Sunday, November 16, 2008

Improving quality through effective implementation of information technology in healthcare

In 2003, two Stockholm hospitals 40 km apart merged to form the one Karolinksa University Hospital. Interviewees reported that there was a need to form a common EMR to increase integration and allow communication between the two sites, and, ultimately, other services.

Three independent appraisal studies were carried out. The reports were made to one session of heads of department: interviewees describe a ‘defining moment’ when the chief medical officer asked for a ‘show of hands’ from the group about which system should be adopted, and nearly all voted for one system. The meeting recommended that all departments at one site (Solna) would move from five different types of medical records to the one system used by the other site, and this was accepted by top management.

The new system would need to be installed in 40 clinics with 7000 users at the Solna site. Some new hardware had to be installed, as well as considerable changes to software. The new system contained patient administration, clinical medical records and referral- and replies to referral information, but it was not an entirely paperless record: there were still many documents such as EKG and ‘pictures’ (e.g. radiology).

Analysis of documents and interviews show four key choices, which were confronted and made before implementation, all related to making the key main change within 1 year using limited internal implementation capacity, and delaying other changes to later phases. The first choice was about the extent to which top-level management and the IT department should prescribe the system and its details, and how much and what type of independence the departments should have.

The preparation process involved the departments, and top leadership made the timetable and managed the project tightly, but departments could choose at what time during the year they would implement and some of the details of the screens which would be created by the hospital IT department.

The second key issue was whether to use an outside implementation service or use the limited in-house resources for implementation. The solution was to manage the project internally, phase-in the change over time, and to use external consultants for specific changed which needed to be made. This was possible because of a third choice and decision, which was not to attempt to implement computer physician order entry (CPOE) to order medications at the same time but to phase this in after the EMR and in the following year.

The disadvantage was that some departments would loose CPOE, which was functional in the current system. The fourth choice was not to implement functions which different departments needed for research during the EMR phase, but to modify the EMR in the second year to allow this.

Project process to introduce the EMR

Once the decision was made in 2004 about which system to introduce, interviewees reported that senior leadership made it clear that departments only had choice about small screen modifications and their date for implementation in 2005. Each department was required to nominate staff internally to form a department project group to work with the information technology department to fine-tune the system for the department and carry out implementation. During 2005, all clinics had the same interventions from the project members and the plan was almost exactly followed.

Effects of the system on personnel and work

An analysis of the interviews carried out half way through implementation (June, 2005) through to 3 months after implementation (March, 2006) identified common themes that are listed below and illustrated with typical quotes from informants. Approximately 95% of the comments were positive about the implementation process and the new system.

The relatively successful Karolinska implementation could be due to:
  1. Consultation before implementation
  2. Consensus about a need for the system and which system was best
  3. Prioritzation and ‘driving’ by management team
  4. Competent IT project leader and team
  5. Tested, user-friendly and intuitive system needing little training
  6. Potential for development of the system
  7. Medication order entry not difficult to integrate after implementation
The evidence from this and other research is that an EMR designed to meet many different needs often does not meet local clinical work needs, is more difficult to implement, and can reduce productivity and access to information critical for patient care and safety.

A new system will need to have benefits which significantly outweigh these disadvantages and which are clearly communicated, if it is perceived to be less user-friendly and requires extra time for operation, which is often reported to be the case in previous research. Time and resources will be needed to develop the system.

Practical implications

In this study, the comparison with other research suggests general lessons for others implementing an EMR system in a hospital:
  1. Choose a system which allows a range of needs to be met and is a tried and tested in a similar setting,
  2. The overriding choice criteria should be a system that works for clinical personnel and saves time. Resistance is not always irrational. If personnel do not think it is easy to use and will save time then implementation will be significantly more difficult and possibly impossible.
  3. The system should be intuitive, requiring little or no training,
  4. The system should be easy to modify and develop, within limits, for different departments and uses.
  5. The decision about the system should be participatory, but once made, implementation should be directed and driven.
  6. Balance local control of selection, implementation and clinical participation with meeting higher-level requirements.
  7. Involve each level in different ways, with clear and appropriate parameters about which decisions can be made locally and which require higher-level decision about common standards.
  8. Assess and address the presence and absence of prior and concurrent factors, which have been repeatedly shown in research to help and hinder implementation.

Health services do not have a good history of cost effective implementation IT and especially of EMRs. The potential for increasing safety and productivity of this ‘quality intervention’ is largely unrealized. The study of EMR implementation presented in this paper was carried out using the same case study method of an implementation in the USA. After reviewing previous research, the research team expected the EMR planning and implementation in this study would follow the same problematic pattern of other implementation.

The findings of the research team, who were entirely independent from the hospital, were unexpected and contrary to most previously reported research: the Karolinska implementation was successful, on time and within budget.

Empirical data of respondent’s perception of what helped and hindered implementation show a consensus about the main ‘helping’ factors. These were the local hospital control of selection of the system, employee involvement in many different ways, leadership and support by a competent on site information technology department, and decisive and full leadership backing.

The Karolinska experience suggests that a tried and tested EMR, which is accepted by physicians can be implemented successfully in 1 year into a teaching hospital with some experience of computerization. It did not show whether such a system allowed the clinical work and process redesign, which some thought necessary and as a missed opportunity during the implementation

Other findings about what helped and hindered were derived by comparing interviewee data to a simple implementation theory developed from a review of previous research. The findings from this revealed the importance of organizational, leadership and cultural factors, as well as a user-friendly EMR, which assists clinical work, is easily modified and which saves time and increases productivity.

This theoretical model for successful implementation is based on a review of research and supported by the evidence of this study. It provides a theoretical basis for future research and a practical tool for implementing an EMR and realizing the potential of this method for improving safety and the quality of patient care.

(Source: International Journal for Quality in Health Care; Volume 19, Number 5: pp. 259–266, 23 August 2007)