Kate Marsden

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.

Safety climate in English general practices: workload pressures may compromise safety

Abstract Objectives Although most health care interactions in the developed world occur in general practice, most of the literature on patient safety has focused on secondary care services. To address this issue, we have constructed a patient safety toolkit for English general practices. We report how practice and respondent characteristics affect scores on our safety climate measure, the PC‐Safequest, and address recent concerns with high levels of workload in English general practices. Methods We administered the PC‐Safequest, a 30‐item tool that was designed to measure safety climate in primary care practices, to 335 primary care staff members in 31 practices in England. Practice characteristics, such as list size and deprivation in the area the practice served, and respondent characteristics, such as whether the respondent was a manager, were also collected and used in a multilevel analysis to predict PC‐Safequest scores. Results Managers gave their practices significantly higher safety climate scores than did non‐managers. Respondents with more years of experience had a more negative perception of the level of workload in their practice. Practices with more registered patients and in areas of higher deprivation provided lower safety climate scores. Conclusions Managers rated their practices more positively on our safety climate measure, so the differences between the perceptions of managers and other staff may need to be reduced in order to build a strong safety culture. Excessive workload for more experienced staff and lower safety climate scores for larger practices may reflect ‘burnout’. Concerns that pressures in primary care could affect patient safety are discussed.

Utilizing a Discourse-Based Understanding of Organizational Change to Explore the Introduction of National Electronic Health Records in England

The authors utilized pragmatic discursive analysis to consider their empirical study of the introduction of an electronic patient record system within hospitals based in a large region of the National Health Service in England. Their aim was to gain insight into the interplay between discourse and change as mediated by technology by exploring how a politically driven programme of change was translated during the introduction of a computer system intended to provide an electronic patient record. They identified contrasting discourses, determined by situated professional practices and stakeholder expectations that framed alternate understandings of the proposed systems implementation and related change processes. Over time, these contrasting local discourses in turn became increasingly dissonant with the national change programme policy rhetoric as the systems software failed to deliver anticipated benefits. The authors’ work emphasizes the mediating effect of technology in discourses of change. Limitations in systems functionality and a related lack of discourses of success slowed social momentum. Consequently, local and political articulations of change began to fragment. The authors suggest that understandings of change are experienced through different interpretive frameworks and mediated through the materiality of technology, highlighting the possibility of many and alternate meanings within any change process, and the considerable challenges in the development and implementation of information technology in healthcare.

Undertaking effective medication reviews

In the General Medical Council-funded PRACtICe study around half the prescribing and monitoring errors identified involved repeat prescriptions. This suggests a need to improve the effectiveness of medication reviews in order to ensure that any errors are detected and corrected. In this article we focus on identifying the elements of an effective medication review; providing examples of medication reviews, and identifying and tackling adherence issues. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Mindful organizing in patients’ contributions to primary care medication safety

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Providing the right dose instructions

The General Medical Council -funded PRACtICe study investigated the prevalence and causes of prescribing errors in general practices. The results showed that around one in three of the prescribing errors detected were associated with incomplete information on the prescription whilst around one in 10 involved giving a medicine at the wrong time. In this article we focus on achieving clear and unambiguous dosing instructions including how clinical computer systems can help to alleviate the problem. We also look at the cautionary and advisory labels added during the dispensing process. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Providing the right medication monitoring

In order for medication to be prescribed effectively and safely, many medications require monitoring. Medication monitoring may involve blood tests but can also include other monitoring such as blood pressure, weight or electrocardiograms. Monitoring can be required before initiating medication, soon after starting, or regularly over the course of treatment. Ensuring that this monitoring has been undertaken is an important part of medication review involving repeat prescribing. The General Medical Council-funded PRACtICe study looked at prescribing and monitoring errors in primary care. Out of the 302 errors identified, 55 (18%) were monitoring errors. Of those drugs that required blood test monitoring, 7% of prescriptions contained a monitoring error. This article gives the reader opportunities to reflect upon different scenarios that involve medication that requires monitoring decisions and how monitoring could be managed in primary care. There are also suggestions for additional continuing professional development activities.

Selecting the right dose

Around one in six of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either the wrong dose or the wrong strength of medication. Around one in 10 of the prescribing errors involved giving a medicine at the wrong time. In this article we focus on the factors that need to be taken into consideration when selecting the right dose for an individual patient. We also highlight the importance of selecting the right timing for particular medicines. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Avoiding hazardous prescribing

Around one in 13 of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either contraindications or hazardous drug-drug combinations In this article we focus on these issues and also cover the problem of selecting the wrong drug, or drug strength, from computer-based drop-down menus. The article gives the reader opportunities to reflect upon different scenarios involving hazardous prescribing, and there are also suggestions for additional continuing professional development activities.