Ela Klecun

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.

A critical approach to evaluation

Within information systems, the question of evaluation remains as a major contentious issue, and perhaps even more so in the field of health informatics where the traditions of medicine meet and mingle with the information systems field. A review of the literature in these areas indicates that there is little agreement on the essential role of evaluation, a ‘best way’ to evaluate, on what and how to evaluate, whom to involve and within what paradigm to proceed. Reflecting on discussion within both traditions, this paper develops an approach to evaluation broadly based on critical theory, and argues that such an approach, while not offering a solution to all the problems of evaluation, does bring into focus fundamental questions relating to evaluation process and content. To illustrate this, the paper reflects on the strengths and weaknesses of an evaluation of a primary care intranet, and suggests how a critical approach might lead to a more meaningful evaluation and provide more significant and useful findings.

Qualitative evaluation of an electronic prescribing and administration system

Objective: To provide a formative socio-technical evaluation of a pilot implementation of an integrated electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on one ward. Design: A qualitative observational approach using discourse analysis within a socio-technical evaluation framework addressing systems functions, human perspectives and organisational context. Setting: Surgical ward in a teaching hospital. Participants: Staff on study ward and in pharmacy. Intervention: Implementation over time of an integrated electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Main outcome measures: Assessment of technical performance, developed attitudes to the new system, changes to delivery of care and work practices. Results: The system was successfully implemented on the ward, and remained in operation for over 2 years. Many of the technical components of the system initially showed problems, but the system evolved, with increased functionality and improved performance. Attitudes to the system in the early stages were mixed. Over time, and with experience of making the system work for them, staff attitudes changed to become more balanced and the potential benefits of the system became clearer to most. The system structured the work of staff, sometimes unexpectedly. Conclusions: Electronic prescribing systems need to be seen as occasions for change and learning rather than as black-boxed technical solutions to identified problems. The evaluation framework allows understanding as well as hypothesis testing, and is recommended for future evaluations of electronic prescribing systems.

Bringing lost sheep into the fold: questioning the discourse of the digital divide

Purpose – The purpose of this paper is to critique the discourse of the digital divide and to propose ways of responding to digital inequalities.Design/methodology/approach – Illustrations of arguments are based on reviews of academic literature, projects reports, policy documents and research findings from the Penceil project, and are informed by critical theory. The research consisted of 47 semi‐structured interviews and action research involving designing an e‐literacy curriculum and running a course based on it.Findings – A discourse of missed opportunities and “being left behind”, present in policy statements and popular media, leads to objectifying non‐users of information and communication technologies (ICT) as “others”. This discourse is often internalised by non‐users, but it does not necessarily lead to positive actions, leaving some feeling inadequate. So far initiatives seeking to address the digital divide have had moderate success. To respond to digital exclusion we need to oppose the unchec...

How (Can) Nonusers Engage with Technology: Bringing in the Digitally Excluded

This paper describes findings from the Penceil Project, which aims to explore the experiences of nonusers and minimal users of ICTs, how nonuse affects their inclusion or exclusion from society, and how they can learn to use ICTs to meet their personal goals. The paper considers the applicability of the technology adoption model (TAM) to understanding the experiences of this group of people. By looking at theories of social exclusion and the project research findings, the paper argues that TAM is limited in the range of social conditions it anticipates and, thus, presumes a facility in formulating aspirations for use that people excluded from the use of ICTs cannot have. We argue that we need to consider engagement with technology rather than just adoption. We consider the implications of these findings for designing a revised basic ICT curriculum and describe the piloting of a new curriculum. We argue that, as ICTs in general—and Internet use in particular—are experienced technologies, perceived usefulness and perceived ease of use need to be reformulated to recognize limitations on people’s ability to construct plans for future action since an actor’s world is disclosed through action not given in advance.

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.

Conducting Critical Research in Information Systems: Can Actor-Network Theory Help?

This paper considers the proposition that actor-network theory (ANT)might be adopted within a broader critical paradigm to conduct empirical studies. The paper outlines the main tenets of the two theories, with the critical perspective primarily represented by Foucault.The aim is not to provide an extensive discussion of critical theory and ANT but to focus on their approach to the nature, scope, and level of empirical studies, particularly in their treatment of micro/macro analysis.The paper concludes that the differences are less significant than it may appear at first and that some of ANT’s ideas are close to Foucault’s position.However, ANT focuses on actors and their actions as they are performed in a particular time and place and does not appear to be concerned to what extent they may be historically conditioned. Thus, ANT on its own, in the view of the author, might not offer sufficient explanations as to why the actors under study take particular actions and why some actors are excluded or marginalized from the innovation process, e.g. from the development and implementation of an IS. For these reasons this paper suggests a critical research agenda enriched by ANT insights.

Transforming Healthcare: Policy Discourses of it and Patient-Centred Care

Information Technology (IT) is increasingly seen in policy and academic literature as key to the modernization of healthcare provision and to making healthcare patient-centred. However, the concept of Patient-Centred Care (PCC) and the role of IT in the transformation of healthcare are not straightforward. Their meanings need unpacking in order to reveal assumptions behind different visions and their implications for IT-enabled healthcare transformation. To this end, this paper reviews literature on PCC and IT and analyses England’s health policy between 1989 and 2013. English policy has set out to transform healthcare from organization-centric to patient-centred and has placed IT as central to this process. This policy vision is based on contested conceptualizations of PCC. IT implementation is problematic and this is at least partly because of the underpinning goals and visions of healthcare policy. If this misalignment is not addressed then producing technologically superior systems, or better IT implementation strategies, is unlikely to result in widespread and substantial changes to the way healthcare is delivered and experienced. For IT to support a healthcare service that is truly patient-centred, patients’ needs and wants need to be identified and designed into IT-enabled services rather than simply added on afterwards.

Digital Literacy for Health: The Promise of Health 2.0

This paper outlines and challenges expectations and promises regarding the potential of the internet and Web 2.0 for empowering patients and citizens. It focuses on literacies required to make a meaningful (to the individual) use of these technologies for health and health care related purposes. The author briefly discusses how these should be taught and concludes that these literacies, including digital literacy and health literacy, are complex and challenging to many while the empowering claims are over-stated. Traditional sources of information and advice will remain essential to maintaining quality of health care.