Evaluation of IT modernisation in the NHS - NETSCC

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Report to SDO for NCRS ProjectSupporting Literaturesmall piecemeal development. Presumably, practical reasons of cost anddisruption prevent larger scale projects occurring. Larger studies are mostly ofNorth American or Australasian origin and focus on ‘users’ experiences. 29Currently, the only large study of EPR implementation is the deployment of 22Veterans Integrated Services Networks (VISNs) in the US department of VeteransAffairs (VA). 30The implementation programme involved the adoption of anational computerized patient record system (CPRS) in 173 VA hospitals.Findings from research into the programme highlight ‘success’ factors such as ahaving a strongly supportive team, user empowerment, and system flexibility.Researchers also emphasise the need to incorporate users’ specialist needs intoany software development. 31Another relatively large study was conducted in five community hospitals in BritishColumbia, Canada, 7 examining the implementation of a patient care informationsystem (PCIS) from the perspective of health care professionals. The researcherconducted 85 interviews across a range of staff. The study highlights thecomplexity of implementing IT innovations, with many unexpected consequencesoccurring and many expected benefits not being realised. It was anticipated thatincreased productivity would free up time but, in reality, any excess time was redirectedto new work programs and activities. This contributed to decreased jobsatisfaction. Workload and turnaround time for processing medical orders alsoincreased, due to the additional information required; this was described by theauthors as a “productivity paradox”. Overall, role changes and a number of otherpractical problems meant that the implementation was far from ‘successful’.2.4. Organisational research examining CPOE implementationOne of our study aims was to explore how innovative pathology and radiologysystems, proposed by Connecting for Health, are experienced by NHS staff, andto describe any impact on working practices. A body of work closely aligned tothese aims has been conducted in the United States by Joan Ash and her team.Ash studied CPOE extensively across three large health care sites (University ofVirginia, The VA Puget Sound campuses encompassing five hospitals, and the ElCamino Hospital site). CPOE allows a clinician to sit at a computer and directlyenter care orders or browse test results. Observations, oral histories, focus18
Report to SDO for NCRS ProjectSupporting Literaturegroups and interviews enabled a comprehensive picture of a diverse range of‘users’ experiences to emerge. Findings from the team’s initial studies 32 outlinedunexpected problems. Initial introduction of CPOE led to an increase, not adecrease, in the amount of paper generated, with staff having a sense that CPOEinterrupted their workflow and decreased decision-making and educationalopportunities. 32Implementation also caused a disruption in the balance of powerwithin the organisations, with users often feeling the organisation gained morethan they did. 33In addition, a separate study conducted on the same hospitalsites 34 found that CPOE had an adverse impact on team relationships, with teamspirit and cohesion undermined.Apart from uncovering these number of unexpected and unwanted disadvantagesto implementation, the researchers also found that qualitative evaluation of CPOEled to a complex array of methodological problems. 33First, when interviewingstaff, the researchers found it was difficult, and often impractical, to isolate CPOEimplementation from other work processes. Secondly, the researchers found itcould not be assumed that people were always talking about the same thing,even when they used the same words, with existential differences in perceptionsand meanings. Lastly, the researchers found there was often a lack ofconsistency between what they observed and what they were being told, makingfirm conclusions difficult.Despite these problems, later work by the group 35 reported recommendations forsuccessful CPOE implementation based on four major themes. The first themeconcerns organisational issues, and indicates that a strong organisational cultureof trust, collaboration and teamwork, combined with supportive leadership, leadsto success. The second theme concerns clinical issues, and emphasises the roleof system customisation and flexibility. A third theme, technical issues, cites theneed for system speed. The last theme concerns the organisation of information,with people wanting information to be organised in a manner that mimics theirown thinking. People did not want to be forced to ‘think like a computer’. Furtherresearch into successful CPOE implementation at Ohio State University HealthSystem served to reinforce these conclusions. Similar factors emerged; the needfor a user-friendly interface, senior management support, physician efficacy,regarding the perceived ability to use the systems, and effective teamwork. In19
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