Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory

Evaluating the Implementation of the Pediatric Acute Care Education (PACE) Program in Northwestern Tanzania: A Mixed-Methods Study Guided by Normalization Process Theory

Background

In low- and -middle-income countries (LMICs) like Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this, we introduced PACE (Pediatric Acute Care Education), an adaptive e-learning program tailored to enhance provider competency in line with Tanzania's national guidelines for managing seriously ill children. Adaptive e-learning presents a promising alternative to traditional in-service education, yet optimal strategies for its implementation in LMIC settings remain to be fully elucidated.

Objectives

This study aimed to (1) evaluate the initial implementation of PACE in Mwanza, Tanzania, using the constructs of Normalization Process Theory (NPT), and (2) provide insights into its feasibility, acceptability, and scalability potential.

Methods

A mixed-methods approach was employed across three healthcare settings in Mwanza: a zonal hospital and two health centers. NPT was utilized to navigate the complexities of implementing PACE. Data collection involved a customized NoMAD survey, focus groups and in-depth interviews with healthcare providers.

Results

The study engaged 82 healthcare providers through the NoMAD survey and 79 in focus groups and interviews. Findings indicated high levels of coherence and cognitive participation, demonstrating that PACE is well-understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practice, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly affecting collective action, were noted. The short duration of the study limited the assessment of reflexive monitoring, though early indicators point towards the potential for PACE's long-term sustainability.

Conclusion

This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges is crucial for its successful and sustainable implementation. Furthermore, the study underscores the value of NPT as a framework in guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

Researching big IT in the UK National Health Service: A systematic review of theory-based studies

OBJECTIVE

To identify and discuss theory-based studies of large-scale health information technology programs in the UK National Health Service.

MATERIALS AND METHODS

Using the PRISMA systematic review framework, we searched Scopus, PubMed and CINAHL databases from inception to March 2022 for theory-based studies of large-scale health IT implementations. We undertook detailed full-text analyses of papers meeting our inclusion criteria.

RESULTS

Forty-six studies were included after assessment for eligibility, of which twenty-five applied theories from the information systems arena (socio-technical approaches, normalization process theory, user acceptance theories, diffusion of innovation), twelve from sociology (structuration theory, actor-network theory, institutional theory), while nine adopted other theories. Most investigated England's National Program for IT (2002-2011), exploring various technologies among which electronic records predominated. Research themes were categorized into user factors, program factors, process outcomes, clinical impact, technology, and organizational factors. Most research was qualitative, often using a case study strategy with a longitudinal or cross-sectional approach. Data were typically collected through interviews, observation, and document analysis; sampling was generally purposive; and most studies used thematic or related analyses. Theories were generally applied in a superficial or fragmentary manner; and articles frequently lacked detail on how theoretical constructs and relationships aided organization, analysis, and interpretation of data.

CONCLUSION

Theory-based studies of large NHS IT programs are relatively uncommon. As large healthcare programs evolve over a long timeframe in complex and dynamic environments, wider adoption of theory-based methods could strengthen the explanatory and predictive utility of research findings across multiple evaluation studies. Our review has confirmed earlier suggestions for theory selection, and we suggest there is scope for more explicit use of such theoretical constructs to strengthen the conceptual foundations of health informatics research. Additionally, the challenges of large national health informatics programs afford wide-ranging opportunities to test, refine, and adapt sociological and information systems theories.

Readiness for Change in the Implementation of a 3D Printing Initiative in a Catalan Tertiary Hospital Using the Normalization Process Theory: Survey Study

BACKGROUND

The high failure rate of innovation projects motivates us to understand the perceptions about resistances and barriers of the main stakeholders to improving success rates.

OBJECTIVE

This study aims to analyze the readiness for change in the implementation of a 3D printing project in a Catalan tertiary hospital prior to its implementation.

METHODS

We used a web-based, voluntary, and anonymous survey using the Normalization Measurement Development questionnaire (NoMAD) to gather views and perceptions from a selected group of health care professionals at Germans Trias i Pujol University Hospital.

RESULTS

In this study, 58 professionals, including heads of service (n=30, 51%), doctors (n=18, 31%), nurses (n=7, 12%), and support staff (n=3, 5%), responded to the questionnaire. All groups saw the value of the project and were willing to enroll and support it. Respondents reported the highest scores (out of 5) in cognitive participation (mean 4.45, SD 0.04), coherence (mean 3.72, SD 0.13), and reflective monitoring (mean 3.80, SD 0.25). The weakest score was in collective action (mean 3.52, SD 0.12). There were no statistically significant differences in scores among professions in the survey.

CONCLUSIONS

The 3D printing project implementation should pay attention to preparing, defining, sharing, and supporting the operational work involved in its use and implementation. It should also understand, assess, and communicate the ways in which the new set of practices can affect the users and others around them. We suggest that health officers and politicians consider this experience as a solid ground toward the development of a more efficient health innovation system and as a catalyst for transformation.

How Safe are Outpatient Electronic Health Records? An Evaluation of Medication-Related Decision Support using the Ambulatory Electronic Health Record Evaluation Tool

BACKGROUND

The purpose of the Ambulatory Electronic Health Record (EHR) Evaluation Tool is to provide outpatient clinics with an assessment that they can use to measure the ability of the EHR system to detect and prevent common prescriber errors. The tool consists of a medication safety test and a medication reconciliation module.

OBJECTIVES

The goal of this study was to perform a broad evaluation of outpatient medication-related decision support using the Ambulatory EHR Evaluation Tool.

METHODS

We performed a cross-sectional study with 10 outpatient clinics using the Ambulatory EHR Evaluation Tool. For the medication safety test, clinics were provided test patients and associated medication test orders to enter in their EHR, where they recorded any advice or information they received. Once finished, clinics received an overall percentage score of unsafe orders detected and individual order category scores. For the medication reconciliation module, clinics were asked to electronically reconcile two medication lists, where modifications were made by adding and removing medications and changing the dosage of select medications.

RESULTS

For the medication safety test, the mean overall score was 57%, with the highest score being 70%, and the lowest score being 40%. Clinics performed well in the drug allergy (100%), drug dose daily (85%), and inappropriate medication combinations (74%) order categories. Order categories with the lowest performance were drug laboratory (10%) and drug monitoring (3%). Most clinics (90%) scored a 0% in at least one order category. For the medication reconciliation module, only one clinic (10%) could reconcile medication lists electronically; however, there was no clinical decision support available that checked for drug interactions.

CONCLUSION

We evaluated a sample of ambulatory practices around their medication-related decision support and found that advanced capabilities within these systems have yet to be widely implemented. The tool was practical to use and identified substantial opportunities for improvement in outpatient medication safety.

Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study

BACKGROUND

In the era of electronic health records (EHR), the ability to share clinical data is a key facilitator of healthcare delivery. Since the introduction of EHRs, this aspect has been extensively studied from the perspective of healthcare providers. Less often explored are the day-to-day challenges surrounding the procurement, deployment, maintenance, and use of interoperable EHR systems, from the perspective of healthcare administrators, such as chief clinical information officers (CCIOs).

OBJECTIVE

Our study aims to capture the perceptions of CCIOs on the current state of EHR interoperability in the NHS, its impact on patient safety, the perceived facilitators and barriers to improving EHR interoperability, and what the future of EHR development in the NHS may entail.

METHODS

Semi-structured interviews were conducted between November 2020 - October 2021. Convenience sampling was employed to recruit NHS England CCIOs. Interviews were digitally recorded and transcribed verbatim. A thematic analysis was performed by two independent researchers to identify emerging themes.

RESULTS

Fifteen CCIOs participated in the study. Participants reported that limited EHR interoperability contributed to the inability to easily access and transfer data into a unified source, thus resulting in data fragmentation. The resulting lack of clarity on patients' health status negatively impacts patient safety through suboptimal care coordination, duplication of efforts, and more defensive practice. Facilitators to improving interoperability included the recognition of the need by clinicians, patient expectations, and the inherent centralised nature of the NHS. Barriers included systems usability difficulties, and institutional, data management, and financial-related challenges. Looking ahead, participants acknowledged that realising that vision across the NHS would require a renewed focus on mandating data standards, user-centred design, greater patient involvement, and encouraging inter-organisational collaboration.

CONCLUSION

Tackling poor interoperability will require solutions both at the technical level and in the wider policy context. This will involve demanding interoperability functionalities from the outset in procurement contracts, fostering greater inter-organisation cooperation on implementation strategies, and encouraging systems vendors to prioritise interoperability in their products. Only by comprehensively addressing these challenges would the full potential promised by the use of fully interoperable EHRs be realised.

Implementing PERFECT-ER with Plan-Do-Study-Act on acute orthopaedic hospital wards: Building knowledge from an implementation study using Normalization Process Theory

BACKGROUND

Delivering care to growing numbers of patients with increasingly 'complex' needs is currently compromised by a system designed to treat patients within organizational clinical specialties, making this difficult to reconfigure to fit care to needs. Problematic experiences of people with cognitive impairment(s) admitted to hospitals with a hip fracture, exemplify the complex challenges that result if their care is not tailored. This study explored whether a flexible, multicomponent intervention, adapting services to the needs of this patient group, could be implemented in acute hospital settings.

METHODS

We used action research with case study design to introduce the intervention using a Plan-Do-Study-Act (PDSA) model to three different hospital sites (cases) across England. The qualitative data for this paper was researcher-generated (notes from observations and teleconference meetings) and change agent-generated (action plans and weekly reflective reports of change agents' activities). Normalization Process Theory (NPT) was used to analyze and explain the work of interacting actors in implementing and then normalizing (embedding) the intervention across contexts and times. Data analysis was abductive, generating inductive codes then identified with NPT constructs. Across the three cases, change agents had to work through numerous implementation challenges: needing to make sense of the intervention package, the PDSA model as implementation method, and their own role as change agents and to orientate these within their action context (coherence). They had to work to encourage colleagues to invest in these changes (cognitive participation) and find ways to implement the intervention by mobilising changes (collective action). Finally, they created strategies for clinical routines to continue to self-review, reconfiguring actions and future plans to enable the intervention to be sustained (reflexive monitoring).

CONCLUSIONS

Successful implementation of the (PERFECT-ER) intervention requires change agents to recognize and engage with local values, and then to enable its fit with practice and wider contextual goals. A context of constant change fragments normalization. Thus, sustaining practice change over time is fragile and requires change agents to continue a recursive two-way sense-making process. This enables implementation and normalization to re-energize and overcome barriers to change.

Satisfied or not satisfied? Electronic health records system implementation in Ghana: Health leaders' perspective

Background

Electronic Health Records (EHR) has been espoused to be an innovation from the paper-based system, with benefits such as fast access to patient information thereby facilitating healthcare provider communication, healthcare continuity and improved quality of care. However, it is the extent of the quality of the electronic health records that determines the access to these stated benefits. The quality of health care records indirectly contributes to patient safety because inaccurate patient data can lead to improper diagnosis and consequently wrong treatment of patients. Most hospitals in Ghana, have recently transitioned into the EHR system, hence, there is a need to assess its accuracy, impact on workflow, staff training on usage, support from the EHR team, and the overall satisfaction of the EHR system. As health leaders are at the frontline of its implementation, their views on the challenges and successes of the EHR system are imperative.

Method

This qualitative study sought to explore the views of the health leaders on the implemented electronic health records system in nine (9) hospitals within three (3) regions in Ghana. Following ethical approval, GHS-ERC:007/04/21, focus group discussions were conducted with a minimum of 10 hospital leaders in each facility. These included quasi, government and private hospitals. Data was collected between September and November 2021.

Results

The study found poor quality of records, lack of involvement of frontline clinicians in the development of the EHR system, inadequate training of staff and limited workstations as some of the challenges associated with the use of EHR in hospitals. Health leaders were generally not satisfied with the EHR system.

Conclusion

It is recommended that addressing inputs from end-users as well as circulating more computers will motivate EHR usage and acceptance. Provision of additional workstations for the various units and involvement of staff in the system development would be most prudent to enable health workers to accept the EHR system in improving the quality of care.

Electronic health record implementation and healthcare workers' work characteristics and autonomous motivation-a before-and-after study

Background

Technological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers’ autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored.

Methods

A quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE).

Results

A total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation.

Conclusions

Our study showed that healthcare professionals’ perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers’ autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers’ values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01858-x.

Implementation of a web-based computerised decision support system for Community Mental Health Services using national electronic health records (Preprint)

Background

A high proportion of patients with severe mental illness relapse due to nonadherence to psychotropic medication. In this paper, we use the normalization process theory (NPT) to describe the implementation of a web-based clinical decision support system (CDSS) for Community Mental Health Services (CMHS) called Actionable Intime Insights or AI². AI² has two distinct functions: (1) it provides an overview of medication and treatment history to assist in reviewing patient adherence and (2) gives alerts indicating nonadherence to support early intervention.

Objective

Our objective is to evaluate the pilot implementation of the AI² application to better understand the challenges of implementing a web-based CDSS to support medication adherence and early intervention in CMHS.

Methods

The NPT and participatory action framework were used to both explore and support implementation. Qualitative data were collected over the course of the 14-month implementation, in which researchers were active participants. Data were analyzed and coded using the NPT framework. Qualitative data included discussions, meetings, and work products, including emails and documents.

Results

This study explores the barriers and enablers of implementing a CDSS to support early intervention within CMHS using Medicare data from Australia’s national electronic record system, My Health Record (MyHR). The implementation was a series of ongoing negotiations, which resulted in a staged implementation with compromises on both sides. Clinicians were initially hesitant about using a CDSS based on MyHR data and expressed concerns about the changes to their work practice required to support early intervention. Substantial workarounds were required to move the implementation forward. This pilot implementation allowed us to better understand the challenges of implementation and the resources and support required to implement and sustain a model of care based on automated alerts to support early intervention.

Conclusions

The use of decision support based on electronic health records is growing, and while implementation is challenging, the potential benefits of early intervention to prevent relapse and hospitalization and ensure increased efficiency of the health care system are worth pursuing.

Understanding nurses' perceptions of barriers and enablers to use of a new electronic medical record system in Australia: A qualitative study

BACKGROUND

Electronic medical record system implementations impact nurses, their work and workflows. The aim of this study was to understand nurses' perceptions of barriers and enablers to using a new electronic medical record in an acute hospital environment.

METHODS

Data were collected just prior to an organisation-wide new electronic medical record implementation at a large tertiary healthcare organization in Victoria, Australia. Sixty-three nurses from five hospital sites participated in 12 focus group interviews. Transcripts were transcribed and deductive content analysis used the 14-domain Theoretical Domains Framework to identify barriers and enablers.

RESULTS

Coded data mapped to 13 of the 14 domains. Nurse motivation emerged as a dominant theme among both barriers and enablers. Nurses' most common perceived barriers related to emotions (24.1%) and environmental context and resources (21.3%). Conversely, the most common enablers related to social influences (21%) and reinforcement (20.8%).

DISCUSSION

In addition to effecting changes in their work and workflows, the dominance of nurses' emotional responses reveals the potential for implementation of a new electronic medical record to negatively affect nurses' psychological well-being. Using data aligned to the Theoretical Domains Framework assisted identification of behavior change strategies to target the barriers and enablers perceived by nurses. Strategies aligned with nine behavioral intervention categories are recommended for successful implementation and optimization of an electronic medical record by nurses.

CONCLUSIONS

Multifaceted strategies targeting multiple behaviors are required to support adoption of the electronic medical record by nurses, and reduce the risk for nurse attrition in the workforce.

Persisting workarounds in Electronic Health Record System use: types, risks and benefits

Background

Electronic Health Records (EHRs) are now widely used to create a single, shared, and reliable source of patient data throughout healthcare organizations. However, health professionals continue to experience mismatches between their working practices and what the EHR allows or directs them to do. Health professionals adopt working practices other than those imposed by the EHR to overcome such mismatches, known as workarounds. Our study aims to inductively develop a typology of enduring EHR workarounds and explore their consequences by answering the question: What types of EHR workarounds persist, and what are the user-perceived consequences?

Methods

This single case study was conducted within the Internal Medicine department of a Dutch hospital that had implemented an organization-wide, commercial EHR system over two years ago. Data were collected through observations of six EHR users (see Additional file 1, observation scheme) and 17 semi-structured interviews with physicians, nurses, administrators, and EHR support staff members. Documents were analysed to contextualize these data (see Additional file 2, interview protocol).

Results

Through a qualitative analysis, 11 workarounds were identified, predominantly performed by physicians. These workarounds are categorized into three types either performed while working with the system (in-system workflow sequence workarounds and in-system data entry workarounds) or bypassing the system (out-system workarounds). While these workarounds seem to offer short-term benefits for the performer, they often create threats for the user, the patient, the overall healthcare organization, and the system.

Conclusion

This study increases our understanding of the enduring phenomenon of working around Electronic Health Records by presenting a typology of those workarounds that persist after adoption and by reflecting on the user-perceived risks and benefits. The typology helps EHR users and their managers to identify enduring types of workarounds and differentiate between the harmful and less harmful ones. This distinction can inform their decisions to discourage or obviate the need for certain workarounds, while legitimating others.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01548-0.

Integrating Option Grid Patient Decision Aids in the Epic Electronic Health Record: Case Study at 5 Health Systems

Background

Some researchers argue that the successful implementation of patient decision aids (PDAs) into clinical workflows depends on their integration into electronic health records (EHRs). Anecdotally, we know that EHR integration is a complex and time-consuming task; yet, the process has not been examined in detail. As part of an implementation project, we examined the work involved in integrating an encounter PDA for symptomatic uterine fibroids into Epic EHR systems.

Objective

This study aims to identify the steps and time required to integrate a PDA into the Epic EHR system and examine facilitators and barriers to the integration effort.

Methods

We conducted a case study at 5 academic medical centers in the United States. A clinical champion at each institution liaised with their Epic EHR team to initiate the integration of the uterine fibroid Option Grid PDAs into clinician-facing menus. We scheduled regular meetings with the Epic software analysts and an expert Epic technologist to discuss how best to integrate the tools into Epic for use by clinicians with patients. The meetings were then recorded and transcribed. Two researchers independently coded the transcripts and field notes before categorizing the codes and conducting a thematic analysis to identify the facilitators and barriers to EHR integration. The steps were reviewed and edited by an Epic technologist to ensure their accuracy.

Results

Integrating the uterine fibroid Option Grid PDA into clinician-facing menus required an 18-month timeline and a 6-step process, as follows: task priority negotiation with Epic software teams, security risk assessment, technical review, Epic configuration; troubleshooting, and launch. The key facilitators of the process were the clinical champions who advocated for integration at the institutional level and the presence of an experienced technologist who guided Epic software analysts during the build. Another facilitator was the use of an emerging industry standard app platform (Health Level 7 Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources) as a means of integrating the Option Grid into existing systems. This standard platform enabled clinicians to access the tools by using single sign-on credentials and prevented protected health information from leaving the EHR. Key barriers were the lack of control over the Option Grid product developed by EBSCO (Elton B Stephens Company) Health; the periodic Epic upgrades that can result in a pause on new software configurations; and the unforeseen software problems with Option Grid (ie, inability to print the PDA), which delayed the launch of the PDA.

Conclusions

The integration of PDAs into the Epic EHR system requires a 6-step process and an 18-month timeline. The process required support and prioritization from a clinical champion, guidance from an experienced technologist, and a willing EHR software developer team.