Interview data was obtained from a total of 19 different participants, two official hospital documents were identified by the key respondents and subjected to documentary analysis. The research team also carried out 30 h of observations, which were recorded in written field notes.
Problematization: weak hospital information systems
The hospital suffered from the lack of integrated information due to the different systems in use at the hospital and the lack of data exchange between them. The situation was marked by the resulting issues: first, there was limited functionality when ordering test results, as the process was still paper-based. Three separate radiology systems existed that did not support the integration of PAC and there was no single Master Patient Index for covering these services. Furthermore, eight different patient databases were in use with different patient numbering systems. This meant that patient information was entered into multiple systems for each patient episode and could not be linked or shared electronically.
The hospital had three separate patient administration systems, with the majority of the patient’s clinical letters written in MS WORD and therefore not linked to any electronic patient record, and two unrelated A&E systems that were not integrated with the rest of the hospital. For this reason, a great deal of important clinical information was only available to A&E and not to other parts of the hospital, except in the form of paper case-notes.
Furthermore, the basic results reporting facility available to clinicians was hampered by huge clinical weaknesses that reduced its usefulness and capacity to support clinical governance, and the hospital was unable to provide a patient’s clinical letters (e.g. discharge letters) and radiology reports generated at regional level.
The Director of eHealth described the situation prior to the adoption of the EMR project very clearly:
“Up to 2004 the situation at [the] hospital was marked by inefficient processes; clinical decision making was based on a minimal information service that was not patient friendly and bore an unacceptable level of risk.” (Interview with the Director of eHealth).
He also added:
“To give you an idea, 5 years ago we had 3 A&E systems, 4 radiology systems and 3 separate patient administration systems. I think we had a total of 17 systems doing almost the same thing and patient details were registered in different systems and it was impossible to get the full picture”. (Interview with the Director of eHealth).
Another interviewee offered an interesting opinion, mentioning the need for patient information in real time throughout the entire hospital.
“The main problem was that paper records were not reliable. We didn’t have any choice; we just needed a better system. At the time, we had a huge storage problem with storing these records. We can’t store them on site, they have to be somewhere else, and then we’ve got to wait until somebody finds them and we periodically lose them. So having an electronic system means that we’ll get easy access to the patient’s record, when the patient is there. Instead of having no records and information about a patient because they’re in a storage facility.” (Interview with a clinical advisor)
These interviews describe the first moment of translation, when the identification of what constitutes a problem to be solved occurs.
When asked interviewees to identify the person who was most influential in encouraging EMR adoption and who played the most relevant role at this stage of translation leading to the enrolment of other actors in the network. All the interviewees, including the members of the Strategy Board and the advisors involved in the project, mentioned the same person: the Manager of the eHealth Programme, who was the EMR project manager at the time of the adoption. All of the interviewees, including clinical and nursing staff who did not know him personally, mentioned him as the leading actor within the project and said he encouraged EMR adoption, playing a major role in making it happen.
He represents the ‘focal actor’ capable of defining the identities and interests of other actors, and of establishing itself as an obligatory passage point thus "rendering itself indispensable" [
17].
Interessement: the EMR solution seen as non-human super actor
Interessement represents the second moment of translation, which involves a process of convincing other actors to accept the definition of the focal actor [
17]. The different actors we interviewed suggested various reasons for the adoption of the system. As noted earlier, we approached the EMR application in health care organizations from the perspective that it can never be a process of simply installing and using a new technology [
48] and that different groups within an organization may see the same technology as achieving different goals.
The interviewees at the hospital identified three main reasons for adopting the system: the need for information within the organization, to integrate information from different systems, and to improve value for end users and patients.
The main push for adoption came from the clinical staff, not management staff, and the preferred system was chosen from two potential solutions during a workshop attended by clinical staff. This emphasizes that the adoption of the system was marked by “consensus” regarding the need to introduce the system and the system selected [
49].
As a result, we investigated how the selection of the system happened. It appeared to be based on a “user-centered approach” during the selection and adoption phase, listing the needs of end users, involving them early on, thoroughly and systematically [
50] [
51]. A participatory process in selecting the EMR system represents a distinctive way to generate and improve commitment to the project within the organization. Conversely, if this process is imposed, it can generate user frustration and have a negative impact on the implementation process and on the overall use of the system.
We questioned several of the people in our sample, but a clinician from the A&E ward offered the most instructive answer.
“Before choosing the system we adopted, we had the opportunity to look at several options” (clinician from the A&E ward)
One option was to identify a new software vendor; the other was to use a company that had already supplied a number of core systems. The name of the other potential supplier was not revealed, for reasons of privacy and ethical considerations.
The clinicians unanimously decided to adopt the first option. The 60 people who took part in the workshop were invited because they were involved in the process in various ways and this was the final part of that process. Thus, the system selection and further developments were user-centered, based on user needs and on a participative approach.
In fact, in order to select the system, the hospital proceeded in a clear way:
“We undertook the usual evaluation: supplier presentation, discussion, cost - benefits analysis. We had to produce a case study for submission to the Scottish Government. The preferred option was chosen halfway through a workshop we organized and I think we had about 60 people at that workshop. The majority were clinicians and all the clinical staff put their hand up for the new system.” (Interview with the Director of eHealth)
Some interviewees identified other reasons for adoption, emphasizing the relevance of the system and clarifying the aspects leading to system adoption.
According to a member of the Strategy Board:
“The overall project is the reflection of the commitment and dedication of both the hospital and supplier teams, working together to make this happen. As part of the move from the hospital’s current systems, over a million patient records were transferred to the new system from both the previous patient administration and A&E systems. Previously these systems were operated independently from each other and led to unnecessary repetition of data entry during the patient care process. The new system will allow all or part of the patient records to be available to clinicians at a time and place when it is needed, supporting high-quality patient care through faster access to patient information.” (Interview with a member of the Strategy Board)
According to a clinical advisor working for the eHealth department and in charge of supporting and supervising the maternity unit:
“From an organizational point of view, clinical staff wanted to have more information about their patients, let’s say about mums, such as more strategic info coming out from the system, so they could do more work with planning activities also for long periods” (Interview with a clinical advisor working for the eHealth department).
The new EMR system is a “connected healthcare information system” with EMRs integrating clinical and administrative modules. As emphasized by the interviewees, the system offered the opportunity for
adequate administrative information for care and operational managers, since it helps to streamline the collection and the processing of administrative data with minimal workload for health care professionals.
“The new system lets you collect and store huge amounts of data. It supports administrative processes related to patients’ data, assuring information is broadly available, timely, reliable and always correct, or as we used to say: ‘correct first time’”(Interview with a member of the Strategy Board)
When asked to identify the main reasons for adoption, a senior clinician from the General Medicine ward explained that:
“This hospital was designed so that the laboratory service has a single central booking area with few staff…so it was looking for help to manage this and electronic ordering provides a way of doing this …It was the possibility to get all the information and demographic data so they do not have to enter this data and look for it in others papers.”(Interview with a senior clinician, General Medicine ward)
This enables multidimensional integration that is particularly relevant for the implementation of EMR systems, enabling the full scope of the clinical and administrative information relating to a patient to be collected together. In this way, the EMR provides a patient-centric display of all available information.
The interface of the system made it simpler to use and to apply. It was clear that this EMR system would be a much better solution in terms of integration compared to the product offered by the other supplier. The Director of eHealth added:
“I think they felt that the first supplier was more able to list what the organization needed, while the other supplier was very rigid and said what they should do and what they should not, so they had very clear reasons for choosing this EMR system.” (Director of eHealth).
Enrolment and mobilization
In this study, the success of both the problematization and interessement phases, which illustrate the relevance of a participative approach in the decision making process, had a significant influence on the enrolment and mobilization phases, which went hand in hand in this study. The manner in which enrolment and mobilization progressed is described below through the experiences of different actors.
In the enrolment phase, a variety of actors agree on the roles and identities defined for them as actions for change: new roles were defined to lead to system implementation with the hospital.
The implementation of the system was structured: it started by implementing the most relevant functions across the entire hospital, and then continued by piloting additional functions in single wards in order to test them and to get feedback from staff working on the selected wards. This helped make any adjustments based on results and the progress made when using the system. Furthermore, by selecting wards for the pilot test of the new functions, they could analyze how the system worked in different scenarios: inpatients, outpatients, emergency ward. The clinical advisor on the General Medicine ward said:
“An area we are currently starting to pilot is the online review of results….Currently almost all results return electronically to EMR system from the laboratory What we are looking at is how we can read these results and we are going to test how we think this can work for us.
We are piloting this function in an inpatient ward, an outpatient ward and the Emergency department. We would like to understand how well it works in the different scenarios: inpatient, outpatient, emergency. Accident and Emergency is a ward where the system is put to good clinical use.” (Interview with the clinical advisor on the General Medicine ward).
The system implementation was managed by the “Information System implementation team” and was overseen by a “Program Board”, namely a group that initially met once a month and still meets on a monthly basis to oversee the implementation, formulate advice, verify if any help is needed and provide it in this case.
Other key roles were identified during the implementation process and people were appointed to these new positions. Clinical advisors were identified who could assist with the implementation of the system in a specific ward. They worked for a specific ward but held different positions at the time of the adoption. For example, we interviewed the clinical advisor for the maternity ward, who explained how this change took place:
“Well when…when I came into the project, they were implementing electronic medical records in the maternity unit. And I was employed at the time as a qualified midwife on the maternity unit, ward 209. Then in July 2008 a job was advertised for a clinical advisor to come and join the project”. (Interview with a clinical advisor working for the eHealth department and in charge of supporting and supervising the maternity unit).
This suggests that a job advertisement was posted to support the implementation of the system within the unit. No external people were taken on by the hospital to support the implementation process; instead, people were selected who already knew the services provided by the hospital and by these particular wards and were moved to cover the new positions.
Clinical advisors perform specific activities:
-
They accurately represent and apply the best practices and methods of clinical and technical expertise and clinical and technical leadership of the project by conceptualizing, developing and administering training and service delivery to improve strategies, projects and tools;
-
They evaluate interventions by developing, enhancing or reinforcing the use of new systems to build the capacity of staff, consultants in technical content areas and provide training and service delivery;
-
They supply technical input on strategic program and system planning, design, implementation and evaluation.
Furthermore, ‘implementation staff’ were defined to carry out the new system implementation. This support team was initially quite informal. According to the clinical advisor in charge of coordinating the implementation staff, the role of the new team, consisting of 3 people, subsequently grew and is now:
“Picking up on the mistakes that people were making….In fact, looking at the EMR system implemented, we realized we needed to go back and support staff, we had to show them what they were doing wrong and correct it. So that’s how we came about. I have been appointed to this new position since January 2007, before that I worked as a nurse in the surgical unit. My contract was due to expire in 2009 but then they asked me to continue and help get staff on the wards using the EMR system properly”. (Interview with the clinical advisor in charge of coordinating the implementation staff).
After extensive training courses arranged at the initial phase to guide the introduction of the new system, support staff managed the training delivered on the wards. A “key users group” was also identified, namely about 200 people from across the hospital who were particularly interested in the EMR system and its strategic development, and “super users” were appointed on each ward. These are clinicians or nurses who are capable of training other people; they work on the ward and are very motivated so they act as “local facilitators” in each department, supporting staff and training new staff.
The implementation group set up a skills-based system in collaboration with the eHealth department, to train the super users on training techniques. The implementation staff also checked their knowledge of the new system and issued a super user certificate so they can operate in a specific ward.
“We have it all down on paper, with check boxes, until it’s electronic and then they’ve got jobs they can do with their staff and their departments, to make sure they’re competent.” (Interview with a clinical advisor).
Super users were very interested in the new system; they were often already conversant in ICT so their experience was a sort of “knowledge tool”, meaning they had developed good skills in using the system in the past by attending training programs held by the implementation staff. They offered themselves as volunteer “super users” for their ward. This implies that people within the department were no longer required to attend training courses outside the ward. As a result, they did not have to leave their place of work and could get all the help and training where and when they needed it. We should remember that people choose to become super users but do not get any extra money for doing this work.
It sometimes happens that the unit managers identify who could be a super user, however according to the chief of the “implementation staff:
“Ideally, we’d like people to volunteer to do it…” (Interview with the chief of the “implementation staff”)
Being a volunteer not only means they offer themselves spontaneously, it also means they will not get any financial reward. It is a way to certify their skills in using an EMR system and could be helpful for them to add this information on their curriculum vitae when applying for another job.
This can also be recognized as a key strategic role supporting the implementation phase. Previous studies (such as [
52]) have also found that knowledge about a specific health information system is best communicated by persons who are familiar with clinical applications and functions and who are able to integrate the ways of performing tasks with the daily working praxis.
This method of training focused on learning how to use the system by looking at the existing work practices within each ward. The introduction of such systems produced effects on existing work conditions and users needed to learn how to integrate electronic and interpersonal communication of information.
Users needed to feel that the value gained from the adoption of the new system will be higher than the challenges and the effort spent learning how to use it and for changing the previous way things were done [
53].
In this specific stage of translation, the role of super users within the departments was extremely precious but also challenging. All of the nurses we interviewed defined the training activities done by super users on the wards to be very helpful and acknowledged that they had more problems and wasted more time trying to figure out how to manage some of the system functions before this role was introduced.
The senior nurse, who is a super user for one of the wards in the analysis, stated:
“I started using the EMR system five years ago and I found it very simple and intuitive to use…I had some experience in using a PC and maybe this helped me. Then, before the system roll out within our department we attended some training courses; let’s say 3 full days training. Then, we started using the system and last autumn the clinical advisor delegated to our wards from the eHealth office asked for people interested in attending a course for training other people in using the system. I usually help my colleagues and so I offered as a volunteer and my colleagues also suggested my name. I think the EMR system is a very useful tool and I think it has changed not only how they manage patient records but also how they communicate with each other, the way we provide patient care services, and perform job responsibilities. For these reasons, I decided to also take part in the skills assessment test, since I think the system can effectively change the way we work and help our patients”.
However, not all the people reacted in such an enthusiastic way as super users.
According to eHealth department advisors, and based on what staff said themselves during the interviews, many people were skeptical because they were asked to do something that they didn’t do before.
“It’s like any change, people automatically say, oh… They’ve got a fear of change. For the majority of them, when they realized all they had to do was a few clicks on a screen, then, most of them thought well, is that it? Okay, we can do that. Another set of people was more unsympathetic to using the system and it took us a long time to convince some of them (that) what they were doing, the way they were working with paper records was actually taking longer and if they would just click on the screen, that’s a lot quicker!! For example if the nursing staff have to do blood exams on patients, the doctors would write the forms out. So they have to wait for the forms, and then they would go and take the blood. Now they do it all online, and there’s no forms, no paper involved. A little label prints out, with the patient’s details, they stick it on the blood sample, and away it goes, that’s it. If you enter the ward and say to them, right, we’re gonna take all that away, and you’re going back to the old system, and you’re gonna do it on paper forms, oh no, no; no, no, don’t do it; don’t do it. They thank me afterwards. So although they complain that it was time consuming initially, they don’t want to take it away either.” (Interview with a clinical advisor from the gastroenterology ward)
The way in which people reacted to the adoption and implementation of the system was also influenced by their age and attitude to ICT in general.
When the implementation started, many people did not use IT. Younger staff knew how to use a PC but older doctors and nurses were a bit more reluctant. After some time, they started to recognize that it can help to cut their workload since a lot of information is stored on the EMR system: clinical letters for nurses, patient discharge letters for doctors, test results.
Doubts were initially raised on the wards about safeguarding patient privacy when using the EMR system. In some departments, staff felt that the initial training was poor:
“We were greatly criticized for training, they felt training was, was very poor.” (Interview with the Director of eHealth)
But the eHealth department and the strategy board understood these needs and came up with solutions, such as implementation staff and the role of super users on the wards.
User-involvement in this case represents an important element in the enrolment and mobilization stage: it helped to promote enrolment and foster ownership of the system. It is not enough to include a few potential users in the project group to have them negotiate the system specifications and discuss implementation plans and the achievement of change in a meeting: it is necessary to include people at different levels, also defining specific roles and the activities to be performed. As the interviews brought to light, people within the wards started to offer themselves as volunteers to be involved at different level and covering different roles in the mobilization of the new system within the hospital.
Focusing on the mobilization phase, namely when the network starts to speak as one and to produce some effects in the hospital, we attempted to achieve an in-depth understanding of the role of the system within the organization and how it affects the conditions at work.
Taking the impacts produced by the mobilization of the network, four main themes emerged from our analysis:
a.
The health care delivery process;
b.
People working within the organization;
d.
Relationships with institutional and other stakeholders
We discuss our findings on the impacts in more detail below.
Based on the interviews carried out, staff working on the wards (clinicians, nurses, receptionists) had the most informed position for answering the questions related to the evaluation and these are illustrated by selected quotes based on significance, in terms of the relevance for the different actors and for the overall process, and frequency, namely how often they occurred.
The health care delivery process
One of the most highly acknowledged benefits since the adoption of the EMR system at the hospital is the time saved as a result of the faster sourcing of information and data related to previous admissions via the EMR system. Most of the clinicians we interviewed maintained that the adoption of EMRs reduces the waiting time for laboratory test results and enables diagnostic images to be viewed immediately, saving time during the execution of daily activities.
“Compared to the initial phase, the system is now used with more functions, such as for example blood tests, X-rays, and so on. At the start, it was only used for a few types of information and later they started to use it for more functions. It was helpful for some activities and it also helped to save time…it is much easier working on the ward.” (Interview with a head clinician of the general medicine ward).
The adoption of EMRs produces important results in terms of the accuracy, completeness, ease of understanding and reliability of information. At the time of data collection, the respondents had some experience of using the system and started to be aware of some adjustments compared to the initial phase.
A clinician, talking about his own evaluation of EMR, gave an interesting answer. He sums up his own usage of the system as follows:
….“first of all, I think that the adoption of the system has improved the accuracy and completeness of data. This means that I can have access to more complete information in terms of laboratory test results, X-rays, and I get them more rapidly compared to before the adoption… I can display them at any time and at any place…… Furthermore, it has helped save time when searching, editing and storing documents. ….The system enabled fewer documents to be printed. It also reduced the need for further exams and investigation… “(Interview with a clinician, A&E ward)
According to the majority of clinicians interviewed, the system helped them to (i) check results; (ii) provide alerts about allergies; (iii) identify the location of patients on the ward; (iv) send letters to GPs.
In particular, one clinician said:
“It helped in ordering investigations, and in knowing which patient is in the department, where he is and who he has been referred to. I think it “improved the patient flow”, in terms of how the process happens when a patient comes to the front door and it is much smoother and easier to manage with the EMR system. After visiting a patient, I simply type into the system what I have written on a sheet for the GP and if I have to prescribe something, I just prescribe it.” (Interview with a senior clinician, gastroenterology ward)
The interviews with the nurses in the study sample revealed that the adoption of the system also helped by producing more legible notes that are easy to understand without the need to deduce or decode clinicians’ handwriting.
“Now, it is easier to understand what clinicians write, without the need to interpret their handwriting. This makes me feel more comfortable when doing my job.”(Interview with a senior nurse, A&E ward)
Results in terms of impacts on risk management are mainly linked to the presence of alerts, whereas the interviewees refer to the reduction of errors associated with the integration of information between different wards and throughout the hospital in all phases of patient workflow.
“… more evident benefits were revealed in terms of error reduction. The system shows previously recorded allergies and alerts and helps in recording any newly identified cases” (Interview with a senior clinician, gastroenterology ward)
Comprehensive medical information not only provides the healthcare provider with alerts, but also with information for avoiding unnecessary invasive clinical tests.
Clinicians reported feeling more confident with the information they receive before they decide on a clinical diagnosis: they have safer and more reliable information thanks to the EMR system. Interestingly enough, we found that respondents acknowledged significant improvements at work in terms of the improved ability to plan admissions, more accurate diagnosis and treatment and the reduction of errors in prescribing tests and compiling reports.
“We have a number of things that follow from the drivers. The integration with PACS has really been one of the major successes, we really had good results and clinicians were very happy about it …since we started to provide laboratory results, final reports and images all together…they were saying that they need to…they need to have information at their finger tips. From the administrative point of view, we have electronic referral receipts from the GPs…Before that, to find a referral, the administrative staff had to go to the referral system, print off the referral from the EMR system, type the name, enter the details into the system to make them available. So it was a very time consuming process.” (Interview with the Director of eHealth)
Detailed sub-themes and the related interview transcripts are summarized in Table
4.
Table 4
Sub-themes and the related interview transcriptsᅟ
The health care delivery process: |
– Time savings in undertaking activities, such as searching, editing and storing documentation or concerning the waiting time for laboratory test results |
– Information quality in terms of the accuracy and completeness of data |
– Improvement of diagnostic and therapeutic activities |
– Accessibility, since the system allows for the checking of images or reposts at any place and at any time |
– Error reduction, since the system shows previously recorded allergies and alerts and helps in recording any newly identified cases |
– Cost savings: the system is paperless and it cuts the need for further exams and investigation |
Some interviewees also acknowledged the importance of the system for improving information sharing and the integration of data among different hospital sites, suggesting positive ‘whole system’ effects.
“The biggest impact now is that we can get information in real time, and that was not something we ever had before. There are a lot of improvement programmers that have been going on since the initial adoption. The EMR system has allowed us to be able to look at the patient pathways and measure them all the way along… and measure the time people are waiting. And then the other big opportunity offered by the system is the information sharing and integration of data among the different hospital sites…we have so many hospitals” (Interview with a senior clinician, general medicine ward)
This led to organizational changes that currently allow for better planning of admissions, more accurate treatment and fewer errors in prescribing tests and compiling reports.
People working within the organization
The interviewees on the different wards agreed that the most significant effects on people working within the organization were at
“communication level
”, in the form of improved interaction between clinicians and nurses on the same ward, and between different units and hospital sites.
“I think the system is a very useful tool and I think it has changed not only how they manage patient records but also how they communicate with each other, the way we provide patient care services, and perform job responsibilities. For these reasons, I decided to also take part in the skills assessment test, since I think the EMR system can effectively change the way we work and help our patients” (Interview with a senior nurse, maternity ward)
The eHealth Director offered a very clear answer to this question:
“Of course, the adoption of the system affected people working within the hospital and their daily activities. When we started the project, many people did not use IT. A doctor does not use IT for his job…there is no reason to use a PC.
For junior staff, they know how to use a PC but older staff, like doctors and nurses, were a bit more reluctant and we continue to have that, even if we reduced their workload since a lot of information is stored on the EMR system….” (Interview with the Director of eHealth)
Furthermore, both nurses and clinicians recognized that the adoption of the EMR system helped them to get better and more complete information, including information on previous patient admissions, and supported interaction and communication between members of staff, helping to link the different actors in the network, as discussed below.
“It has definitely improved relationships between clinicians and nurses…. in the sense that we can all access the same information without going around and asking for details, or results and information in general terms.” (Interview with a senior nurse, general medicine ward)
“We can also check and get all the information about previous attendances, and about particular problems we need to be aware of, such as if children are on the protection registry or if they suffer chronic problems, such as diabetes, or if they have any allergies.” (Interview with a nurse, A&E ward)
There was general consensus that the adoption of the system did not enhance the commitment of clinicians and nurses.
“The system did not affect clinicians’ and nurses’ commitment as this is not related to the use of the system.”(Interview with a senior clinician, general medicine ward)
Staff involvement and their level of commitment seems to be independent of the adoption of the EMR system. This may or may not be present within an organization, but is not related to the adoption and use of EMR.
Patients
When asked about the impacts that the system produced on patients, there was general agreement that patients are not aware of the use of the system. In the maternity ward we studied, clinicians and nurses agreed that patients know the system is in use and this made them feel safer. The ward staff we interviewed reported that patients staying on their ward tend to be younger than most people admitted to hospital; as a result they are more familiar with computers and seem to expect care to be computerized.
In Maternity, we are dealing with a generation, because obviously it’s young reproductive women that are having babies, so you know, when I started midwifery, over 20 years ago, the people I was looking after were the same age as me…Whereas now, the people that are coming in to have babies are 20 years younger than me. And they’re a generation who have been brought up with computers. They use computers at school, they work with computers in their job, they might be IT people, they are involved with computers. So they seem to expect care to be computerized. They don’t expect you to be sitting writing lots of sheets of paper. So I think their acceptance of an electronic system is probably much better than in the past. So from that point of view, I think they are accepting it, and it doesn’t matter.” (Interview with a senior clinician, maternity ward)
However, many of the clinicians and nurses we interviewed were concerned about the possibility that confidential patient data could be disclosed and used improperly. In particular, a clinician on the gastroenterology ward said:
“I’m especially worried about it being possible to access patient data from outside the hospital, when working from home. This may help by improving the allocation of a clinician’s time but could lead to privacy issues: laptops can be stolen and confidential data could then be accessed by unauthorized persons.” (Interview with a clinician, gastroenterology ward).
Given the bearing of the matter, privacy issues linked to the adoption of EMRs were a concern for certain members of the network. Such tensions are typical of the unsettling process of network identification and network building [
17].
Based on the analysis carried out, it is possible to classify the privacy reservations associated with EMR systems into 3 macro-categories: i) apprehension about inappropriate delivery of information, due to unauthorized users accessing data and using it with purposes that conflict with organizational policy or unauthorized database access by people from outside; ii) concerns about the information exchanged between health care organizations and other institutions, such as primary care organizations, governmental organizations, or pharmaceutical industries; iii) concerns about the possibilities of data confidentiality loss.
Indeed, the clinicians and nurses we interviewed were concerned about the possibility that confidential patient data could be disclosed and used inappropriately for a variety of purposes, and worried that it is possible to access patient data from outside the hospital, when working from home. Attempts have been made to resolve these concerns about privacy, confidentiality and security issues related to EMR use within healthcare organizations in terms of regulations, standard and guidelines, code of conducts, codes of ethics, technical solutions. However, this major issue has not yet been resolved, and permanent solutions are needed that take all of the previous issues into consideration in order to develop a more effective approach to ethical issues for all the situations.
Relationships with other stakeholders
When asked about this impact dimension, six interviewees reported that the system had the potential to strongly affect relationships between professional and institutional stakeholders through better information and data exchange, even if this is only noticeable in the long term [
54]. All added that these influences would be mediated by the fact that NHS Scotland had signed a contract in 2012 with the vendor of the hospital system, to develop a new national patient management system, as the eHealth Director stated:
“In this country, in a number of years, when the system will be implemented at all other sites, the system will help to share the same view …I think that in terms of full EMR, we have to wait a few years after the hospitals go together, but I think that it can happen. Clinicians and patients will both be winners from a system which will track patient journeys from referral to discharge. It means clinicians will have easier and quicker access to medical records and patients will benefit from having more time with healthcare professionals.” (Interview with the Director of eHealth).
Based on the official documents collected and analyzed, a consortium of five Health Boards in Scotland created a team of more than 160 users to agree on requirements, and selected this system as the national patient management system in a rigorous two-year procurement process.
An official document reported that when the contract was signed, the Chairman of the eHealth Program Board of the National Health Service in Scotland said: “We believe that the system will play an important role in streamlining patient services leading to faster diagnosis and treatment while enhancing patient safety.”
The new system will help to accelerate and improve the effectiveness of patient care throughout the country by ensuring patient information only has to be entered once for it to be immediately accessible by authorized staff in other health care settings. The new patient management system includes administration of hospital and mental health patients, confirmation of orders, results reporting and clinical support tools. A number of optional modules are available for accident and emergency, electronic prescriptions and administration of drugs, pharmacy management, maternity and neonatal care.
As mentioned above, we had the opportunity to access and analyze documents issued by the organization, including an evaluation report with data related to the results delivered by the systems produced at the end of 2010 for the Program Board. In this report the Director of eHealth pointed to some of the economic outcomes produced by the EMR system representing the non-human super actor:
“We did some examinations and we had a conservative estimate of how much time it saves in the departments by having details electronically and we found that they saved hundreds of Mondays a year. We estimate that by stopping printing all clinical discharge letters for GPs, we will be printing 1 million less pieces of paper a year. And then you have to put each one of them in an envelope and send them to GPs. This means that there is potential for savings from an administrative perspective and it can help make us more efficient.” (Director of eHealth, extracted from evaluation document).
According to this document, adopting the system improved the delivery of care, offering clinicians immediate access to results. It also eliminated the need for repeated tests due to lost reports and improved laboratories’ ability to handle and respond to test requests. Five years after the adoption of the system, it was also acknowledged that it had improved the clinical information provided electronically to laboratories. Data on the percentage of blood tests ordered electronically in July 2010 is worth noting: 99 % of blood tests were ordered electronically by the A&E ward, 97 % of blood tests by in-patient wards and 89 % by outpatient wards. The same results were found for the ordering of x-rays in Radiology. The possibility to send electronic GP referrals helped save more than 300 h per month. Communications with clinical wards took 1 day less compared to before the adoption. Electronic discharge letters also helped save time for communications with GPs, since letters are now received 3 days earlier than before EMR adoption.
This is a selection of the information provided in the report, offering an idea of the indicators used for monitoring system performance and the results achieved in previous years.
We carried out observations on various wards including A&E, one of the busiest in the hospital, taking account of over 100 hundred patient admissions. We observed a very organized reception and efficient admission of patients: when patients arrive at reception, the receptionist asks the patient or his/her attendant if this is their first admission. If the patient has been already admitted, all his/her information is already stored in the EMR; if not, some basic information has to be provided. The triage nurse assesses the patient’s condition at the time of arrival at A&E, identifies the problem and allocates a triage classification. This information is entered into the EMR system, which is also used to book a bed on the ward and check all the relevant information.
During the time we spent on the ward, some patients were treated and discharged. In this case, the receptionist accessed the patient’s EMR and sent the discharge letter to the GP electronically. In other cases, patients were sent to a different ward after being seen in A&E and a bed was booked in the new ward via the EMR system.
Based on the observations we carried out, some actors showed great confidence in using the system while others appeared to be less experienced.
The doctors had tablet PCs to use during their daily rounds. In addition there were several computers and printers located in spaces within each ward. Clinicians and nurses were also observed to be using laptops during their field visits. This use of technology appears to have influenced patients’ awareness that the system was being used within the hospital and their perception that the organization seemed to be ‘integrated’. Furthermore, when patients move around the hospital they are not asked several times for the same information. This seems to have produced a ‘safer feeling’ in patients: they know all their data is stored together and easily accessible and this gives them a good impression and helps them feel better. (Researcher’s field notes).
We also observed that many tools were used in the process: the EMR system, clinical records, diaries, sheets of paper, and post-it notes, however the most important tool appeared to be the computer and the EMR system. These objects play a part in the admission process and comprise ‘ordered relations that materialize in patient/nurse interaction’ (as affirmed by Bruni [
55]). All these objects are closely connected and all the information they contain is subsequently integrated in the EMR system representing the non-human super actor. However, these non-human objects require human intervention, even if they guide human interaction and involve other objects.