Refereed Studies

From Nhs It Info

Revision as of 16:53, 7 May 2007

Privacy in clinical information systems in secondary care (15 May 1999)

BMJ 1999;318:1328-1331

http://www.bmj.com/cgi/content/short/318/7194/1328

". . . In the BMA consultation document Security in Clinical Information Systems Anderson identifies nine principles governing the design of a clinical information system meeting the requirements for patient privacy.2 Doubts have been raised about the feasibility of adopting the code for governing access to patients' electronic records in secondary care. Our experience is that the principles are achievable. This article is based on our experience of a large scale clinical information system in use in three British hospitals---Conquest Hospital, Hastings; Aintree Hospital, Liverpool; and Royal Devon and Exeter Hospital, Exeter. We describe the approach taken to ensuring control over access to confidential patient information on the basis of expected relationships between staff and patients. . . . This can be achieved by matching a patient's current clinical contacts with a user's rights; this has been shown to be workable in a hospital-wide clinical information system . . ." [Denley & Smith]

Issues in the multi-disciplinary assessment of healthcare information systems (Sep 1999)

Information Technology & People 12, 3

http://www.emeraldinsight.com/Insight/viewContentItem.do?contentType=Article&hdAction=lnkhtml&contentId=883513

"Abstract: Considers the problems of a multi-disciplinary team working together to understand and evaluate a healthcare information system, which itself is situated in a complex organisational and political environment. Provides general discussion of problems faced by evaluators of such systems. Describes this specific evaluation project (Electronic Patient Records in the UK National Health Service), gives an account of the evaluation process as it occurred, highlights some of the problems encountered, and discusses attempts to overcome these. Suggests that social, organisational and political factors are inherent in all such research enterprises, and that in order to facilitate a rich understanding of complex systems, these factors must also be considered as part of the research data." [Heathfield et al]

Construction of a Virtual EPR and Automated Contextual Linkage to Multiple Sources of Support Information on the Oxford Clinical Intranet (1999)

Proc AMIA Symp

http://adams.mgh.harvard.edu/PDF_Repository/D005850.PDF

"Abstract: We have used internet-standard tools to provide access for clinicians to the components of the electronic patient record held on multiple remote disparate systems. Through the same interface we have provided access to multiple knowledgebases, some written locally and others published elsewhere. We have developed linkage between these two types of information which removes the need for the user to drill down into each knowledgebase to search for relevant information. This approach may help in the implementation of evidence-based practice. The major problems appear to be semantic rather than technological. The intranet was developed at low cost and is now in routine use. This approach appears to be transferable across systems and organisations." [Kay et al]

Evaluating computerised health information systems: hard lessons still to be learnt (Apr 2003)

BMJ 2003;326:860-863

http://www.bmj.com/cgi/content/full/326/7394/860

"Enormous investment has gone into computerised hospital information systems worldwide. The estimated costs for each large hospital are about $50m (£33m), yet the overall benefits and costs of hospital information systems have rarely been assessed. When systems are evaluated, about three quarters are considered to have failed, and there is no evidence that they improve the productivity of health professionals. To generate information that is useful to decision makers, evaluations of hospital information systems need to be multidimensional, covering many aspects beyond technical functionality. A major new information and communication technology initiative in South Africa gave us the opportunity to evaluate the introduction of computerisation into a new environment. We describe how the project and its evaluation were set up and examine where the project went wrong. The lessons learnt are applicable to the installation of all hospital information systems." [Littlejohns, Wyatt and Garvican]

Integrating Child Health Information (11-12 Dec 2003)

Integrated Care Records: Problems and Solutions Workshop, Edinburgh

http://www.iccs.informatics.ed.ac.uk/~mjh/chameleon/ICRworkshop/Submissions/Copping.pdf

"Abstract: The Scottish Executive highlight that better sharing of children’s information is crucial to providing improved co-ordinated care, for all Scotland’s children, especially for those most in need. The “Shared Information Project” a £340,000, flagship 2 year programme, funded by the Changing Children Services fund was set-up to meet this goal. The project is clinically lead, by a Consultant Paediatrician, Primary Care Management and supported by a Clinical Specialist in Health Informatics, a Senior Social Worker and a Project Manager. Information Requirements have been defined using evidence based health informatics methodologies and the outcomes analysed using thematic-analysis. Importantly this work highlights the benefits of systematic evidence based informatics in defining actual requirement, their strength and variation across care providers. This project highlights that for successful integration of children’s information human systems and IT systems need to be developed in parallel." [Hammond et al]

dbMotion: Virtual Health Community (11-12 Dec 2003)

Integrated Care Records: Problems and Solutions Workshop, Edinburgh

http://www.iccs.informatics.ed.ac.uk/~mjh/chameleon/ICRworkshop/Submissions/halevy.pdf

"Clalit Health Services is the largest health organization in Israel and the second largest in the world. It is a decentralized organization that provides services to approximately 3.7 million clients through 14 hospitals, 1,300 clinics and medical centres. The organization employs approximately 20,000 care providers, each of which can create medical data and, more importantly, request up-to-date data about patients. The medical information systems in the organization differ from one another and lack unification between the systems. The dbMotion system is currently installed at all Clalit hospitals, and in some specialty hospitals. The system is also in use at in all the districts and clinics. Since the system is Intranet-based, it is accessible to any service or care provider for whom an account has been defined in the organizational network. The dbMotion solution, implemented at Clalit, was based on the requirement to collect data from the existing legacy systems without the need to replace them, change their function or the way they are utilized. dbMotion integrates data from clinical sources that are dispersed geographically all throughout the Clalit, and contain various types of information. For example, the solution integrates data from the hospital Emergency Room and wards, the local clinics, as well as the several Clalit laboratories. In addition, the solution needed to utilize existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet, as well as a web-based viewer, where the physician can browse through his patient's history.The solution provides available, up-to-date medical information while maintaining the highest level of information security." [Gillon et al]

Trusting The Record (2003)

Methods inf. med. 42,4 (2003) pp. 345-352

http://www.dirc.org.uk/publications/articles/papers/81.pdf

". . . The setting for our study is the toxicology ward within a large Edinburgh hospital. The aim was to subject work within the ward, and in particular document work, to close empirical investigation. . . Paper-based records are criticised for being hard to access, poorly organised, incomplete, inaccurate, hard to read, lacking consistency in format and use of terminology. The electronic medical record (EMR) is consequently seen as providing the conditions for the imposition of greater discipline and structure on record-keeping practices and it has also become a major factor in the drive for the standardisation of medical record formats. This standardisation is, in turn, expected to lead to better treatment and the realisation of 'joined-up', 'seamless' healthcare. Our fieldwork data points to a number of trust issues - related to the way that record use is a fundamental aspect of the moral order of the working division of labour . . . Existing patient admission procedures involve the concurrent physical handover of the patient, and of information relating to the patient's admission in the form of the pink and blue sheets. This naturally provides the opportunity not only for the transfer of information about the patient, but also for the checking of its accuracy by the admitting nurse. . . With the deployment of the EMR, future admission procedures might reasonably be expected to dispense with the handover of paper: Ward nurses will be able to access the information recorded at A&E directly through the nurses' station EMR terminal. While this may seem to exemplify the ways in which the EMR can streamline and improve information-handling procedures, we suggest that, in as much as this will decouple the arrival of patient and patient information, it may undermine the robustness and reliability of the process. " [K. Clarke et al]

Supporting Informality: Team Working and Integrated Care Records (2004)

Proc. 2004 ACM Conf. on Computer Supported Cooperative Work (2004) pp.142 - 151

http://portal.acm.org/citation.cfm?id=1031607.1031632&coll=&dl=&type=series&idx=1031607&part=Proceedings&WantType=Proceedings&title=Computer%20Supported%20Cooperative%20Work&CFID=15151515&CFTOKEN=6184618

"This paper reports findings from an ethnographic study of the work of Adult and Care of the Elderly Community Mental Health Teams in the context of the deployment of an Electronic Medical Record. Our findings highlight the importance of informal discussions and provisional judgments as part of the process by which teams achieve consensual clinical management decisions over time. . . it would appear that lessons learned from CSCW studies have not, as yet, made a major impact on how large-scale IT systems are designed and implemented. Most work is collaborative, but large-scale IT systems are often poor at supporting the collaborative dimensions of work. . . It would seem that integrated care records systems are, in the main, modelled along the same lines as airline reservation systems - always online, and always up to date. While this model may have its advantages in that it increases organisational control and enables strict auditing (what information was recorded in the system at a particular time and who had access to it), it fails to acknowledge and support the kinds of professional practices we have described. The consequence of this in practice may well be that the system fails to achieve one of its main aims, namely to make more information accessible on time, as people develop practices around the system, committing information to it only once it is 'publication ready'. . ." [G. Hardstone et al]

‘That’s How The Bastille Got Stormed’: Issues of Responsibility in User-Designer Relations (17 Mar 2005)

Proc. 5th DIRC Research Conference, Edinburgh

http://www.dirc.org.uk/publications/inproceedings/papers/115.pdf

"This paper presents data and analyses from a long term ethnographic study of the development of an electronic patient records system in a UK hospital Trust – TA ‘Dependable Deployment’. The project is a public private partnership (PPP) between the Trust and a US based software house (USCo) contracted to supply, configure and support their customizable-off-the-shelf (COTS) healthcare information system in cooperation with an in-hospital project team. We use data drawn from our observational studies to highlight a range of responsibility issues in designer-user relationships." [Martin & Rouncefield]

Out with the old in with the new: What gets missed when deploying new technologies in A&E? (21 Mar 2005)

Medical Informatics and the Internet in Medicine 30(2) 34-40.

http://www.uclic.ucl.ac.uk/annb/docs/cbaaHCpreprint.pdf

"Abstract: This paper presents a longitudinal study (over 4 months) of an A&E department where the existing whiteboards were replaced with PC based computer systems. The study was conducted in two parts; an observation of the physical whiteboard usage and in-depth interviews with all users of both the traditional whiteboard usage and the replacement technology. The research was conducted with systems manager and all whiteboard users (i.e. nursing management, nurses, doctors, porters, and agency staff) across a spread of time-frames. Although the technology supported simple information requirements complex co-ordination, collaboration and awareness issues were left unsupported. The important role of a ‘pen-holder’ (information co-ordinator) was poorly supported by the replacement technology as was the task of annotating information with changing situations and needs. Specific deployment issues are derived from these findings that should guide designers when implementing technology replacements for current physical information formats (e.g. whiteboards, notice boards, shared paper notes)." [Broome & Adams]

Implementing digital resources for clinicians' and patients' varying needs. (21 Mar 2005)

Medical Informatics and the Internet in Medicine 30(2) 107-122.

http://www.uclic.ucl.ac.uk/annb/docs/aaabsaHC05preprint.pdf

". . . Traditional design and implementation approaches, isolated from communities, produce users – both clinicians and patients – who are either unaware of the technology or perceived it as complex and inappropriate for their needs. Random deployment of technology within communities, with poor design and support, is perceived by many as complex, inappropriate for their needs and a threat to current roles and practices, including the maintenance of clinician–patient relationships. . ." [A. Adams et al]

Implementing the National Programme for IT: what can we learn from the Scottish experience? (2005)

Informatics in Primary Care 2005; 13:105-11

http://www.ingentaconnect.com/content/rmp/ipc/2005/00000013/00000002/art00004

"The National Programme for IT (NPfIT) promises to revolutionise the delivery of health care by enabling seamless and secure electronic exchange of clinical information within the NHS. Challenges to NPfIT highlighted in the media and academic commentary are common to such initiatives worldwide. This paper offers key messages and recommendations derived from a comparable electronic clinical communications programme in Scotland, and elsewhere, as a means to aid the implementation process. . . Observations, recommendations and lessons learned:

• Complex IT projects usually take longer than anticipated and cost more than initially estimated
• Never underestimate the complexity of a multi-faceted programme
• Target realistic and timely outcomes
• Avoid raising stakeholder expectations unrealistically
• Involve end-users early in the process of developing new systems and act on their feedback
• Ensure communication and integration between related programmes
• Clarify the conceptual nature of the programme
• When commissioning evaluation research, recognise what can and cannot be demonstrated in the timescale and budget that you are considering
• There should be openness about the processes of the programme and a willingness to accept and respond to feedback from objective observers
• Human factors are as important as technological ones in getting systems into practice"

Who and what are electronic patient records for? (13 Sep 2006)

Proc. Symp, Current Development in Ethnographic Research in the Social and Management Sciences

http://www.liv.ac.uk/managementschool/ethnography/papers/14_David_Martin_-_Liverpool_Paper_Martin.pdf

"[We] report on a field study conducted between 2003 and 2005 at an NHS Trust in the North of England. The choice of case study is interesting because the Trust in question was an 'early adopter'. Before the current version of the NHS IT programme had been announced, the Trust had already signed a contract with an Anglo-American software firm - hereafter 'OurComp' - for them to implement and support a full blown EPR system. The NHS gave them the go-ahead, and so the study provided an opportunity to investigate what some of the issues might be when the larger scale deployment of such systems across England and Wales got underway. . . When the system eventually went live we were lucky enough to observe the first week in the hospital. Unfortunately our concerns were proved valid - the system proved to have multiple problems. Most notably it did not fit well with a number of existing work patterns but to compound this, due it its strict model of governance, when work did not fit with the system the system broke down. . . The unfortunate postscript to this is that after the first week our access was denied as the drama unfolded. It was not particularly unfortunate for us as our project has gone well. However, we do feel very sorry for the members of the project team as it appears that the blame fell as some of their doors even though it was clear from our fieldwork that the system had not failed through lack of skill or effort but rather it had been bound to fail because of the massive ambition for the 'EPR' in general and the way the NHS has conceived of the requirements for such systems. . ." [David Martin]

A Local Sociotechnical Design Approach to Exploiting the Potential of The National Healthcare IT Programme NPfIT (3 Nov 2006)

The Bayswater Institute

http://www.bayswaterinst.org/downloads/Exploiting%20the%20Potential%20of%20NPfIT.pdf

". . . In practice the use of a NPfIT system will depend on its match with local requirements. If the 'push approach' is limited to training the users in the operational detail of each IT system, it will be left to each specialty and each unit to find its own way of 're-constructing' the system to suit their needs. The users will decide what to use and what not to use and how to 'workaround' the obstacles or inadequacies. This will become a piecemeal approach, largely hidden and informal, and may well involve a lot of delay and stress. It is likely to be dysfunctional from the point of view of the staff and management of each Trust and also for those who have invested in the development of the systems. Is there a better way of implementing these systems? . . . A striking feature of the NPfIT programme is that many people in the NHS seem to agree with its overall goals. What they have trouble with is the way it is being implemented. There is a lot of work to be done in every Trust to implement the new systems. If we can mobilize the reservoir of expertise in healthcare matters that is available in every location it may be possible to find ways of 'pulling' these systems in the direction of significant local goals. If not, unintended consequences will be rife as we try to cope with systems that do not serve local needs. Under these circumstances neither national nor local goals will be met." [By Ken Eason]

Understanding and Improving the Design, Deployment and Use of Electronic Health Records: Final Report (2007)

Chameleon Project - EPSRC GR/R86751/01

". . . We used ethnographic studies of EHR projects, interviews with stakeholders and workshops to examine fundamental assumptions surrounding EHRs, and explore the fit with existing and emerging practices, technologies and regulatory requirements. The case study design enabled examination of factors such as project scale, clinical setting, professional and organisational boundaries, and the different integration strategies adopted by NHS England and NHS Scotland. . . Our findings raise a number of issues that must be seriously considered as NHS programmes continue:

• The NHS has seriously underestimated the scale of the task involved in deploying EHRs. Constantly changing government and NHS policies has led to EHR procurement being very protracted: requirements have to be continually re-drawn and re-shaped and often leads to unsatisfactory compromises. Procurement is also made problematic because these systems will be used as instruments of significant organisational change. However, the Trusts (and the NHS itself) do not have a concrete idea of what the results of those changes will lead to, consequently it is very difficult to assess system suitability.
• Although ‘supporting medical practice’ and ‘patient centred’ are twin mantras of EHR design in the NHS, an over-riding design emphasis is on implementing ‘proper’ process, and on coding medical and administrative procedures ‘correctly’ so they may be standardised, counted and reported on. These ‘other’ requirements that stem from the need to provide fully technically and organisationally integrated systems can actually disrupt current medical practices. Standardisation implies that some features of local practice will be re-configured around new models that may run contrary to the way staff organise and understand their work; technical constraints can reduce flexibility. Since these ‘other’ requirements must be met, support for tried and tested local work routines may be removed with serious consequences later down the line.
• Currently, NHS hospitals have a poor understanding of exactly how they function in any kind of overall, comprehensive manner. Processes, if they are documented, are done so on a departmental or speciality basis, so particularly achieving ‘integrated, computer-supported’ working represents a massive organisational challenge that consideration might have been better paid to before the purchase of systems. Addressing this problem calls for better management of stakeholder – and local user – participation in EHR projects but this is very difficult to achieve. Identifying the ‘right’ stakeholders is problematic in such large and diverse organisations, they will likely have some competing versions of current practice and competing ideas about where they want the design to go. Managing this effectively is a big challenge. . ."

Interpretive Flexibility Along the Innovation Decision Process of the UK NHS Care Records Service (NCRS)

Int. J. of Technology and Human interaction 3(2), 1-12, April-June 2007

http://csrc.lse.ac.uk/asp/aspecis/20050093.pdf

". . . In this paper, we look at how interpretive flexibility manifests through the diverse perceptions of stakeholders involved in the diffusion and adoption of the NHS Care Records Service (NCRS). Our analysis shows that while the policy makers acting upon the application of details related to the implementation of the system, the potential users are far behind the innovation decision process, namely at the knowledge or persuasion stages. We use data from a local heath authority from a county close to London. The research explores, compares, and evaluates contrasting views on the systems implementation at the local as well as national level. . . With medical errors becoming a cruel reality in the provision of healthcare worldwide, the role of information technology in preventing those errors becomes predominant. It is recognised that more people die every year due to medical errors than from vehicle accidents, breast cancer, or AIDS . . . One way to reduce medical errors is to make efficient, accurate, reliable medical decisions, based on reliable and up-to-date information or patient records. Integrated patient records can reduce medical errors by using information technology . . . NCRS is one of the National Program for Information Technology (NPFIT) targets and, as with many healthcare IT projects, its evaluation will be difficult, provided that government led IT projects in the NHS have a history of notable project failures. The complexity of such huge investments, currently £7.6 billion, calls for a clear understanding of the environments in which healthcare networks exist. The research focus here is the diffusion of the NCRS from the policy makers at a highest decision making level to the users of the system. We examine how diffusion receivers (users, such as doctors or nurses) perceive the NCRS implementation in comparison to policy makers. We argue that there is a gap between the demand and the supply side of the diffusion process, which reveals a broad barrier in the NCRS implementation. We use primary and secondary data to capture the perceptions of both diffusers and diffusion receivers in order to get a better understanding of the NCRS diffusion process. The primary data was collected through interviews with the managerial and technical staff as well as future users of the NCRS within a specific county in the United Kingdom. . ."