Elsevier

Health Policy

Volume 84, Issues 2–3, December 2007, Pages 181-190
Health Policy

Implementation of electronic medical records in hospitals: two case studies

https://doi.org/10.1016/j.healthpol.2007.05.013Get rights and content

Abstract

There is evidence that health information technology can improve quality, safety and reduce costs but that health care providers needed more information about how to implement these technologies to realise its potential. This paper summarises the research and proposes a theory of implementation based on the research evidence. The second part describes two implementations of electronic medical record systems and compares the theory against the findings of these two case studies. The paper provides implementers with research-informed guidance about effective implementation, contributes to developing implementation theory and notes policy implications for current national strategies for IT in health.

Introduction

Health services do not have a good history of cost effective implementation of health information technology systems (HIT), or of electronic medical records (EMR) which are at the center of such systems. The potential for increasing safety and productivity is largely unrealised. Many countries and services have policies for introducing EMRs, but there is a wide gap between policy and practice. Implementation experience has been varied and sometimes negative, notably in public health systems where there may be the greatest benefits from EMR systems which allow connections between services. The ambitious and well-funded UK policy for all NHS hospitals was to have electronic patent records by 2005. In 2003, 3% of NHS hospitals had implemented the policy [1], and by mid 2006 the EMR implementation date was estimated to be “2007 at the earliest”. Some of the challenges are technical, but mostly they are professional and political. There are also large financial and commercial interests at stake, some of which have national strategic policy implications. A recent USA review noted that most health care providers needed more information about how to implement IT successfully, as well as the limited research on this subject [2]. Implementation theory provides explanations of why certain actions were taken to carry out an idea or policy, and of the conditions which help and hinder the actions. It can sometimes predict the actions and conditions necessary in a particular situation to get the results desired from a change. IT implementation theory in health care is at an early stage of development, in part because of the few studies, but also because of the complexity of healthcare, the many different settings and the types of IT which are developing at a rapid pace.

The purpose of this paper is to provide evidence for implementers and policy makers to make more informed decisions about EMR implementation, and to contribute to theory of EMR implementation in healthcare. To do this, the paper:

  • Provides a description of two implementations; one of a full conversion from a paper to an EMR system (USA), another of an upgrade-integration from many older different systems to one integrated EMR system (Sweden);

  • Derives an evidence-based theory of EMR implementation in health care from a review of research, and by refining the review through comparison to empirical data from the two case studies.

Section snippets

Methods

A review of research was undertaken using a Medline search and papers referenced in retrieved studies which were not shown in the search. Two recent reviews of research were also used [2], [3]. Twenty one papers were finally selected for a short summary of features which helped and hindered the implementation and successful operation of an EMR system.

The empirical research were two case studies of implementation, using the same methods. One has already been reported of a conversion in one

Previous research

Studies of implementation and impact of EMRs are relatively few, mostly retrospective, without controls, with most data from informants’ self-reports and often from surveys. Many of the limited studies are of a few US health systems which have developed EMRs suited to their needs over a number of years, which makes the experience less generalisable. A review of research was carried out for this study and is summarised below. It concentrated on the more recent empirical studies of EMR hospital

Findings from two case studies

Methods and data from the USA Kaiser implementation have already been reported and will only be summarised here [4]. This implementation may be characterised as a “centralised conversion” from a paper to an electronic medical record. The data from the Swedish Karolinska hospital implementation, which were gathered using the same methods, have not been presented and are given in more detail below. This implementation was a “decentralised integration” of a number of older EMR systems to one new

Discussion

The study shares some of the limitations of much research into EMR implementation in relying largely on self-reports by a limited sample of informants. Also, the analysis does not assess the relative importance of the different factors in helping or hindering implementation, or synergies between the factors. The findings are stronger than some studies because the research was carried out prospectively and concurrently, drew on detailed project documentation, and involved a comparison between

Conclusions

Many countries have national policies for establishing EMRs and many hospitals are selecting, planning, implementing or upgrading their systems. There are few independent descriptions of implementations, little research into what helps and hinders, and no research-based theories of EMR implementation. This paper derived an EMR implementation theory from the available research and described implementations in two case studies. These data provide some limited support for the theory and also

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