Healthcare professionals’ organisational barriers to health information technologies—A literature review
Highlights
► This is a explicit, transparent and rigorous systematic literature review. ► This review focuses on organisational management issues. ► Databases used in this review are broader than previous exercises in the field. ► Organisational barriers to HIT adoption in healthcare are identified. ► Results are categorised in organisational barriers from a management perspective.
Introduction
Healthcare systems are at risk due to increasing demand, spiralling costs, inconsistent and poor quality of care, and inefficient, poorly coordinated care processes. In response, governments are developing various strategies, one of which consists of heavy investments in information and communication technologies (ICT) for health or health information technologies (HIT) [1], [2]. For example, the recent health reform in the USA includes plans to spend $18.9 billion to promote HIT and provide incentives for information technology (IT) adoption [3] by healthcare organisational systems. Europe has allocated €500 million of EC funding to research in this field since the early 1990s [2], put in place the eHealth Action Plan [4] and made public statements in support of HIT applications in healthcare organisational systems [5].
At EU Member State level, there is wide diversity in the implementation of HIT and in particular the development of Electronic Health Records (EHR) which is considered a central component of an integrated HIT [6]. For instance, Finland implemented EHR in 2008 [7]; Slovenia launched its eHIT project in 2008 [8]; Italy has recently budgeted €1.3 billion as part of its eGov 2012 Plan [3]; England launched the National Programme for IT (NPfIT) in 2002 [9] with an estimated budget of £12.7 billion though its completion deadline has been extended until 2014–2015 [10].
Today the range of possible applications of HIT in healthcare organisational systems is enormous. The technology has progressed significantly and HIT implementation is expected to result in higher quality and safer care that is more responsive to patients’ needs and, at the same time, more efficient (appropriate, available, and less wasteful) [11]. Examples of HIT are electronic health records (EHR), e-prescriptions, computerised provider order entry (CPOE), picture archiving and communication systems (PACS), access to medical journals and databases on the internet, videoconferencing for doctor appointments, or feedback via the Internet to doctors so they can improve the care they provide. For instance, advocates point to the potential reduction in prescription errors as a critical advantage [12]. Out of the broad spectrum of HIT applications in healthcare organisational systems, the adoption and use of EHR has received a lot of attention in recent policy discussions [13].
Despite their promise, HIT have proved difficult to implement [14]. More than a decade of efforts provide a picture of significant public and private investments, notable successes and some highly publicised and costly delays and failures [15]. This has been accompanied by a failure to achieve widespread understanding of the benefits of electronic record keeping and information exchange [11]. Even though computers are increasingly being used in hospitals and practices, not all healthcare professionals use HIT [16] and little is known about the organisational changes, costs, and time required for healthcare centres to successfully implement systems.
Software vendors are often held responsible for the slow uptake due to their inability to effectively deliver reliable products [17], [18], [19], by for instance offering off-the-shelf products with little room for customisation. Quantifying the extent of HIT failures explained by technology problems has proven a challenging and controversial undertaking. Some authors report that technical factors explain 5% of HIT failures [20], some estimate them at 20% [18] whilst others report that the problems are not likely to be related to the technology itself but to the lack-of socio-technical consideration [21]. Notwithstanding the fact that technical problems definitely explain failures in HIT implementation, the introduction of HIT should not be viewed as a problem in technology exclusively but rather as a problem in organisational change [22].
For the above reasons, many different strategies, beyond procurement, are being used to try and promote the use of HIT. These include training groups of healthcare professionals to use a specific HIT, teaching someone one-on-one to use an HIT, or simply providing training materials. However, HIT remain underused by healthcare professionals [23] who still struggle to integrate them into their practice. At the same time, because HIT are transforming the overall healthcare system, scholars have identified a need to use holistic approaches when studying HIT in healthcare and to include organisational management models and knowledge from other disciplines [24], [25], [26].
If HIT systems are to deliver their promise, it is of paramount relevance to ease its adoption by obtaining evidence in support of the cost-effectiveness claims when constructing business cases. Currently, such evidence is insufficient [6]. Furthermore, socio-technical factors are given insufficient attention and addressing them properly is expected to enhance HIT adoption [22], [27].
The socio-technical approach relies in our capacity to model systems and predict the impact of new technologies within existing social systems [27]. The literature related to socio-technical systems is often approached from two different perspectives. Studies where the focus is related to lack of customisation of the technology – i.e.: how suboptimal IT solutions or poorly designed systems – and results in low use or unintended workarounds [28], [29], [30], [31], [32], given the weak intrinsic utility of the software. On the other hand, there is a full body of socio-technical literature focusing on organisational issues that arise when introducing IT within clinical practice.
The objective of this systematic literature review is to identify the barriers to HIT adoption from an organisational management perspective and categorise them using the five-star model developed and refined by Galbraith [33], [34], [35]. Once identified, the barriers are analysed and their interrelations are discussed using an organisational management perspective and applying it to healthcare organisational systems. Whilst authors often raise the need for a strategic fit and organisational or cultural changes [25], [36], [37], [38], [39], most of them fail to address the impact of these on a variety of organisational factors. For instance, the Agency for Health Care Research and Quality (AHRQ) [39] conclude that current practice in clinical medicine may have to undergo major structural and ideological reorganisation in order to integrate itself with, and benefit from, HIT. These approaches would provide an understanding of the impact of HIT in healthcare organisational systems and resulting policies would aim to strategically align and fit them together, taking into account how they interact.
For the purposes of this review, given the different terms in use for HIT, the terms “Health ICT”, “eHealth” and “Health Information Systems” (HIS) and their variations were considered as equivalents. Similarly, the terms Electronic Health Record (EHR), Electronic Medical Record (EMR), Electronic Patient Records (EPR), Summary Health Record (SHR) or Personal Health Record (PHR) were also considered as equivalents. Notwithstanding the fact that these terms are not actually equivalents, differences in their definition and use have been widely reported [40], [41] and it is recently that consensus about what each of them means has been achieved. Thus, it was considered that treating them as equivalents would ensure inclusion of the relevant literature and help in summarising the findings. In addition, it is relevant to point out that currently the term most commonly used is EHR and the most accepted definition is that provided by HIMSS [42].
Section snippets
Search strategy
The search was carried out during December 2009 and January 2010. Additional on-going reviews of updates through automated system alerts took place up until the submission of this paper.
A search was carried out of software platforms which include databases from the following disciplines: Management, Business, Health, Information Systems and Social Policy. An assessment of publications in these disciplines and their availability in software platforms revealed that it was appropriate to search in
Overview of results
A total of 31 sources were searched. The searches originally returned a total of 4035 references and additional automated updates.
Two types of repetition were identified: titles repeated within the same source (internal repetition) and titles repeated when combining sources (external repetition). Following a manual exercise, a total of 372 duplicate references were identified. One learning point is that relying on EndNote to identify duplicates can result in inaccuracy and the author recommends
Discussion
The scope of this literature review is broader than those previously carried out in the field [13], [16], [46], [47], [48], [49], [50], [112], given that it includes searches in management databases. In addition, the taxonomy used follows an organisational management approach, as the literature identified a need for this.
When assessing the types of drivers and barriers identified, the literature identified socio-technical, cultural and organisational issues associated with resistance to HIT.
Limitations
This study has attempted to combine a large amount of diverse literature into a unifying organisational management model applied to healthcare organisational systems. The methods used were systematic – explicit, rigorous and transparent – and independently verifiable. However, the literature was vast and complex, the approach in this review was emergent and somewhat unconventional, and many subjective judgments were inevitably made. A different group of researchers with the same objective would
Conclusions
The advantages of HIT over paper records are readily discernible to techno-enthusiasts: i.e. digital environments allow reliable and efficient storage, gathering and exchange of data, thus improving performance and quality of care, especially for patients with multiple chronic conditions. They also reduce costs. However, without better information, stakeholders interested in promoting or considering adoption of health information technology may not be able to determine what benefits to expect,
Author's contributions
ML has developed the concept underpinning the paper and the subsequent search strategy. She also interpreted and analysed the data and developed the taxonomy based on the management literature. She has read and approved the final manuscript.
Competing interests
The views expressed in this article are the author's and do not necessarily reflect those of the European Commission. The author declares that she has no competing interests.
Acknowledgments
The author is grateful to David McDaid, Adam J. Oliver and Josep Valderas at the LSE for their support to this work and comments on earlier drafts of this paper. In particular, DM gave the author one-on-one coaching on managing software databases and references. DM was also the second reviewer of the 100 references screened and AJO was the arbitrator. The author is also grateful to Patricia Farrer at IPTS for her contribution in English editing this study. Last but not least, the author would
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