Socio-technical considerations in epilepsy electronic patient record implementation

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Abstract

Purpose

Examination of electronic patient record (EPR) implementation at the socio-technical interface. This study was based on the introduction of an anti-epileptic drug (AED) management module of an EPR in an epilepsy out-patient clinic. The objective was to introduce the module to a live clinical setting within strictly controlled conditions to evaluate its usability and usefulness.

Methods

Qualitative and quantitative methods were employed in an observational field study. A purposeful sample of specialists in epilepsy care (2 doctors and 2 nurses) was recruited. Perception of usefulness and ease of use of the AED module, impact on work processes, and accuracy of use were evaluated using feedback meetings, evaluation forms, ethnographic analysis and data validation techniques. Emerging issues were grouped into three key themes: human, organisational and technological.

Results

The electronic patient record use was studied for 49 patients over the course of 18 out-patient clinics. While participants varied in their approach to interacting with the AED module, they expressed satisfaction with its usability and performance. The necessary co-existence of the paper and electronic record, and changes to customary work practice were considered the biggest challenges. 82% accuracy in the use of the electronic record was determined.

Conclusions

Achieving successful electronic patient record implementation is complex. While technical challenges exist, it is possibly more important to acknowledge the social considerations. Initially, an increase in medical record fragmentation and disruption to workflow can arise with the introduction of the technology. Realising the benefits of electronic patient records will require the management of a lengthy transition phase.

Introduction

An organisation can perform optimally only if the social and technical dimensions are designed to fit the demands of each other and of the environment [1]. Early studies in socio-technical systems (STS) demonstrated a negative (rather than an expected positive) impact on productivity when changes are made to the technical aspects of work processes without adequate attention to the social structure of the organisation and its human requirements [2]. Similarly, many unintended and undesired consequences of Information Technology in Healthcare can result from interactions between the technology and the healthcare organisation's workflow, culture and social interactions [3].

The socio-technical nature of health informatics and Electronic Patient Record (EPR) projects is becoming better understood [3], [4], [5], [6] and presents an inter-relatedness of Human – people, their behaviour and attributes (skills, attitudes, values), Organisational – environment, structure and Technological – system processes, tasks and quality dimensions. Perceived barriers to electronic record adoption such as cost of purchase and implementation, resistance on the part of physicians, uncertainty about return on investment, and lack of adequate IT personnel reflect these socio-technical dimensions [7]. Similarly, in addition to the installation of a technically adequate to superior application, determinants considered essential for success with EPRs include: establishing clear strategies for implementation that are strongly aligned with organisational goals; active user involvement in all stages; continually measuring performance of EPR-enabled processes; investment in IT infrastructure; and effective IT governance [8], [9] Therefore, human, organisational and technological elements of an EPR project should be viewed and managed as a network rather than separate entities [10]. In accordance with this integrated approach evaluation frameworks for health information systems (HIS), including EPRs, have been developed [11], [12], [13]. Evaluating the human dimension focuses on system use and user satisfaction, organisation evaluation assesses the business structure and environment while technical evaluation centres on the quality and usability of the information system or EPR.

The motivation for the study was to examine EPR implementation at the socio-technical interface. It is a case study based on the introduction of an anti-epileptic drug (AED) management module of an EPR in an epilepsy out-patient clinic. The AED module was the first of a number of components of functionality of an epilepsy-specific EPR (see Section 2.2) to be deployed in the clinical setting. The aim was to investigate the challenges faced by initial adopters of the AED module from human, organisational and technical perspectives. It was intended that the findings could inform larger scale implementation of the full epilepsy EPR, i.e. additional users and more modules of functionality. This study was conducted in the context of a wider research and development programme which is examining the role of information and communication technology in chronic disease management (CDM).

The objective of this study was to introduce the AED module to a live clinical setting within strictly controlled conditions and to evaluate its usability and usefulness. The study was approved by Beaumont Hospital Ethics (Medical Research) Committee.

Section snippets

An epilepsy out-patient service and the medical record

Epilepsy is a common (prevalence 0.75–1%) chronic neurological condition [14], [15]. Like other complex chronic conditions, optimal management relies on the integration of clinical data from a number of healthcare disciplines in a variety of healthcare settings e.g. community based, general practice, hospital based [16], [17], [18], [19], [20]. Information and communication technology has the potential to support such integration and to facilitate shared care [21], [22], [23], [24], [25].

Study design

An observational field study employing qualitative and quantitative methods was conducted over a 20-week period to evaluate the usability and usefulness of the AED module. The study design was based on the HOT-fit evaluation framework for health information systems described in [12] and incorporated factors of usefulness and ease of use of information technology as outlined in [32].

Participants

A purposeful sample of four healthcare professionals from the epilepsy programme and involved in the delivery of

Results

Over the course of the study, the AED module of the EPR was used at 18 out-patient clinic sessions and during this period AED data was entered for 70 patients (i.e. 87.5% of what was planned – see Section 3.2). On average 43 individual patients attended each of these OPD sessions (total patients over 18 weeks = 771). In general, participants considered the AED module to be useable and useful and of potential benefit to the process of patient care. However, their feedback highlighted factors that

Discussion

Achieving an optimum EPR solution for enhancing healthcare delivery requires a convergence of the social and technical dimensions of the healthcare system [33]. The journey to realising this socio-technical ensemble [34] should start as early as possible so that both of these dimensions receive adequate attention and there is human and organisational readiness for the technology. With this in mind, our study was conducted during the preliminary implementation of an AED module of an epilepsy EPR

Conclusion

Despite the prevalence of ICT in modern life, its exploitation in healthcare has thus far been limited. Changes in organisational structure and process are often needed to implement and accomplish the benefits of EPRs [6], [33]. This study was conducted within bounded conditions to examine the sociological and technical components of EPR implementation. Lessons learned contributed to enhancements to the AED module functionality such as data validation facilities to alert the user should they

Acknowledgements

Funding for this study came from the Irish Health Research Board (HRB) as part of a 5-year health services research grant awarded to the Epilepsy Programme, Beaumont Hospital, Dublin, entitled “Revolutionising Chronic Disease Management with Information and Communication Technology: A socio-technical project applied to epilepsy care in Ireland”.

We would like to thank the clinical, nursing, research and administrative team of the epilepsy programme at Beaumont Hospital for support in conducting

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