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Evolving Systems – Engaged Users: Key Principles for Improving Region-wide Health IT Adoption
Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Division of Visual Information and Interaction. Uppsala University, Disciplinary Domain of Science and Technology, Mathematics and Computer Science, Department of Information Technology, Computerized Image Analysis and Human-Computer Interaction.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Many countries have formulated their eHealth visions and billions of dollars have been spent on supporting the eHealth development throughout the world. An important part of the development is the electronic patient record (EPR). To enable sharing and increase cooperation between care providers, most Swedish county councils have decided to use a region-wide EPR. The health professionals often experience numerous problems and consider the region-wide EPR to be too generic and require them to tailor their practices instead of the system evolving towards supporting their needs.

The aim of the PhD research is to gain knowledge of adoption when deploying and using region-wide health IT systems. This is accomplished by studying, analysing and reflecting upon what region-wide health IT systems are and how professionals use them in their practice. In the research a grounded theory method has been used, which means that the empirical data, not theories and hypotheses, have driven the research process. The data-gathering methods have been interviews, observations, participating in meetings, questionnaires, seminars and conducting literature reviews.

In order to be able to improve the adoption, a set of four key principles has been identified: (1) Evolving systems-Engaged users, (2) Treat IT deployment and usage as part of organisational development, (3) Identify, respect and support differences, and (4) Identify what must be customised and what can be centralised.

These four principles challenge the traditional way of developing enterprise-wide IT and emphasise the importance that users must engage in the development, procurement and deployment process to identify their similar and unique needs and procedures. It is crucial that both the similarities and uniqueness are respected and supported. The similarities can be supported by a centralised, standardised solution, while uniqueness requires a customised solution. In order to accomplish that, the IT deployment and usage needs to be treated as an important part of the on-going organisational development, and the IT systems must evolve, i.e., be continuously developed in order to engage the users to participate. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 85 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Science and Technology, ISSN 1651-6214 ; 1030
Keyword [en]
HCI, eHealth, EPR, sociotechnical systems, enterprise-wide systems, deployment, change management, usability, health care
National Category
Human Computer Interaction
Research subject
Computer Science with specialization in Human-Computer Interaction
Identifiers
URN: urn:nbn:se:uu:diva-196510ISBN: 978-91-554-8623-5 (print)OAI: oai:DiVA.org:uu-196510DiVA: diva2:610296
Public defence
2013-05-24, Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, 13:30 (Swedish)
Opponent
Supervisors
Available from: 2013-05-02 Created: 2013-03-11 Last updated: 2014-07-21Bibliographically approved
List of papers
1. Physicians' concept of time usage: A key concern in EPR deployment
Open this publication in new window or tab >>Physicians' concept of time usage: A key concern in EPR deployment
2010 (English)Conference paper, Published paper (Refereed)
Abstract [en]

This paper is based on an interview study with 19 resident, specialist and senior physicians. The study was initiated by a Swedish Hospital management to investigate physicians’ attitude towards their EPR (Electronic Patient Records) and give recommendations for improvement in organization, development, deployment and training. The management had experienced that the physicians were unwilling to take part in the EPR deployment process and simultaneously complained about the low usability and potential safety risks of the systems. The study shows that the EPR must be considered a shared responsibility within the whole organization and not just a property of the IT department. The physicians must consider, and really experience, EPR as efficient support in their daily work rather than something they are forced to use. This includes considering work with the EPR as an important part of their work with patients.

Place, publisher, year, edition, pages
Berlin: Springer-Verlag, 2010
Series
IFIP Advances in Information and Communication Technology, 335
National Category
Human Computer Interaction
Identifiers
urn:nbn:se:uu:diva-134219 (URN)10.1007/978-3-642-15515-4_8 (DOI)978-3-642-15514-7 (ISBN)
Conference
World Computer Congress 2010
Available from: 2010-11-22 Created: 2010-11-22 Last updated: 2013-04-29
2. Same System – Different Experiences: Physicians' and Nurses' Experiences in Using IT Systems
Open this publication in new window or tab >>Same System – Different Experiences: Physicians' and Nurses' Experiences in Using IT Systems
2011 (English)Conference paper, Published paper (Refereed)
Abstract [en]

In this paper we use a sociotechnical approach and theories about group processes to analyse how two main clinician groups, nurses and physicians, are influenced by their main IT tool, the Electronic Patient Record (EPR), in their clinical practice. The paper is based on interviews with 19 physicians and 17 nurses that work at a Swedish university hospital. The clinicians considered the use of an EPR system necessary, but experienced the need to change their clinical practice to less efficient work routines in order for the EPR system to support them. The main result of the paper is that the EPR system affected nurses and physicians differently. The physicians were more frustrated and experienced that the EPR system worsened their clinical practice and a decreased status among the other clinical professions. The nurses on the other hand experienced that their work became more visible than before and found it easier to claim the importance of their work towards the physicians.

Place, publisher, year, edition, pages
New York: ACM Press, 2011
Keyword
electronic patient records, group and organization interfaces, group processes, health care, sociotechnical system, studies of organisations, technology and work, usability
National Category
Human Computer Interaction
Identifiers
urn:nbn:se:uu:diva-163527 (URN)10.1145/2071536.2071562 (DOI)978-1-4503-1090-1 (ISBN)
Conference
23rd Australian Computer-Human Interaction Conference
Available from: 2011-12-13 Created: 2011-12-13 Last updated: 2013-04-29
3. Three Key Concerns for a Successful EPR Deployment and Usage
Open this publication in new window or tab >>Three Key Concerns for a Successful EPR Deployment and Usage
2011 (English)In: User Centred Networked Health Care: Proceedings of MIE 2011 / [ed] Anne Moen, Stig Kjær Andersen, Jos Aarts, Petter Hurlen, 2011, 260-264 p.Conference paper, Published paper (Refereed)
Abstract [en]

The health care environment is unique because of the large and complex organisation with a traditional hierarchic structure that is governed by laws and regulations. This paper examines how a large Swedish health care organisation work with usability issues regarding Electronic Patient Record (EPR) deployment and usage. EPR systems have great impact on work environment and clinical work routines will not be performed in the same way as before. This paper analyse how the EPR management and core business understand their EPR responsibilities and work with usability aspects at different levels in the organisations. The paper reveals that there is a conflict about responsibility between EPR management and core business management. The reasons for the confusion are contradictive understanding of what an EPR system is, an IT system or a tool for the core business to perform better health care work. This leads to that care staff's experience regarding the EPR system's usability, is not being listened to within the organisation. Three key concerns for a successful EPR deployment and usage are identified and further analysed; education, evaluation and support & improvement ideas.

Series
Studies in Health Technology and Informatics, ISSN 0926-9630 ; 169
National Category
Human Computer Interaction
Identifiers
urn:nbn:se:uu:diva-163528 (URN)10.3233/978-1-60750-806-9-260 (DOI)978-1-60750-806-9 (ISBN)978-1-60750-805-2 (ISBN)
Conference
MIE 2011 - XXIII International Conference of the European Federation for Medical Informatics, August 28-31, 2011, Oslo, Norway
Available from: 2011-12-15 Created: 2011-12-13 Last updated: 2013-04-29Bibliographically approved
4. Time Does Not Heal Usability Issues!: Results from a Longitudinal Evaluation of a Health IT Deployment Performed at Three Swedish Hospital Units
Open this publication in new window or tab >>Time Does Not Heal Usability Issues!: Results from a Longitudinal Evaluation of a Health IT Deployment Performed at Three Swedish Hospital Units
2012 (English)In: OzCHI '12 Proceedings of the 24th Australian Computer-Human Interaction Conference, New York, NY, USA: ACM Press, 2012, 273-280 p.Conference paper, Published paper (Refereed)
Abstract [en]

This paper presents a longitudinal evaluation of user adoption during a Patient Administrative System (PAS) deployment. The research was performed at three units within a Swedish university hospital. Both qualitative and quantitative methods have been used to gather data before, during and up to two years after the deployment. The results show that all users experienced usability problems. After two years of usage the system was still not considered to be as supportive as the old system. The users that were required to use the system felt unsure and stressed about whether all information was consulted or not. The users that were less dependent on the system solved the problems by not doing the tasks; instead they let the clerks continue to do the PAS tasks as they did before the deployment. The results indicate that time will not heal usability problems; instead they need to be addressed in other ways.

Place, publisher, year, edition, pages
New York, NY, USA: ACM Press, 2012
Keyword
EPR, deployment, ehealth, evaluation, implementation, organisational change, sociotechnical systems, usability, user adoption
National Category
Human Computer Interaction
Research subject
Medical Informatics; Human-Computer Interaction
Identifiers
urn:nbn:se:uu:diva-188363 (URN)10.1145/2414536.2414582 (DOI)978-1-4503-1438-1 (ISBN)
Conference
24rd Australian Computer-Human Interaction Conference
Available from: 2013-01-17 Created: 2012-12-16 Last updated: 2013-04-29Bibliographically approved
5. Evaluation of User Adoption during Three Module Deployments of Region-wide Electronic Patient Record Systems
Open this publication in new window or tab >>Evaluation of User Adoption during Three Module Deployments of Region-wide Electronic Patient Record Systems
2014 (English)In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 83, no 6, 438-449 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

In Sweden there are modular region-wide EPR systems that are implemented at various health organisations in the region. The market is dominated by four IT systems that have been procured and deployed in 18 out of 21 regions.

METHODS:

In a 2.5-year research study, deployments of three region-wide EPR modules: a patient administration system, eReferral module and eMedication module were followed and evaluated. Health professionals, EPR maintenance organisation, IT and health care managers were observed, interviewed and responded to questionnaires.

RESULTS:

Although the same deployment process was used during the three deployments, large variations in the units' adoptions were observed. The variations were due to: (1) expectation and attitude, (2) management and steering, (3) end-user involvement, (4) EPR learning, and (5) usability and the possibility of changing and improving the EPR.

CONCLUSIONS:

If changes in work processes are not considered in development and deployment, the potential benefits will not be achieved. It is therefore crucial that EPR deployment is conceived as organisational development. Users must be supported not just before and during the go-live phase, but also in the post-period. A problem often encountered is that it is difficult to make late changes in a region-wide EPR, and it is an open question whether it is possible to talk about a successful deployment if the usability of the introduced system is low.

National Category
Human Computer Interaction
Research subject
Human-Computer Interaction; Medical Informatics
Identifiers
urn:nbn:se:uu:diva-196508 (URN)10.1016/j.ijmedinf.2014.02.003 (DOI)000335903400005 ()24630924 (PubMedID)
Available from: 2013-03-11 Created: 2013-03-11 Last updated: 2017-12-06Bibliographically approved
6. Secondary Users Interpretations on Key Concerns for Achieving an Effective and Efficient Region-wide Electronic Patient Record Usage
Open this publication in new window or tab >>Secondary Users Interpretations on Key Concerns for Achieving an Effective and Efficient Region-wide Electronic Patient Record Usage
2013 (English)In: The 21st European Conference on Information Systems (ECIS 2013), AIS Electronic Library , 2013Conference paper, Published paper (Refereed)
Abstract [en]

The paper presents secondary users interpretation of key concerns (KC) for achieving an efficient and effective electronic patient record (EPR) usage. The evaluation is based on twelve interviews with Clinical Directors and IT Directors that are responsible for delivering high quality care, procuring and implementing IT. The participants represented five Swedish county councils who all use a region-wide EPR for all primary and hospital services. The analysis indicated that there were an unresolved conflict regarding what influence the IT should have on how the health professionals performed practice. Either the systems’ usability or the health professionals unwillingness to change, were blamed for the problems. We argue that the conflict is based on the idea that one EPR is going to support all user groups. Using a region-wide EPR must not be a problem. In the studied organisations, however, it became a problem because to achieve “one system that fits all” the fact that different user groups had different needs, roles and responsibilities were neglected. Neglecting the users’ needs is not solving the problems; instead it will increase the conflict. Using the KC will shed light on differences between primary and secondary users interpretations of the aim of the region-wide EPR. 

Place, publisher, year, edition, pages
AIS Electronic Library, 2013
National Category
Human Computer Interaction
Identifiers
urn:nbn:se:uu:diva-196509 (URN)
Conference
The 21st European Conference on Information Systems (ECIS 2013)
Available from: 2013-03-20 Created: 2013-03-11 Last updated: 2013-10-02Bibliographically approved
7. Interpretation of the Concepts of Enterprise-wide and Best of Breed IT within the New Zealand eHealth Community
Open this publication in new window or tab >>Interpretation of the Concepts of Enterprise-wide and Best of Breed IT within the New Zealand eHealth Community
2013 (English)In: Health Care and Informatics Review Online, ISSN 1176-4201, Vol. 17, no 1, 11-17 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The New Zealand eHealth landscape is diverse with hundreds of systems ‘wired together’ in a complex puzzle. The purpose of this paper is to explore the current debate about selecting and using Best of Breed (BoB) or Enterprise-wide (EW) eHealth systems.

Method Strategic eHealth documents were analysed and 14 senior IS executives from health and IT organisations were interviewed.

Findings There appears to be agreement about: (1) what the concepts mean; (2) the problems caused by the mix of BoB and EW, e.g., the strong influence of clinicians on IT decision making; and (3) a possible solution to the complex puzzle lies in changing the mix to emphasise patient-centric eHealth. However, when discussing to what degree IT systems should be customised and/or centralised disagreements become visible.

Discussion and conclusions There is a trend among decision-makers towards patients’ needs rather than the physical context in deciding system use and design, with an emphasis on what is considered to be ‘best practice’. In this process the preferred systems are EW, however it is important to remember that it is not the only option. There is a risk that if the IT system is too generic (centralised) it might be an unsupportive tool for clinicians and undermine its purpose. 

Keyword
eHealth, enterprise-wide systems, Best of Breed systems, procurement, development, system usage
National Category
Human Computer Interaction
Research subject
Medical Informatics; Human-Computer Interaction
Identifiers
urn:nbn:se:uu:diva-196505 (URN)
Available from: 2013-04-01 Created: 2013-03-10 Last updated: 2017-12-06Bibliographically approved

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