analysed in line with the social constructionist paradigm. Findings - Contrary to the mainstream e-government literature, the paper argues that the introduction of performance monitoring technology does not always ensure accountability in the public sector. Overall, it suggests that performance technology may not necessarily lead to a form of accountability that always has the interests of the public at its heart. Instead it argues that it may lead to a narrowing down of accountability and the emergence of an instrumental rationality. Originality/value - The paper argues that the critical literature on management accounting provides important insights in understanding the consequences of performance monitoring in e-government projects and conceptualising the relationship between performance and accountability.

Chapter 8 – Defining the virtual organization

Never before in the history of business have organizations been subjected to as much change or so some argue. According to du Gay (2003, p.664) chance has become an imperative in contemporary society so much so that those who fail to thrive in ongoing conditions of radical transformation become ̳history‘. The conditions of this change are both complex and various. Stewart (1993) suggests that there are four large, unruly forces that condition chnage: the globalisation of markets; the spread of information technology (IT); the birth of the information economy; and the dismantling of hierarchy. These forces are simultaneous and inter-reactive. Not only have these forces threatened the very survival of many great corporations such as IBM (Chesbrough and Teece, 1996) and General Motors (Drucker, 1994), but they may have caused the disintegration of traditional organizations and their once seemingly untroubled environment:

Recognising the limits of virtual organizations

The preceding chapters in this section have examined the notion of virtual organization in a number of respects. However, the predominant view is that of support for this concept. It therefore also seems appropriate to step back and take a critical perspective. Is the virtual organization the model for future corporate life or is it merely another management fad? This must be a substantive question in need of articulation and debate; there is so much at stake for those firms that choose to embark on this road. Hence, the purpose of this chapter is to develop a critique of the virtual organization. It is then up to the reader to draw from both the thesis and the antithesis a set of ideas that will develop into a sensible judgement about the validity or not of the now all too pregnant concept of a virtual organization. The critique will draw mainly on the phenomenological and critical schools of thought.