Zoe Morrison

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.

Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems: England, the USA and Australia

As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera’s typology of national programmes – ‘top-down’, ‘bottom-up’ and ‘middle-out’ – to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy.

Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review

Background Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable. Methods A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990–2010. The focus was on the current patient history, defined as information reported by a patient or the patients caregiver about the patients present health situation and health status. Findings were synthesised through a theoretically based textural analysis. Findings Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history. Conclusions There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.

National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation

Objective We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). Materials and methods Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. Results Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. Conclusions The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.

A toolkit to support the implementation of electronic prescribing systems into UK hospitals: preliminary recommendations

Hospital electronic prescribing (or ePrescribing) systems have the potential to reduce drug-related morbidity and mortality. However, their implementation and adoption has been slow to date, despite the considerable service interest in implementing systems and the long-standing policy drive towards computerization. The underlying reasons may include the demise of the National Programme for Information Technology; a lack of change management expertise and capacity in the National Health Service (NHS); the relatively immature and fragmented market; limited standards guiding procurement, functional specifications and expected benefits; and lack of resources.

Interpersonal influence in the workplace – part two: some research findings – influencing behaviour, personality and context

Purpose – The purpose of this paper is to present findings, and discuss the relevance of those findings, with regard to research undertaken about interpersonal influence in the workplace.Design/methodology/approach – This paper is the second part of a three‐part paper considering influencing behaviour in the workplace, the ways in which people at work go about getting their way with others. This part of the paper is divided into two main sections. The first section presents the research findings. The second section discusses the relevance of the findings. In particular, it considers how the observed relationships may provide guidelines for action, suggesting the circumstances in which particular influencing strategies and styles may be appropriate and inappropriate.Findings – The findings support the idea that influencing behaviour is related to the characteristics of the person, their work role and their orientation to that work role.Research limitations/implications – There is clearly a need for further...

The effectiveness and variation of acute medical units: a systematic review

PURPOSE To evaluate the evidence for the effectiveness of acute medical units (AMUs) compared with other models of care and compare the components of AMU models. DATA SOURCES Six electronic databases and grey literature sources searched between 1990 and 2014. STUDY SELECTION Studies reporting on AMUs as an intervention for unplanned medical presentations to hospital with the inclusion of all outcome measures/study designs/comparators. DATA EXTRACTION Data on study characteristics/outcomes/AMU components were extracted by one author and confirmed by a second. DATA SYNTHESIS Seventeen studies of 12 AMUs across five countries were included. The AMU model was associated with a reduction in-hospital length of stay (LOS) in all analyses ranging from 0.3 to 2.6 days; and a reduction in mortality in 12 of the 14 analyses with the change ranging from a 0.1% increase to a 8.8% reduction. Evidence relating to readmissions and patient/staff satisfaction was less conclusive. There was variation in the following components of AMUs: admission criteria, entry sources, functions and consultant work patterns. CONCLUSION This review provides evidence that AMUs are associated with reductions in-hospital LOS and, less convincingly, mortality compared with other models of care when implemented in European and Australasian settings. Reported estimates may be affected by residual confounding. This review reports heterogeneity in components of the AMU model. Further work to identify what constitutes the key components of an AMU is needed to improve the quality and effectiveness of acute medical care. This is of particular importance given the escalating demand on acute services.

Understanding experiences of participating in a weight loss lifestyle intervention trial: a qualitative evaluation of South Asians at high risk of diabetes

Objective To explore the reasons for enrolling, experiences of participating and reasons for remaining in a family-based, cluster randomised controlled trial of a dietitian-delivered lifestyle modification intervention aiming to reduce obesity in South Asians at high risk of developing diabetes. Design Qualitative study using narrative interviews of a purposive sample of trial participants following completion of the intervention. Data were thematically analysed. Setting The intervention was conducted in Scotland and resulted in a modest decrease in weight, but did not statistically reduce the incidence of diabetes. Participants We conducted 21 narrative interviews with 24 participants (20 trial participants and four family volunteers). Results Many participants were motivated to participate because of: known family history of diabetes and the desire to better understand diabetes-related risks to their own and their familys health; ways to mitigate these risks and to benefit from personalised monitoring. Home-based interventions, communication in the participants chosen language(s) and continuity in dietitians supported their continuing engagement with the trial. Adaptations in food choices were initially accommodated by participants, although social and faith-based responsibilities were reported as important barriers to persevering with agreed dietary goals. Many participants reported that increasing their level of physical activity was difficult given their long working hours, physically demanding employment and domestic commitments; this being compounded by Scotlands challenging climate and a related reluctance to exercise in the outdoors. Conclusions Although participants had strong personal interests in participation and found the information provided by dietitians useful, they nonetheless struggled to incorporate the dietary and exercise recommendations into their daily lives. In particular, increasing levels of physical exercise was described as an additional and in some cases unachievable burden. Consideration needs to be given to strengthening and supporting lifestyle interventions with community-based approaches in order to help overcome wider social and environmental factors.

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.