Health services do not have a good history of cost effective implementation of health information technology systems (HIT), or of electronic medical records (EMR) which are at the center of such systems. The potential for increasing safety and productivity is largely unrealized. Many countries and services have policies for introducing EMRs, but there is a wide gap between policy and practice. (Marion, 2004) Implementation experience has been varied and sometimes negative, notably in public health systems where there may be the greatest benefits from EMR systems which allow connections between services.
The ambitious and well-funded UK policy for all NHS hospitals was to have electronic patent records by 2005. In 2003, 3% of NHS hospitals had implemented the policy, and by mid 2006 the EMR implementation date was estimated to be “2007 at the earliest”. (Green, 2007) Some of the challenges are technical, but mostly they are professional and political. There are also large financial and commercial interests at stake, some of which have national strategic policy implications.
The National Health Service (NHS) has undergone rapid changes in the last few years. Most Hospitals have adopted IT solutions as Electronic Patient Record (EPR) systems instead of paper-based patient record. Their diffusion is frequently pushed by a vision of considerable time and cost savings, of increased quality of health work, and of a seamless integration with the existing local systems. (Berg, 2001) On the other hand, the high complexities of the technology and possibly not adequate implementation strategies have led to failures.
The degree of complexity and heterogeneity of this technology resembles the one of an Information Infrastructure. According to this framework, the EPR is an enabling, shared, open, heterogeneous socio-technical network built on an installed base. An infrastructural interpretation of the EPR implies its understanding as layers on an already existing installed base of technologies, processes, people, standards and knowledge. In this view the implementation process is considered to be more than simply changes in work practices and routines, which are required when shifting from a paper-based record to an electronic solution.
Electronic Patient Record
An electronic patient record (EPR) system is a set of clinical information systems designed to store detailed, longitudinal information about patients nonredundantly at every stage of the clinical process. (Green, 2007)
Information ‘Routes’ through the NHS
When a patient has been treated there is a record of that treatment. These records are called ‘organizational records’ and were mainly in paper records. However through new technological advancements these records have now become electronic, Electronic Patient Records (EPR’S) that have will contribute to the lifelong record of a patient’s health and healthcare-the Electronic Health Record. Through these electronic records, patients have access to reliable information to improve their knowledge and involvement in their own treatment and care. (Reinhold, 2004) Healthcare professional, have rapid access to individuals medical history and current condition to enable them to provide the highest quality care when and where it is needed. Health manager s and planners have ready access to aggregate information to improve analysis and decision-making.
Online information is available through NHS Direct for individual to access on healthy eating, illnesses, conditions and treatment with interactive healthcare. People can navigate the maze of health and care information through the development of consistent information and services with easy access from their homes or work. NHS Direct provides a one-stop gateway to give people more choice without about accessing the NHS, accessing out of hours treatment without actually visiting a GP’s practice.
The NHS direct nurse advises on all major issues to do with health. They advise on care at home, visiting the local pharmist, making a routine appointment, arranging for an emergency consultation, calling an ambulance or getting social services support. (Armoni, 2004) A structured sight search and email facilities aid individuals in solving their problems. The NHS Direct staff finds out their information by a range of on-line databases and by a wide range of links to health services and other specialist help lines in case an individual chooses to have a referral. As well as this there is an online directory available (Green, 2007) for a patients guide to the NHS with public information on local healthcare authorities, healthcare priorities and performances within the NHS. The NHS Direct information points are available in public places across the UK providing public access to the information available Direct online.
There are only 150 touch screen information points in use at the moment but by 2004 there should be over 500 available. This might be useful for the vulnerable such as the elderly who would not necessary have access to a computer or other technology. The NHS recognizes this and has sought to make improvements for these individuals in face-to-face contacts, community facilities and over the telephone.
NHS digital is a programme of pilot projects that is still ongoing to explore the potential of digital TV in providing health information. This new technology opens up new possibilities if successful for rapid access and advice to health services in supporting NHS Direct. A person from the comfort of their own home will be able to search for information in health related databases across the world, seek advice from a variety of help lines, watch broadcast of public meetings, share experiences with other people in similar situations and take part in discussion groups or book or change appointments at the hospital or health centre. New technology such as voice-activated software can overcome the poor access to information by many people with disabilities.
A National Electronic Library for health contains research evidence behind the health news stories. It keeps doctors and nurses up to date with the latest clinical research and best practice at the time they need it. This will help the NHS staff find accessible information quickly on latest advances, accredited best practices guidance with particular help on important topics in order to make the NHS provide a faster service. (Karen, 2005)
The NHS walk-in-centers has been set up throughout England in order to provide a faster more accurate service to people. They will provide a complimentary service to GP surgeries and A&E departments by offering a service at convenient times. They are particularly suited to those people who find it difficult to get an appointment with their GP or attend A&E departments with a minor problem. Using patient Group Directions, walk in centers nurses will be able to supply mechanisms for common ailments and conditions. New information systems in place will ensure that continuity of care is not jeopardized by ensuring that-subject to patient consent, information about walk-in centre contacts flows through to the patients’ GP’s. (Berg, 2003)
EPR consists of much information owned and managed by different entities: yourself as a patient, your referring doctor, and the various specialists you are dealing with (e.g. physical therapist). In addition, the purpose of EPR is to provide a comprehensive, longitudinal electronic patient record system that facilitates patient care, education, and research. Specifically speaking, the purpose of EPR can be classified into 3 main points:
- Assisting the clinician to structure his or her thoughts and make appropriate decisions. That is to say the EPR systems provide crucial information about the patient like allergies to drugs
- Providing information to patients about their health and health care. In that case, patients can access information about their health condition any time they want.
- Clinical research. That means the EPR system can help clinical research by enabling epidemiological monitoring and surveillance of possible adverse effects of drugs
Benefits of EPR system
- Patients will have easy access their records, increasing understanding and encouraging more involvement with decisions about their healthcare.
- Electronic records will avoid the problem of duplication because: There will be no need to duplicate routine personal details on new documents as these can appear by default.
- Electronic records cannot be damaged, lost or misfiled; the relevant document can be found without the need to flip through files or trace files not on the shelf.
- Electronic medical records will potentially eliminate the problems of unnecessary duplication, lost files and difficulty with interpretation. This will mean more time and money for hands on patient care, and the reduction of waiting times.
When organizations want to improve their performance, they usually benchmark. That is, they measure and compare the company’s operations, products and services against those of top performers both within and outside that company’s primary industry. The aim of this process is to identify the leading companies’ secrets to success.
The benefits of benchmarking:
- Improvement in the quality of goods or services
- Decreasing costs of operations
- Improving customer delivery service or response time
- Strengthen culture-sensitising employees to the need for continuous improvement
Difficulties with benchmarking:
- Emphasis is upon quantitative measurements
- Accuracy is required, yet information varies
- Data contains errors. Present process cannot be used to determine the potential results of changes
There are many versions of Benchmarking Steps used by very successful organizations. The simplest framework is recommended by GOAL/QPC. It has six steps: Plan, Research, Observe, Analyze, and Adapt Improve.
Typically, the concept of organizational change is in regard to organization-wide change, as opposed to smaller changes such as adding a new person, modifying a program, etc. Examples of organization-wide change might include a change in mission, restructuring operations (e.g., restructuring to self-managed teams, layoffs, etc.), new technologies, mergers, major collaborations, “rightsizing”, new programs such as Total Quality Management, re-engineering, etc. Some experts refer to organizational transformation. Often this term designates a fundamental and radical reorientation in the way the organization operates.
Change can be undertaken at various levels:
How Organization-Wide Change Is Best Carried Out?
Successful change must involve top management, including the board and chief executive. Usually there’s a champion who initially instigates the change by being visionary, persuasive and consistent. A change agent role is usually responsible to translate the vision to a realistic plan and carry out the plan. Change is usually best carried out as a team-wide effort. (Karen, 2005) Communications about the change should be frequent and with all organization members. To sustain change, the structures of the organization itself should be modified, including strategic plans, policies and procedures. This change in the structures of the organization typically involves an unfreezing, change and re-freezing process.
The best approaches to address resistances are through increased and sustained communications and education. For example, the leader should meet with all managers and staff to explain reasons for the change, how it generally will be carried out and where others can go for additional information. A plan should be developed and communicated. Plans do change. That’s fine, but communicate that the plan has changed and why. Forums should be held for organization members to express their ideas for the plan. They should be able to express their concerns and frustrations as well. (Berg, 2003)
EPR Implementation Strategy
In this section we will discuss the point listed in the theoretical chapter regarding strategy for implementing the benchmarking. Complexity in the healthcare industry is huge. Today healthcare delivery channels provide patient services in an environment of inherent complexities such as:
Multiple stakeholders lead to an increasing complexity of the delivery system. These include government at the national and local levels defining the policies & guidelines; healthcare providers in the form of government medical center and hospitals; general practitioners or specialists working in the government or private care set-up as the principal care providers; healthcare social service support agencies; healthcare vendors such as pharmaceutical and medical equipment companies; IT vendors and the patients as the consumers of care services. (Green, 2007)
Financial strain due to rising healthcare costs is impacting the availability of patient care services.
Increasing staff shortage of qualified physicians and nurses is increasing demand for patient care services at all levels within the delivery process.
Hospitals are also facing significant pressure from changes in disease profiles. An increasing proportion of seniors in the population have increased the need for focusing on geriatric care.
The challenge for the healthcare industry is to devise cost effective strategies with an objective of improving the quality of healthcare delivery and increasing patient satisfaction. There is an increasing need to maintain privacy and security of the patient’s confidential clinical information.
Information Technology and the right solution can provide effective solutions for streamlining processes and addressing the various issues of healthcare complexity. Efficiency and security have become key differentiators in the industry. Implementing technology to reduce medical errors and promote patient safety is one of top focus areas. Software companies servicing the healthcare vertical are gravitating towards a variety of solutions to improve the communication of data with healthcare organizations. One of these solution areas is Electronic Patient Record. (Smith, 2000)
EPR implementation cannot be a “Big – Bang” as it affects all the aspects (strategy, organization, process, technology) of any organization. Most of the EPR initiatives are nationally supported, making it imperative that the approach is an incremental / phased one so as to address all aspects of implementation. (Davidson, 2004)
These increments can be segregated under five generations & each generation can then be subdivided based on EPR functional units. Earliest generation of EPR implementation encompasses basic mechanisms of Knowledge Management such as scanned documents, transcribed texts, and minimal static or graphical display. This gradually moves to a more structured documentation with advanced clinical pathways, advanced diagnostic support, complex intuitive visualization of clinical data and population specific data. These advanced and integrated functional components become an intelligent tool, assisting clinician in providing care. It also ensures the seamless integration of all the basic functional components of EPR as one functional unit.
This incremental segregation methodology of EPR into functional components and these components into various generations helps in generating an “EPR Solution Roadmap” which becomes a guiding principle in the implementation plan.
Solution Performance Management
Any such large nation wide initiative needs to have a strong backbone of tangible, measurable benefits, which are accrued at every stage of implementation plan. EPR can help improve organizational performance in 3 critical dimensions of:
- Clinical Care
- Cost Savings
- Patient & Staff Satisfaction
It helps an organization achieve an optimal stage of operational/financial functioning ensuring the benefits such as:
- better medical outcomes,
- reduced medical errors,
- reduced follow-up costs,
- better informed clinical decision,
- reduced variance of clinical care,
- evidence based clinical care model,
- better resource allocation/ usage,
- streamlined business processes,
- maintain healthcare continuum,
- greater empowerment of healthcare consumers (Jones, 2003)
It also facilitates achievement of seamless clinical care operations across institutions and professionals.
Institute of Medicine report: Building a Safer Health System, suggests that, of the 33.6 million admissions to US hospitals in 1997,
- between 44,000 and 98,000 deaths occurred as a result of medical errors
- Medication errors result in more than 7,000 deaths annually
- Roughly 50% of medication errors are preventable.
Solution Implementation Framework
EPR Implementation Framework helps an organization or a public healthcare governing body to put forth an actionable implementation plan. It ensures that the strategic vision is in line with what the realized ground benefits are. It helps define multidimensional CSFs (Critical Success Factors) from strategy, financial, process, organization and technology perspective at each stage of the implementation plan. It also helps in defining an end-to-end EPR Prototype Execution Program driven success measurement, result assessment and synthesis mechanisms.
Organizational Changes in EPR
In this section we will discuss the point listed in the theoretical chapter regarding organizational changes. Electronic patient records (EPRs) typically require substantial change in the way clinicians work and may contribute to transformation of health care organizations.
Some information, such as test equipment readings, are already highly structured and easily converted to electronic formats. At the other end of the spectrum, physician’s handwritten notes have been compared to diary entries or phone conversations (Davidson, 2004). Given the inherent complexity of medical information, the regulatory, legal and financial requirements on how data must be collected and stored and the multiple audiences for patient data, researchers in the emerging field of medical informatics are addressing the question of how computerized patient records should be standardized and structured for collection, storage, and use.
Affect established communicative practices
Because health care delivery is a collaborative activity in which patient records mediate communication among various specialists, changing from a paper-based to an electronic patient record and from a manual to a computerized clinical information system is likely to affect established communicative practices. (Smith, 2000) Applications such as computerized order entry, for example, can alter the content and patterns of interactions between departments, resulting in both beneficial outcomes, such as increasing speed of communication, and detrimental outcomes, such as interdepartmental friction. Computerization may also create situations that require new communicative practices, such as the need to cooperatively maintain a common database and consulting or teaching interactions to facilitate system use.
Importance of IT people grows higher
The IT department has been actively involved in the implementation since 1996. Initially they decided to adopt an in-depth implementation strategy focusing on one department at the time. On the agenda for the implementation for each department the items were:
- upgrading of the technical infrastructure, if required;
- installation of the package;
- customization to local needs;
- integration with local systems. (van Ginneken, 2002).
Patients become more independent
Patients are surprisingly receptive to the idea of taking a more active role in the management of their health and are prepared to become more engaged with health professionals in the neutral ground offered by the EPR. Patients were enabled to correct or challenge personal health information recorded in the practice and they were able to correct errors. The Patient Held Paper Record Project confirmed that giving ownership of the health record can empower patients and help foster partnerships between patients and professionals. The combination of the EPR with the wealth of information that is available on the Internet makes the EPR and the Web natural partners. (James, 2005)
The role of the GP changes
An example of this is the shift in emphasis in the role of the GP from being the gatekeeper for secondary services to one of commissioning and coordinating care.
Clinician Champions and Leaders for EPR Innovations
Installing an EPR system in a large organization is a complex and difficult undertaking.1 Achieving acceptance by clinicians is among the greatest challenges.2 EPR typically require substantial change in the way clinicians work; indeed, introduction of EPR may transform health care organizations. Nearly any change is associated with instability and resistance, and this is well documented among physician users of EPR; fortunately, however, effective leadership may help mitigate and overcome this resistance.
“Change capability” as a factor in EMR implementation
This is that individual- and organizational- “change capability” which is proportional the changes under consideration are important in implementation. Employees have to adjust cognitively, behaviorally and emotionally to use a new EMR in everyday work—it affects work tasks central to their practice. Employees also experience other changes in their work and surroundings due to the constantly changing nature of health care. The EMR change may exceed people’s capacity to cope with change, or other changes may combine to exceed these limits, causing resistance, rejection and other behaviors by employees trying to continue to provide an adequate standard of care.
In addition to individual change capability, organizations have different formal systems for managing change. Some organizations use project teams regularly, have project management systems and personnel with training and they can be called upon to can lead or work in change projects: changes can be carried out using a system and structure which many are familiar with and trained for. Organizations vary in their development and use of such change management or learning organization systems.
An organization’s ability to implement an EMR, however, may be more than the sum of individual and formal organizational change capability. Features of the organization which have been summarized as “change readiness” or “change friendly culture” may enhance individual and organized change capability as well as being developed by the latter: these include a climate of optimism about the future, trust in leadership, good inter-professional, interdepartmental and professional-management relations, shared experience of successfully managed changes, and a learning organization culture and structures. (van Ginneken, 2002)
Finite change coping capability may also explain why nearly all EMR implementations “fail to use the opportunities for process redesign”. All EMR implementation involve some work redesign, but major redesign at the same time exceeds the change coping capacity of most organizations and the tolerance of most clinicians trying to keep a service running during the change. (James, 2005) Although it would be more efficient to “computerize an improved process” it is more realistic to treat this as a two-stage process, so long as the system can be easily modified to support new work processes.
Many countries have national policies for establishing EMRs and many hospitals are selecting, planning, implementing or upgrading their systems. There are few independent descriptions of implementations, little research into what helps and hinders, and no research-based theories of EMR implementation. This paper derived an EMR implementation theory from the available research and described implementations in two case studies. These data provide some limited support for the theory and also suggest that a previously unreported factor is important to implementation success: “change capability” relative to the EMR and other changes taking place.
Findings from the two case studies suggest that EMR implementation is a “conditional intervention” and success depends on many prior and concurrent environmental factors. The findings also suggest a concept and hypotheses for future research which are not reported in earlier studies. The hypothesis is that, the less change the EMR system demands and the fewer the other changes which are occurring at the same time, then the more likely implementation will be successful.
The second hypothesis is that four factors may be amongst those which facilitate effective EMR implementation: the number and depth of changes demanded by the EMR and other unrelated concurrent changes; individuals’ change capacity; the organizations formal system for managing changes; and a change-ready culture.
Some of the practical implementation and policy guidance from the research includes:
- Choose a system which allows a range of needs to be met, rather than make compromises for a clinical or a business system, and an EMR which can serve this system.
- Choose a tried and tested EMR which works for clinical personnel and saves time. If personnel do not think it will save time then implementation will be significantly more difficult and possibly impossible.
- The system should be easy to modify and develop, within limits, for different departments and uses.
- The system should be intuitive, requiring little or no training.
- The decision about the system should be participatory, but once made; implementation should be directed and driven.
- For successful implementation, balance local control of selection, implementation and clinical participation with meeting higher-level requirements.
- Involve each level in different ways, with clear and appropriate parameters about which decisions can be made locally and which require higher-level decisions about common standards.
- .Assess and address the presence and absence of prior and concurrent factors which have been repeatedly shown in research to help and hinder implementation.
Future research is needed for different implementations of EMRs in different situations, reported in a standardized way to allow comparisons. Knowledge on the subject would be improved if studies built on previous research to test hypotheses, especially about which conditions are critical for successful operation and how different parties define this.
The EPR implementation framework provides a robust methodology to implement EPR while addressing existing deficiencies in the healthcare value and supply chains in building Electronic Patient Records. Furthermore, the view of the EPR as an integrated part of a larger Information Infrastructure opens up a new perspective on the whole innovation process and the organizational changes of EPR bring many good benefits for different entities today. In addition, we also can clear know that there is a number of benchmarking clubs’ available throughout the NHS. Some are facilitated by the private sector; others have been established within the NHS.
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