Swiss Medical Informatics - SGMI

PROCEEDINGS ANNUAL MEETING 2009
Validation of an implementation methodology
for information systems in healthcare
Marc Oertle
Summary
Integration and implementation of information systems
(IS) in healthcare is achallenging task. Only aminority of
US (as wellasEuropean)hospitals have, for example, fully
implemented computerised physician order entry (CPOE)
in their daily practice (see HIMSS analytics homepage).
The reasons for this situation are many:late computer implementation
in healthcare compared with other industries,
resistance by professionals, complex and sometimes
unpredictable workflows difficult to model in an IT system,
past failures and mistakes in implementation, to
mention just afew.
Since the implementation of ICT inhealthcare isknown
to be problematic, auniversally applicable framework
would be of use. Although many case studies are published,
only afew publications focus on practicable lists
or methodologies supporting the implementation of IS.
On the basis ofaliterature review, the only generally applicable
framework is chosen for validation. The framework
consists of 110successand 27 failurefactorsfor different
types of healthcare IS. Validation is performed by a
retrospective analysis of CPOE implementationinthe hospital
ofThun (Switzerland).
Overall, from our perspective, the framework offers a
valid possibility for planning and implementing CPOE in a
hospital, although, on aone-off basis, the framework
could bewidened. In general, it offers adetailed and usable
list of success and failure factors for implementation
of IS in ahealthcare institution. Although distinct differences
between e.g. CPOE and other IS exist, many of the
items indicated inthe framework can be used in ageneral
setting.
The framework under study could thus enable many hospitals
or other healthcare institutions to successfully implement
informationsystems, even thoughthe list of items
to be observed can never be complete.
Introduction
In healthcareingeneral and especially in hospitals, working
routines, workflows and interdisciplinary work are
nearly always complex, non-linear, inmany ways unpredictable
and sometimes even chaotic [1]. Due tothe publicly
financed structure of many hospitals, financial support
for the introduction of computerised systems is often
lacking and for years knowledge of the potential advantages
of computerised support was limited. Last but not
least, the working environment is quite well organised
even though most hospitals still rely on paper-based systems.
Paper as an information source has distinct advan-
tages over computerised systems and for decades has
proven its suitability [2]. These are only some of the reasons
why for many years information and communication
technology (ICT) was not widely used in hospitals.
The latest booster effect in support ofthe introduction of
information systems (IS) arose from the report “To Err is
Human” by the Institute of Medicine (IOM) [3] and thereafter
from initiatives of many quality organisations, e.g.the
Joint Commission on Accreditation of Healthcare Organisations
(JCAHO) and the Leapfrog Group. Many publications
have so far reported on enhanced patient safety,
decreased adverse drug events, relevant return on investments
and improvements in work processes und workflows
[5, 6]. But implementationofISharboursnew problems
as well. Systems may be badly designed, may be
incorrectly used [3] or lead to wrong conclusions. Several
reports also show increased error rates in prescribing
medication [7, 8], despite sophisticated algorithms. Furthermore,
some studies show totally new behavioural
problems such asgoal conflicts when some actions are
monitored: nurses pay more attention to monitored activities
and neglectactivitiesthat would have been prioritised
in the traditional setting [9]. Insummary, there may be a
price topay for increased patient safety: the risk of safety.
Thus, we nowadays face an enormous gap between
knowledge of problems created by the current system, the
available technical resources and the realisation of such
projects in healthcare institutions. Implementation is obviously
one of the problems surrounding IS and especially
CPOE; support on the basis of avalid implementation
framework would bemost welcome.
Objective
Finding adetailed framework, methodology orstrategy
that is universally applicable and offers maximum chances
of successful implementation of aCPOE system in ahospital.
Perform avalidation of this framework based on experienceofCPOE
implementationinThun hospital, which
is considered to be successful.
Correspondence:
Marc Oertle
MD, MSc
Leitender Arzt Medizin &MedizinInformatik
Krankenhausstrasse 12
CH-3600Thun
Switzerland
marc.oertle@spitalstsag.ch
Swiss Medical Informatics 2009; n o 67
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