Background
Methods
Aim
Study design
Theoretical approach
Study setting
Description of preparing for EHR use
Sampling and recruitment
Participants
Interview design and content
Analysis
Results
Theme | Sub-theme |
---|---|
Coherence | Understanding of reasons for introduction |
Purpose of EHR | |
Anticipated benefits | |
Who think will benefit | |
How it differs or compares to paper records | |
Cognitive participation | Concerns that have about using the system |
Training and support | |
Collective action | Perceived impact on practice |
Perceived impact on existing work practices | |
Perceived impact on working relationships | |
Reflexive monitoring | Perceived long-term benefits |
Perceived opportunities to adapt system | |
Perceived barriers to use | |
Disadvantages to use |
Coherence – do staff understand the reasons for EHR implementation and the potential value of incorporating use of the EHR into their routine work?
Clinicians, on the other hand, viewed EHR as treatment-centric and an aid to patient flow and decision making:Nurse (Sister): “It’s going to become more of a task-orientated job, where you’re having to input stuff into EPR, rather than just getting on and carrying on with your clinical work like you normally would … ” (10:54-57).
The idea of using an EHR in routine practice was strongly supported by the majority of participants, with a number of anticipated benefits proposed. Participants were particularly enthusiastic about the prospect of having all information in one place. The majority of views coincided with the ‘official perspective’ of the anticipated rewards of EHR implementation. The presentation of information in a standardised, legible format was particularly well-received:Doctor (Consultant): “ … you will be able to get a better overview of the department, so to run the department will probably be easier.” (3:289-290), and Manager: “[It will] reduce clinical variation, improve the safety of care for patients and drive decision-making … it tells them [clinicians] what to do so we get consistency in practice.” (7:181-185).
Use of the EHR was expected to improve efficiency of transfer of information between different specialties, leading to improved prescribing and test requests: “… the electronic prescribing, the electronic requesting, those things will be better”. (Consultant, 4:558–559). One participant, with direct responsibility for hospital governance, expected that over time, use of the EHR would improve capacity for audit and research. This would optimise opportunities to produce robust evidence for good quality care, as well as highlighting areas for improvement:Doctor: “The thing that I am looking forward to most is being able to read the consultant’s writing, which I, personally, struggle with at the moment, whereas if it’s dictated and typed there is no, sort of, room for error. So, that is the best part of it for me.” (2:114-116).
Beyond improving access to and legibility of information, the anticipated benefits of the EHR varied across and between staff groups and services. EHR implementation was expected to be of most benefit to the working practice of junior doctors. For example, it was expected that the risks of missing important information or steps required within clinical decision making processes would be minimised through prompts to enact specific protocols within the EHR:Manager: “ … once it settles in … the benefits of what the outputs are from the system … I think it will prove that actually we deliver high quality care across the board. And then we’ll know the areas where we don’t and we can target them.” (7:161-173).
It was less clear how nurses would benefit, particularly with regards to the volume of information that they would need to record into the system. Nurses were concerned as to how important information could be safely passed on to their colleagues:Doctor: “ … when you try to do a ward round for a person, or clerk somebody in, you physically can’t do anything until you do a VT prophylaxis, until you put their weight to prescribe a drug … if you prescribe a blood thinning medication … somewhere it forces you to do a certain score of their risk of bleeding … things that basically can be missed out quite often if we are doing paper versions.” (2:138-144).
Nurses were also concerned that using the EHR could take them away from the business of nursing:Nurse: “ … we don’t physically know how we are going to give handover … people worry about how that’s going to happen safely, for the information to be passed on safely from one shift to the next … because there’s a lot going on, tests and results chasing, all that sort of thing … ” (1:47-54).
Senior clinicians, who were not members of the EHR support team, expected to benefit least from implementation, primarily because use was perceived to have the potential to slow down their pace of work:Nurse (Sister): “We’re all a bit scared of is it going to be task oriented, taking you away from your patient care … taking time away from the patient so we can tick all the boxes on the system … ” (10:20-26).
A cumulative effect of least benefit existed between senior clinicians and outpatient services. The relatively fast pace of patient flow in clinics, and a perception that the staff working in these services were less computer literate than their acute services colleagues, meant that the introduction of the EHR was perceived as a potential threat to service delivery: Doctor (Consultant): “… I think outpatients will be an absolute disaster...” (4:516).Doctor (Consultant): “When I clerk someone … I'm going to have to put that on to [EHR]. Takes me two seconds to write it down … It's going … to take me 30 minutes … well, I don't know, 15 minutes a record plus. It's not going to be quick.” (4:160-165).
Cognitive participation – are staff prepared to engage and commit to using the EHR?
Concerns raised about using EHR
Despite a positive appraisal for the perceived benefits of the EHR, some health professionals felt unprepared to operationalise the system within their usual work practice. Senior staff reported a lack of engagement with them as to how the EPR could best work for them:Nurse: “ … we don’t have any ward clerks … we have to wait for admissions to do it … so we’re waiting to put a patient actually on to the system before we can do anything really … ” (13:351-357).
Participants were concerned that patients with complex needs or co-morbidities did not easily fit into EHR templates. They were concerned that drop-down menu options would be rigid, which could result in triggers for tests, which, in clinical opinion, may not be necessary:Doctor (Consultant): “No one’s engaged with us at what we want on the wards and we are being told what we want” (4:44-46).
Those participants who believed that the go-live weekend was imminent were concerned that they lacked access to computer equipment or lacked physical space in which to operate computers. Additional challenges related to the practicalities of agency staff using the EHR system. For example, for wards that depend on agency staff, there was concern that these staff may not know how to use the system, and that this deficit would lead to an increased workload for nurses. Despite online training provision for agency staff, participants were concerned this pre-requisite would put some agency staff off coming into the hospital, thereby reducing further the numbers of staff available:Doctor (Consultant): “ … One of the problems with my particular speciality … is that everybody has got a slightly different type of problem … if you’re a delirious 80 year old, that can be because you’ve got subdural haematoma; it can be because you’ve got a UTI; it can be that you’ve just got dementia. So it doesn’t fit easy into a tick or drop-down box … and you’ll just have to populate various things, which will then populate various tests … So that concerns me.” (8:51-60).
Nurse: “ … we don’t even know how the agencies [staff] are going to log in to it. They just all going to turn up on that night and we don’t have a clue what they’re going to do. Apparently at other trusts they have got to go and get the nurse in charge to verify what she’s doing … ” (11:692-696).
Training and support
Many participants were not experienced in using computers in their daily work practice and reported a lack of opportunity to move beyond the classroom setting. Some participants believed that the training inadequately addressed generational differences in computer literacy and felt that it fell short of their expectations:Nurse: “We are not trained enough to be sure we know what to do … I don’t feel confident to back up somebody who doesn’t know what they are doing.” (11:218-224).
There was dissonance between staff expectations and training objectives. One senior member of staff suggested that: “… the knowledge of the system is now ready, the skill of how you use it will only happen when we go live …” (Manager, 7:63–65). However, lack of capacity during shift hours and lack of access to play domains impeded some participants’ ability to engage with the EHR. Where they were able to practice on play domains, some participants found there was inadequate simulation of what they would do in practice:Doctor (Consultant): “ … the people who did the education just told us what they wanted us to know. They didn’t work out what I needed to know to make it work” (4:331-333).
Doctor (Consultant): “The play domain isn’t fit for purpose, for a number of reasons … it isn’t integrated as it should be … ” (8:77/120), and:
Several participants reported that they were efficient in performing ‘little tasks’ using the EHR, yet were anxious as to how they would integrate use of the EHR into their usual working practices:Nurse: “ … some of the patients don’t have drug charts set up on them, and yet it’s a nurse domain but nurses don’t prescribe. So that part of the training package is not quite really what it should be … ” (1:175-177).
This was compounded by uncertainty over the level of support that would be available to them, particularly during the early implementation phase. Some participants were suspicious that plans for additional resources would not materialise, and they would be pushed to deliberately fail in order to gain access to additional support:Doctor (Consultant): “ … There’s a lot of stuff in the middle, which is the important bit … and that is why so many people are anxious about what is going to happen in three weeks’ time” (8:154-158).
Nurse: “ … I think we have to fail in a way in order to … get loads of screens in there.” (11-12:416-422).
Collective action – do staff feel able to do the ‘work’ to use EHR?
Nurse: “ … we have in our practice found out that you don’t have to fill them all out, so we’re already cutting corners.” (1:545-546).
Working relationships
It was anticipated that some members of staff would require more support to use the EHR than others. With the introduction of the EHR, some participants were concerned that junior doctors would be left to: “sort their own selves out … and get themselves up to a certain level” (Nurse, 1:94–95). There was variation in understanding of the anticipated change to working relationships between different professions, with some staff unclear as to how their role would evolve: Ward Clerk: “… but apparently there are other things that we’re going to be doing instead [of filing paper records], which I don’t know …” (5:116–117). Unfortunately, some participants anticipated that staff may leave the NHS as a result of implementation as they would find use of the EHR too cumbersome:Doctor (Consultant) “ … one of my issues with junior doctors is that they will spend time being clerks on the computer rather than being a junior doctor … they won’t be behind the curtain with [the patient] … I think it will have a significant impact on their potential training on the job”. (8:512/551-555).
One participant suggested that where there was strong team cohesion, they were confident that they would ‘ride the storm’:Nurse: “ … some staff on the ward are older and are frightened of the computer, even in this day and age. Two staff may leave on the back of this, because I think they will find it too much … ” (1:27-30).
Nurse: “ … we’re a good team on here, and I think if they can’t manage on here then they’re not going to manage anywhere else; and we know that it’s doable … ” (1:105-107).
Patient flow
Participants accepted that compulsory completion of templates may reduce the risk of important information or decisions being missed. However, anecdotal reports from a neighbouring hospital who recently implemented the same electronic system caused concern. Specifically participants discussed the potential for the EHR to increase duration of ward rounds, which may delay discharges, affecting A&E waiting times and in turn pose risks to patient safety. They also based their perceptions on experiences in primary care following the introduction of EHR. Participants were also concerned that sometime after implementation in primary care, wait times had not returned to pre-implementation levels:Doctor: “ … typing it all out, and drop down boxes, and searching … which is just a long drawn out version of what we do at the moment. So it will take longer … ” (2:200-206).
Similarly, in out-patient services, participants were concerned that EHR use would limit and slow down productivity in services which were ‘working flat-out’ (Consultant, 4:66). Longer wait times as the staff got used to using the EHR system were anticipated-with services considered unprepared to respond. Although there was a planned 25% reduction in clinic referrals for the first 2 weeks of the EHR going live, some participants believed that this did not allow enough time for the system to be fully embedded. This was compounded by an observation that the majority of staff working in out-patients were comparatively slow typists and so EHR implementation was, to a point, considered an unjustified additional use of time. As a result, the initial implementation period was predicted to be:Doctor (Registrar): “You go back to GPs … When their electronic records came in years ago they were on six and two third minute appointments. They changed to ten minute appointments and they’ve never been able to go back … ” (14:120-123).
Doctor (Consultant): “ … horrendous … ” (9:326) and “ … there’s no turning back now, it’s going to happen … we wait with baited breath” (8:820/828).
Available information
Similarly, clinicians were concerned that they would not be able to provide a comprehensive picture of their thinking around patient care, which may change the nature in which clinical opinion is communicated. Some participants were worried that although they could find ways to work around this issue, the rationale underpinning their clinical decisions would be lost through use of the EHR. The loss of information on clinical opinion was considered to potentially result in a lack of transparency as to how patient care is carried out:Nurse: “ … you could take a phone call from some relatives who were concerned about their mum, and you could be on the phone for 45 minutes, and you are getting all sorts of information thrown at you … you could have 4 or 5 of these conversations in one day … Most of us are only two-finger or one-finger typists … We’re worried about how long it is going to take up to record accurately their concerns … so that nothing gets missed.” (1:419-430).
Doctor (Registrar): “You will lose a lot of information … you really need all that information in there … because it is a clear record of what story we were given, what examination findings we were given and what is the clinical opinion. And that is still a really vital part of what we do … there is a danger of losing some of that information … ” (14:166-171).
Reflexive monitoring – how staff appraise the EHR
Advantages
Participants believed that patient safety and quality of care would be improved through use of the system. They expected that EHR use would result in a reduction in risk of errors, particularly around prescribing. They also anticipated transparency in errors and safer practice as all information would be legible and collected in a consistent manner:Doctor (Consultant): “I think once they first start out, there’s going to be a lot of input going in. But the benefit after a few years is when they [patient] come back to us, you’ve got all the history, you’ve got all the past medical history, you’ve got the drugs, instantly you can see what they’ve been in for before … there’s no delay … ” (9:288-293).
Doctor: “ … I think with prescriptions and prescribing, often it [EHR] flags up errors. So I am hoping that if … you try to prescribe … five hundred grams of amoxicillin which I have seen … it will flag that up and say, that is not an appropriate dose for a drug … ” (2:158-163).
Disadvantages
For some participants, there was uncertainty as to what actions they could take if the system was not working for them, with the exception of reverting to paper records:Doctor (Consultant): “ … the people telling you how to do it are telling you how they think you should do it and not telling you how you currently work, and therefore how the system will best be developed for you … ” (4:58-62), and Doctor (Registrar): My understanding is there are going to be people about. There are EPR friends. I don’t know any... I’m just going to wait and see and deal with what we’ve got and take it from there” (14:365-368).
Use of the EHR was expected to expose further frustrations in the hospital system and that blame could falsely be apportioned to the EHR. Participants were also concerned that patients could be harmed as people did not know how to use the system. To off-set this, EHR implementation was ultimately perceived as moving towards ‘paper-light’ as opposed to a paper-less system:Doctor (Registrar): “ … We’ve got to maintain patient safety … I’m going to have a sheet of paper that I will … I’m sitting in front of the patient, I’m still going to have my little notes … So whether they want to keep that bit of paper as a record for whatever reason, I’m going to leave it for them to decide … ” (14:371/482-488).
Manager: “I am anxious that we’ll harm patients because people don’t know how to use system, haven’t got the skill. But the mitigation to that is that the patient takes priority, the system is just there. If you can’t get it to work or you don’t know how to do it, you write on a piece of paper … ” (7:265-269).
Discussion
Strengths and limitations
Recommendations
Conclusions
Key learning points
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Health professionals’ perceived potential value in using EHR and that benefits to use would be reaped after an initial embedding period.
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Health professionals were motivated to invest in implementation.
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There was variation across staff groups and services on the perceived impact of EHR use on their ability to carry out their role.
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Junior doctors and acute services could be responsive to the system. Outpatient services, nurses and senior clinicians would have to react to the system.
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There was variation across staff roles and services in perceived opportunities to facilitate their engagement. Nurses and senior clinicians perceived that they were least prepared, and that opportunities for them to engage in preparation were limited.
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There was consensus that staff would find ways to make EHR work for them in practice and that this would likely involve a move towards being a paper-light, rather than a paper-less system.
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The four core mechanisms of NPT provided a useful framework to explore individual and group expectations for change and outcome following procurement of an EHR.