Tony Cornford

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.

Experience with a structure, process and outcome framework for evaluating an information system

There are a number of problems in assessing the quality and performance of any information system, but these are particularly acute when it is intended for use within a developing country environment. This paper presents the case for structured evaluation of such systems, based on experience with a medical decision-aid system for developing countries. The paper provides a framework to approach the evaluation task combining work in the area of information systems and health policy analysis. The model used is built around the three concepts of a systems structure, the process it supports and the outcome of its use. This three-part analysis is then applied at three main levels: that of the systems functioning, human and user perspectives and the overall impact of the system, in this case the impact on the health care system.

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.

Telehealth acquires meanings: information and communication technologies within health policy

Over the last decade, British health policy has increasingly considered the role of information and information technologies in the provision of health care. Recently, there is a growing interest in new health applications, often referred to as telemedicine and telehealth, and incorporating a diverse range of services that can be provided in electronic form over various telecommunications networks. This paper discusses how such use of information and communication technologies (ICTs) in health acquires meanings through a policy process, and what implications it has for telehealth in particular. This is done through a hermeneutic exploration of four principal UK health policy papers published between 1989 and 1998.

Computers in the home: domestication and gender

This paper investigates the integration of the home computer into the domestic sphere through a gender perspective on the notions of domesticity and domestication. The study is based on a series of interviews with seven British families in the late 1990s. The analysis is used to identify some of the characteristics that contribute to make the home computer domestic or undomestic, and to explore the processes of domestication. A focus on fears and anxieties around the computer as well as the emergence of myths and magical notions allows for deeper insights into the gender‐domestication “problematique”.

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.

A review of the methodologies movement

Methodologies seem to have dominated the past two decades of research into information systems. They have been a focus of direct research, and seen as the obvious outlet for many other research finding and ideas. This paper presents a review of the methodologies movement, and explores some of the consequences that have arisen as a result of this particular focus.

Collective agility, paradox and organizational improvisation: the development of a particle physics grid

This paper examines systems development in a global collaborative community of high‐energy physics and offers insights and implications for agile systems development in other large scale and distributed settings. The paper studies the ongoing construction of the UKs computing grid for particle physics (GridPP), a grid that is itself part of the worlds largest grid, the Large Hadron Collider Computing Grid. We observe in this project a collective, agile and distributed performance through which the Grid is constructed. We express this through the concept of ‘collective agility’ which captures a large distributed performance rather than the more conventional sense of agility as small‐group and deliberate systems development practices. The collective agility of GridPP is analysed as a process of ‘enacted emergence’ expressed through the dynamics of six improvisation paradoxes.