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Why is it difficult to implement e-health initiatives? A qualitative study

Why is it difficult to implement e-health initiatives? A qualitative study Background: The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers – the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives. Methods: We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with ‘on the ground’ experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT). Results: Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to ‘normalize’ where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization. Conclusions: Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners’ attention to potential problems with a view to addressing them during implementation planning. Background resources [1]. Although each country is pursuing indivi- The challenges facing healthcare systems in the twenty- dual solutions to these challenges, some common first century have been well described: an aging popula- approaches are clearly apparent, including the use of tion; increasing prevalence of long-term conditions; information and communication technology (ICT) [2]. improving health technologies leading to better survival; The use of ICT is expected to lead to improvements in and rising expectations of healthcare all combine to put healthcare quality (e.g., through better communication) ever increasing pressure on available healthcare and efficiency (e.g., through reduced duplication of investigations) [3]. Australia, New Zealand, and the UK have been at the forefront of attempts to embed ICT * Correspondence: elizabeth.murray@ucl.ac.uk into routine healthcare [4], with the UK investing £12.4 e-Health Unit, Department of Primary Care and Population Health, University College London, Royal Free Campus, Rowland Hill Street, London billion over 10 years [5]. However, despite political com- NW3 2 PF, UK mitment and substantial investment, there has been Full list of author information is available at the end of the article © 2011 Murray et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Murray et al. Implementation Science 2011, 6:6 Page 2 of 11 http://www.implementationscience.com/content/6/1/6 significant variability in the success of different e-health were interested in taking a social action approach to implementations across the British National Health Ser- implementation, rather than focusing on socio-technical vice (NHS) [6]. Many projects have been subject to con- relations or higher-level theories of structuration. We siderable delay, increasing budget deficits, and in some wanted to understand the work that implementers did, cases, severely negative impacts on the quality and effec- and our approach was informed by the analysis of col- tiveness of care [7,8]. lective action, a core construct of Normalization Process Difficulties in e-health implementation are an interna- Theory (NPT)[28], whichweusedtoprovideageneral tional phenomenon, with similar problems being widely framework for this study. In particular, we focused on reported [9-12]. This work has taken many forms and, those of its components [29] that support the analysis of importantly, it has raised questions about what ‘success- enacting implementation and other social processes. ful’ implementation actually means. For example, de NPT focuses on the work that individuals and groups Bont and Bal [13] have described how a telemedicine have to do foranewtechnologyorpracticetobecome service met organizational criteria for ‘success’ and yet embedded and sustained in routine practice. failed to normalize in practice. Despite this critical con- We were interested in exploring the application of ceptual problem, much research has focused on issues four of NPTs concepts: interactional workability (IW); of efficacy or effectiveness, with trials addressing the relational integration (RI); skill set workability (SSW); ‘can it work/does it work?’ questions [2,3]. How new and contextual integration (CI) (Figure 1). IW refers to systems are ‘implemented’ remains a problem, and an the impact that a new technology or practice has on important theme in much recent work has been the interactions, particularly the interactions between health problem of ‘resistance’ or refractory behaviours of pro- professionals and patients (consultations). RI refers to fessionals – and the assumption that their ‘attitudes’ to the impact of the new technology or practice on rela- e-health are the root problem [14]. Studies exploring the tions between different groups of professionals, and the views of senior staff charged with implementing an degree to which it promotes trust, accountability, and e-health innovation are rare [15]. This is surprising, responsibility in inter-professional relationships. SSW because these people (henceforth referred to as ‘imple- refers to the fit between the new technology and exist- menters’), with their direct experience of planning and ing skill sets. An example of poor SSW would be a tech- managing implementations, are likely to have useful per- nology that required clinicians to do clerical work, or spectives on the factors contributing to the success or conversely, required administrative staff to take clinical failure of new systems, which might contribute to brid- decisions. CI, which refers to the fit between the new ging the gap between research and its wider implemen- technology and overall organisational context, including tation into practice [16,17] organisational goals, morale, leadership, and distribution Although there is a considerable body of work on fac- of resources. tors promoting successful implementation in healthcare The assumption that informed our analysis was that [18,19], implementation research within healthcare has technologies that are understood by their users to been described as a ‘relatively young science’ [20]. This have a positive impact on consultations (IW), inter- is reflected in vigorous debates about how to understand professional relationships (RI), and which fit well with implementation processes and about the theoretical existing skill sets (SSW) and organisational context (CI) tools that can be used to do this [21]. These offer us are more likely to normalize than those with a negative generalisable frameworks that can apply across differing impact or poor fit [30]. settings and individuals; the opportunity for incremental This study had two aims: first, to determine imple- accumulation of knowledge; and an explicit framework menters’ views of factors which promote or inhibit suc- for analysis [21]. There are a number of theoretical fra- cessful normalization (implementation, embedding, and meworks that have been applied to studies of technolo- integration) of e-health innovations; and secondly, to gical change in healthcare and informatics, and explore whether the collective action components of important contributions have been made to understand- Normalization Process Theory (NPT) provided an ade- ing the role of attitudes [22], and social transmission of quate explanation for different perceived degrees of nor- innovations between [23] or interactions within [24,25] malization. Although NPT was derived from a large actor-networks. More recently, Greenhalgh et al. have body of empirical work, at the time this study was offered a high level and abstract theorization of designed (2006), there were relatively few studies which ICT programmes from the perspective of Structuration had attempted to test NPT’s power as an explanatory Theory [26]. model across a range of technologies [31-33]. We Like de Bont and Bal [13], Berg [24], and Greenhalgh adopted a case study methodology as the most effective and Stones [26], our study falls within the general frame way of addressing these two aims because case study of science and technology studies [27]. However, we methods are appropriate for studying complex systems Murray et al. Implementation Science 2011, 6:6 Page 3 of 11 http://www.implementationscience.com/content/6/1/6 Figure 1 Constructs of the collective action component of normalization process theory. which are in a state of flux [34] and for exploring why case, the implementation had occurred between 2004 to and how particular outcomes occurred, rather than sim- 2006, with data collection undertaken 2007 to 2008. ply describing what happened [35]. Case study methods Case study one (CS1) was the implementation of the are distinguished by their in-depth focus on a relatively Choose and Book (C&B) system in a hospital trust ser- small number of units or ‘cases’ [36], and benefit from ving an inner city population in a large metropolitan prior development of theoretical propositions to guide area in England and the lead Primary Care Trust provid- data collection and analysis [37]. ing referrals to that hospital. C&B was a national elec- tronic service that provided patients with the Methods opportunity to choose which hospital their general prac- Design titioner (GP) referred them to for a particular problem, We report case studies of three e-health innovations. and to book the time and date of their first appoint- Data were collected using semi-structured interviews ment. C&B was a flagship project for the multi-billion with implementers and analyzed using the Normaliza- pound programme for improving use of information tion Process Model. technology in the English NHS, known as Connecting for Health [40]. Implementation involved three main Setting stakeholders: the hospital receiving referrals, the Primary Our theoretical framework, as well as previous research Care Trust (PCT) commissioning out-patient appoint- conducted by members of the team [38,39], led us to pos- ments, and the GPs making referrals. tulate that the characteristics most likely to influence the Case Study two (CS2) was the implementation of the success or failure of an implementation were the clinical Picture Archive and Communication System (PACS) in context (primary, secondary, or community care) and the one acute hospital trust, which included several hospi- nature of the e-health technology [29]. In addition, we tals at different sites, located in a largely rural area of wished to ensure that the implementation was recent England. PACS was a system for digitizing images, such enough to remain alive in respondent’s memories, while as X-rays, scans, or photographs. The digitized images sufficiently established to allow for assessment of the could be stored online, and accessed simultaneously extent to which the initiative had become embedded and from different locations. integrated into routine practice (normalized). These cri- Case Study three (CS3) was the implementation of a teria led to the selection of three cases (Table 1). In each Community Nursing Information System (CNIS) for Murray et al. Implementation Science 2011, 6:6 Page 4 of 11 http://www.implementationscience.com/content/6/1/6 Table 1 Summary of Case Study characteristics Case Study Choose and Book Picture Archiving and Community Nurse Information System Communication System Health care Primary/Secondary care interface Secondary care Community care setting Aim of Allow patients to book first Digitise x-rays and other images so Electronic record system that also allows patient technology outpatient appointment at they can be stored and viewed registration, clinic and visit scheduling and access to hospital of choice electronically clinical algorithms. Professionals Primary care: GPs, administrative Doctors, radiologists, radiography Community nurses affected by staff. administrative staff technology Secondary care: Consultants, outpatient administrative staff Data collection district nurses in an urban area in Scotland. The CNIS Semi-structured interviews were used to determine not consisted of hand-held wireless enabled Personal Digital Assistant devices (iPAQs). District Nurses could use them only ‘what happened’ but also participants’ explanations to record clinical assessment information while out in the of ‘why it happened’ in that way. Interviewees were community, and download the information to the central asked for a description of the e-health implementation server once back at base. The system also included some process from their perspective, their views about factors decision support in the form of standardized assessment which had promoted or impeded implementation and tools with associated care algorithms. The system had ori- their assessment of how normalized (embedded into ginally been intended to form a single shared assessment routine care) the e-health initiative had become. Inter- that could be shared between district nurses and social views were tape-recorded and transcribed verbatim, with services; however, social services had been unable to pur- the interviewer keeping additional field notes. sue their side of the implementation and so this function had not become available by the time of data collection. Data analysis Data were analyzed using the framework method pro- Participants posed by Ritchie and Spencer [41] according to four com- Participants were staff with responsibility for planning ponents of the collective action construct of NPT (May and/or executing an e-health initiative (’implementers’ 2006): IW, RI, SSW, and CI (Figure 1). Data were coded to as defined in Figure 2). We purposively recruited a the four constructs and overall degree of normalization. maximum variety sample, aiming to include senior Initial interviews were coded by the interviewer (JB) and chief investigator (EM) in order to develop a coding Department of Health or Connecting for Health staff framework. This framework was then tested and refined with responsibility for a number of e-health projects at a two-day multidisciplinary data analysis clinic invol- across multiple organizations, senior staff from within ving all authors. The revised coding frame was reapplied the Trust or Health Board with lead responsibility to the previously coded interviews and all subsequent for implementing a number of e-health systems within their organization (such as chief executive officers), and interviews by three authors independently (JB, EM, middle management with day-to-day responsibility for CM). There were no significant disagreements in apply- the implementation under study. Recruitment within ing the coding framework. each case study continued until we reached saturation, Data are presented in the text with each quotation fol- i.e., until no new data were emerging from subsequent lowed by case study number and role of interviewee. interviews. Based on previous experience, we estimated Where quotes include remarks by the interviewer, the that up to ten interviews per case study would be interviewer is denoted by ‘I’ and the participant by ‘P.’ needed [38]. Results Twenty-three interviews were undertaken: ten for CS1, five for CS2, and eight for CS3. Our intended sampling In this study, an implementer is any person charged with assisting with an e-health system implementation. Depending on the policy level, sponsor implementers may be frame was achieved, with interviewees including regional found at national, regional, and/or local levels, and may include health service tsars, chief executives, clinical directors, senior healthcare managers, ICT staff, health leads for the cluster (CS2) or local service provider (CS1), professionals, local NHS managers, staff involved in training, and staff working for Chief executives for the trust or health board for all three private companies contracted to supply, facilitate, or support technology implementations. Although our focus was not health professionals, some health case studies, and clinical or IT leads and a range of mid- professionals with a lead role in an e-health implementation were interviewed. dle management with ‘on the ground’ responsibilities Figure 2 Definition of implementers. (Table 2). Data saturation was achieved quickly in the Murray et al. Implementation Science 2011, 6:6 Page 5 of 11 http://www.implementationscience.com/content/6/1/6 Table 2 Roles of Interviewees Case Study Choose and Book (CS 1) PACS (CS 2) CNIS (CS 3) Regional Level Lead for Local Service Provider Regional Implementation Director for Cluster Chief Executive CEO of Trust CEO of Trust Managing Director of provider company; General Manager of Health Board Senior Management Clinical Lead for Hospital Trust Clinical Lead for Hospital Trust IT Manager Health Board; Clinical Services Manager Middle Management or “on the GP and clinical lead in PCT; Radiology Manager; Lead Project Nurse; ground” Consultant; IT Manager IT training manager Health Board; Senior Practice Manager; Nurses x 2 Project Manager for Hospital Trust; Outpatient Manager; Primary Care Director for Hospital Trust two case studies (CS2 and 3), which were located in a understand that they have been started last May, and single context, but took longer in C&B, where there were they’re only 80% on the system.’–CS3 senior nurse very different perspectives emerging from the three dif- ‘It’sa newgadgettoshowoff amongsttheir friends ferent groups of stakeholders in the hospital, the primary and stuff like that.’–CS3 IT trainer care trust, and individual general practices. Thepicture in CS1(C&B) wasmorecomplex.It Assessments of normalization appeared that there had been a high degree of normaliza- For each case study, we explored interviewee perspec- tion in the hospital, with references to it as ‘away of life tives of the degree to which the e-health innovation had here’ (CS1 hospital chief executive officer) or ‘completely become normalized. Data were triangulated across the embedded in standard operational workings’ (CS1: project different interviewee perspectives. The three case studies manager for C&B in the hospital). In primary care, there demonstrated a wide range of normalization (Table 3). was variable (and often low) normalization with certain For example, CS2 (PACS) had completely normalized practices contributing the bulk of the electronic referrals: and was totally embedded into routine practice: ‘Yeah, well most GPs don’tuse it!’–CS1 hospital ‘It’s just taken for granted that you come in and you chief executive officer use PACS and that’s how your images are that’sit... Just normal practice now.’–CS2 IT training manager Even in those practices that were high users of C&B, it was considered problematic, and had not become part In contrast, CS3 (CNIS) had at best, only partially of routine practice: normalized, and provided a good example of the differ- ence between adoption and normalization. Although ‘Right you are saying within my 10-minute slot and some 80% of the district nurses were using it, many you have said Choose and Book will take a couple of teams were still running dual systems (old paper-based minutes – it doesn’t – what, even two and a half and new electronic), and it was evident that not all years on it takes at least four and is not even work- nurses felt comfortable using it, with the hand-held ing properly today. So it took me 10 minutes to do devices still seen as new or strange: one this morning.’–CS1 GP early adopter ‘Ithink it’s fair to say it’s not integrated into normal This variability in perceived normalization was further routines very much at all in my area, but the previous analyzed using NPT as an explanatory framework (Table 3). area that they were in before, they, I mean, I Where implementers perceived good levels of CI, IW, RI, Table 3 Summary of factors affecting normalization of study technologies Case Study C & B (hospital) C & B (primary care) PACS CNIS Degree of normalization ✓✓✓ ✗/✓ ✓✓✓ ✓ Interactional Workability (impact on consultations) ✗ ✗✗✗ ✓✓✓ ✓ Relational Integration (impact on inter-professional relationships) ✗ ✗ ✓✓ ✗/✓ Skill Set Workability (fit with existing skill sets) ✓ ✗✗ ✓ ✗✗✗ Contextual Integration (fit with organizational context) ✓✓✓ ✗/✓ ✓✓✓ ✓ Murray et al. Implementation Science 2011, 6:6 Page 6 of 11 http://www.implementationscience.com/content/6/1/6 and SSW, high levels of normalization had occurred. How- was no way of getting the information to them.’–CS ever, where implementers perceived problems in one or 3; Clinical Services Manager more of these areas, the level of normalization was lower. In contrast, C&B had a negative effect on IW in gen- Interactional workability eral practice, with interviewees commenting adversely Data were considered to refer to IW if they reported the on thetimerequiredtomakeaC&B referraland the impact of the new technology on health professional – negative impact this had on patient consultations. C&B patient interactions or consultations. PACS was per- had little impact on IW in hospital, except where the ceived as having a very positive impact on doctor- system allowed patients to be booked into the wrong patient relationships on two grounds. The first was that clinic, which led to unsatisfactory consultations. images were always available when needed, allowing clinicians to make decisions in a timely manner: Relational integration Data were coded to RI if they referred to the impact of ‘The biggest advantage is in having images available the new technology on relationships between groups of all the time to everyone. So as soon as I take a picture professionals. of you, somebody can see it. In fact, everybody can PACS was reported as promoting communication and see it. So where, if you were come into A and E and trust between different professional groups because it you’ve broken an arm and you have to be referred to enabled multiple users to view the same image from dif- the orthopaedic surgeons, there is no backwards and ferent locations. This was felt to have improved working forwards of one piece of film following you around or relations between for example, orthopaedic surgeons and not as the case may be. The fact that you have a pic- radiologists, or within multidisciplinary team meetings ture that any doctor can see, the orthopaedic surgeon for planning complex cancer care for individual patients: can see; it can be in the theatre if you get up there in 10 minutes time. It can be on the ward if you are ‘Yes and I think its aiding clinicians to have a better admitted to the ward, it can be in the department for conversation if you put it in the cancer or renal unit specialist, um, review of it and report being done – ...the multidisciplinary team meeting.... I can remem- all at the same time.’–CS2 radiology manager ber, my senior pathologist has just retired and she said sitting in some of these meetings now and Second, doctors liked being able to show patients their you’ve got the pathology there and you’ve got the images, and found this easier to do with PACS than images there and she said the quality of the clinical with film: conversation that’s going on around what’sbestfor an individual patient and their circumstances has ‘you did get good doctors saying ‘it’ssonicebeing moved on and is a higher quality clinical discussion able to point things, and rotate things, and show which I would then argue must lead to better treat- things more easily,’ because you can magnify and ment planning and clinical decision making and things like that I suppose, so you can do that sort of therefore must lead onto better outcomes for thing, and share that with the patient.’–CS2 IT patients.’–CS2 chief executive officer training manager ‘And I think, particularly with the interaction between say one of the clinicians and one of the The datasuggested that theCNIShad apositive radiologists, that’s improved because the consultant impact on IW. The iPAQ devices were cheap, robust outside knows that the consultant radiologist inside and portable, allowing nurses to feel comfortable carry- has access to those images – and has probably ing them around as they visited patients, and hence pro- already seen them, probably already done a report – viding access to the patient record during home visits: so what they are doing is they are starting off from another point. In the old days, if a CT scan was ‘You’ve seen how streamlined they are quite you done and it went to the ward, the consultant on the know petite. You can put them in your pocket.’ ward wouldhaveto pickit upand bringitdownto –CS3 IT trainer the radiologist and that would be the first time the ’[Before the CNIS] if you needed information about radiologist was seeing it. Because it had never come someone whose condition had deteriorated, perhaps down from the ward before. Whereas now, he rings on a Friday afternoon, you then had to write a dif- him up and say –‘you’ve seen so-and-so, and said ferent set of documentation and drive it to the place so-and-so – what about this little bit over there?’ that the patient needed to be seen, otherwise there And then he looks up and ... Or they still come Murray et al. Implementation Science 2011, 6:6 Page 7 of 11 http://www.implementationscience.com/content/6/1/6 down to the department to talk because they like the that task themselves. However, the advantages of PACS interaction, but it is not the first time the radiologist swiftly won them over: is seeing that scan.’ CS2 radiology manager ‘And the orthopaedic surgeon said ‘What happens The CNIS had been intended to have a positive when I go on the ward and the nurse can’tget the impact on inter-professional relationships because it was image up on the screen?’‘The nurse can’tget the originally intended to form the basis for a joint record image up on the screen – you’re going to!’ And off held by both social services and community nurses. he went, mumbling that he didn’twant PACSintro- However, problems within social services led to exten- duced until he retired. He’s now on that DVD that sive delay, and at the time of data collection, social ser- wasdoneasachampion of it.’–CS2 radiology vices were not using the system, preventing any positive manager impact of the system on RI. The impact of C&B on relations between professional Ease of use was seen as essential for the CNIS, where groups was most marked for the relations between hos- the nurses started from a low level of IT literacy. Many pital consultants and GPs, with both groups regretting were alarmed that poor IT skills could jeopardize their the loss of personal contact between referring doctor future employment: and specialist (negative impact on RI): ‘It’s basically nurses who don’t even have a computer ‘I think one of the points about Choose and Book in their own homes and they haven’t actually come was to basically - is part of a systematic disenfranch- across this sort of technology and they’re having to isement of clinicians basically - so that we now refer face it at work and sometimes you get that sort of to a generic gastroenterologist or a generic chest nervous reaction that they maybe might feel a bit physician.’–CS1 GP early adopter inadequate in the sense that that oh this is really ‘I think it is all a bit more distant. Because it used to daunting. I’ve never used a computer system before. be the GPs referred to their main buddies. And they Will this mean I’ll be out of a job?’–CS3 IT trainer can’t really do so much anymore. What we hope is we substituted for that theconfidencethatthey Trainers had to spend a great deal of time on one-to- patients will be seen the first time by someone who one training and emotional reassurance: can deal with the problem.’–CS1 consultant and clinical lead for C&B in hospital ‘I must say, to be honest, they we do hold their hand quitealot andwe’ve probably spoilt them in a sense that we tend to go out to the health centres and actu- Skill set workability ally do the training rather than tell them to come out Data were coded to SSW if they referred to the fit to an unfamiliar environment.’–CS3 IT trainer between the new technology and existing skill sets, or efforts made to teach the requisite skills to users. C&B fit well with the skill sets in hospital, where In many ways PACS fit well with existing skill sets. It administrative and IT staff tended to deal with it. In was seen as relatively intuitive to use, and intensive efforts general practice, C&B had a poor level of SSW because were put into training clinical staff before implementation: GPs were expected to make the C&B referral within a consultation. They perceived this as a clerical function ‘... and basically there were a number of sessions set that was a poor use of their clinical skill: up by our training department with five or six web browsing terminals, andtheyjustwentinand they ‘I think the doctors would say that they are doing a [clinical staff] were shown how to get into their bit more with Choose and Book administration than patient; they were shown how to pick an image, and they used to. They are not happy about that. Really. how to adjust and image and read a report. I think And that is why that brings out the worst headlines we probably got about 60% of the clinical staff in the in the comics - ‘Iamnot atravelagent’ sort of trust trained before go-live. thing...’–CS1 GP early adopter I: Before go-live. Oh fantastic. P: Which was bad. And the other 40% very quickly Contextual integration learnt afterwards.’–CS2 radiology manager Data were coded as pertaining to CI if they reported on Some clinicians were used to nurses displaying images the fit between the technology and the overall organiza- for them, and were initially reluctant to have to take on tional context, including organizational goals, the quality Murray et al. Implementation Science 2011, 6:6 Page 8 of 11 http://www.implementationscience.com/content/6/1/6 of leadership within the organization, resources allocated over in...toberolledout... But also – andthisisthe to the implementation, and overall morale. other driver was – that as the rest of the world, all PACS was perceived as a way of meeting several orga- the other service providers that they were engaging nizational goals, including national targets for shorter with, were increasingly becoming... conducting their waiting times for investigations, increased efficiency business through, through the electronic medium, if within the hospital, and the chief executive officer’sper- they had... if at the very minimum, if you get them sonal goal of encouraging clinical engagement with IT. onto a platform, if I use that expression, to get them PACS helped the organization achieve their goals by onto something which would enable a, a transfer eliminating the problem of x-ray films that had been maybe at some future date, to, to another potential ‘lost’ or were unavailable at the time and place they system, depending on what their various service part- were needed: ners may, may develop, because if you’re simply not on anything, then it becomes quite difficult to, to be ‘they were never in the right place at the right time. part of an information technology strategy for, for the Well, never is too strong a word, but I think there wider sector... It would introduce them to - as indivi- were times when we were running up to about 20% duals, as professionals - to this world of electronic lost films. And what I mean by ‘lost films’ is just not record-keeping and information sharing, which they being in the right place at the right time.’–CS2 radi- just simply had no experience of.’–CS3 director, ology manager. community health and care partnership This had considerable knock-on costs in terms of On the negative side, there had been significant orga- repeat X-rays, delays to consultations or treatments, and nizational change locally, which had absorbed staff time staff time in looking for films. PACS eliminated this and energy, distracting them from the e-health imple- inefficiency: ‘throughPACSwebecomemore efficient, mentation: more productive’–CS2 consultant radiologist The chief executive officer was very committed to ‘It’s a huge piece of change, re-organizational change introducing PACS and provided strong leadership for at the time we were trying to introduce this, coupled the implementation process, ensuring that sufficient with the Agenda for Change, means we’dthree big resources, including time, senior staff and funds were things that did create issues, and we just had to kind available for the implementation to go well and com- of manage our way around it.’–CS3 joint services plete on time: manager ‘A lot of the nurses just feel it’s been one constant ‘Well I drove it, I chaired the project board...It’s about change after another.’–CS3 lead project nurse change and the way we do things, changing the cul- ture. So I chaired the project board and brought the Possibly related to this organizational change was a relevant people, so the lead radiologist who was my perceived problem with leadership, including the dis- key clinical champion was there. My head of IT was banding of the dedicated implementation group after there. There were other people involved and in a the first year and inadequate allocation of resources for sensewedoeverythinghere byproject management training and support, leaving nurses without the input methodology. That’s the way we make sure we deliver needed to build their confidence and expertise with the things.’–CS2 chief executive officer system: The data from CS3 (CNIS) demonstrated both positive ‘Um, I think a couple of years ago, there was a steer- and negative features about CI. On the positive side, the ing group set up to move this forward. And there system was seen as a way of achieving the policy goal of was also a reference group set up to look at what sharing assessment information between community should be on the system. Um, because of organiza- nursing and social services. This enabled funds to be tional change, more than anything, I think we’ve lost identified and targeted on this implementation, while the implementation group... I think, really, what’s also achieving a long-term goal of engaging a profes- been happening in [city] is that some training has sional group that had little experience of IT: been given to nursing staff, but there’sbeennofol- low-up within that area to make sure it’s happening.’ ‘This was a, a group of staff who had no access to –CS3 senior nurse electronic record-keeping at all. And there had been ‘not having help out of hours. I’mnot sure if that’s a series of efforts to do this over the years, and over resolved yet; they hadn’t resolved it when I moved in the previous decade, all of which had failed to... failed 2007 because there was no helpdesk out of hours. Murray et al. Implementation Science 2011, 6:6 Page 9 of 11 http://www.implementationscience.com/content/6/1/6 They would train the staff and support them but normalization of these technologies from their perspec- they only worked nine till five, Monday to Friday.’ tive of being involved in service implementations. NPT –CS3 clinical services manager – with its emphasis on the degree to which a new tech- nology fits with professional-patient interactions, rela- CI of C&B varied according to context. The hospital we tionships between staff groups, existing skill sets, and studied was in competition with 3 or 4 others located organisational context – provided a good explanation within a few miles, including highly regarded teaching hos- for the observed variability in normalization of three pitals. The overall number of referrals from primary to sec- contrasting technologies in different contexts. ondary care was decreasing, and the study hospital could Strengths of this study include the use of case study only survive financially if it could attract an increasing pro- methodology with case studies selected to include a range portion of a decreasing pool of referrals. C and B became a of healthcare contexts and types of e-health initia- central part of this hospital’sbusinessplantomaintain tives. Identifying ‘implementers,’ apreviouslyunder- inward referrals and hence overall financial viability: studied group, proved straightforward, and they did provide data from a perspective that differed to clinicians. ‘So I wanted to make it so easy to book an appoint- The multidisciplinary nature of the research team, the ment in this hospital that people would start to use convening of a data clinic to refine the coding framework, this hospital for booking.’–CS1 hospital chief execu- and the independent coding by three authors all added to tive officer the reflexivity and rigour of the research [42]. Weaknesses include the relatively small number of case studies due to Awareness of this overwhelming importance of C&B resource constraints and the low number of interviews. A to the organization’s survival plan had permeated every wider range of case studies would have been useful in con- level of management, leading to considerable investment sidering the common features of ‘successful’ implementa- of energy and resource into the implementation: tion. At the time that this study was performed, the collective action components of NPT were those that were ‘we had very strong executive leadership so it was best developed and had survived robust processes of con- always top of the priority. We had quite a strict pro- struct validation. We therefore focused analysis through ject methodology in terms of the meeting structures that lens. However, as the study continued other con- that we had. And we had a project board that met structs of NPT also reached construct validation stage consistently and was chaired by chief execs.’–CS1 [43]. We do not think, however, that more interviews per project manager for C&B in the hospital case study would have materially strengthened our find- ings. It could be argued that the study is weakened by our During the study period, however, C&B bore little rela- reliance on interview data, which must of necessity present tionship to the goals of the Primary Care Trust or the subjective interpretations of activity and observed phe- general practices, apart from an awareness of the govern- nomena. Observation is the ‘gold standard’ of socio-tech- ment promotion of policies aimed at improving patient nical studies (STS) research but in practice is hard to choice. Some individual general practices saw the electro- accomplish in studies like this without large numbers of nic booking component of C&B as a way of cutting down fieldworkers and privileged access to often contentious on administrative time spent chasing appointments in and complex settings. We hadtodothe best we could secondary care for their patients, but this advantage was with resources and ethics committee permissions available often offset by the amount of administrative time taken to us. The latter was an important restriction on our work, sorting out problems caused by C&B: since it was a condition of ethical committee approval that all respondents in this study were given 24 hours to con- ‘because we felt there would be real advantages to it sider and make informed consent before we interviewed and it would hopefully streamline the process of them. Documents would have been useful to us, but much referring patients to hospital and from the whole of what we were interested in did not reside in documents starting point here through to when the patient was but rather in knowledge in transit (emails, telephone con- actually seen at the other end. That was what we versations, ad hoc conversations, and meetings) that are initially thought.’–CS1 practice manager hardly ever available to the researcher. Our ethics commit- tee approval made it impossible for us to pursue ad hoc conversations; therefore, interviews were the only window Discussion onto events that happened far from the researcher’s gaze. Senior staff with responsibility for implementing new We note that they seem to be more frequently and inten- e-health technologies in the NHS had clear views sively used in STS studies generally, perhaps reflecting the about factors that promoted or inhibited perceived increasing complexity of fieldwork arrangements as STS Murray et al. Implementation Science 2011, 6:6 Page 10 of 11 http://www.implementationscience.com/content/6/1/6 Author details work like ours shifts into the more distributed social e-Health Unit, Department of Primary Care and Population Health, spaces of ‘whole systems.’ University College London, Royal Free Campus, Rowland Hill Street, London Our qualitative data on normalization of two of the NW3 2 PF, UK. Primary Care Research Network for Greater London, London South Bank University, 103 Borough Road, London SE1 0AA, UK. Faculty of case studies fits with published quantitative data. The Health Sciences, University of Southampton, Southampton SO17 1BJ, UK. problems with C&B that were occurring at the time of 4 5 Institute of Health and Society, University of Newcastle, UK. Academic Unit our data collection are well documented, with just 63 of General Practice and Primary Care, Centre for Population and Health Sciences, College of Medical, Veterinary and Life Sciences, University of referrals made using C&B in the first year [44], and Glasgow, 1 Horslethill Road, Glasgow G12 9LX, UK. Primary Care Trusts only halfway to the C&B target in 2007 [45]. A questionnaire study found that the major- Authors’ contributions All authors have made substantial contributions to the conception and ity of GPs were not in favour of C&B, citing problems design of the study, have been involved in drafting and revising the with time constraints and the inflexibility of the system manuscript and have approved the final version. JB collected the data for [46], reflecting our finding that poor IW impeded nor- case studies one and two; EM, JB and CM coded the data. EM is the guarantor of the paper. FM was PI on the grant that funded this work. malization in primary care. In contrast, the literature on PACS suggests that this has been widely adopted Competing interests internationally [47], accompanied by marked improve- CRM led on developing NPT, and all authors have made important contributions to its development. ments in workflow [48], reporting times, productivity [49], and reduced requests for repeat x-rays [50]. An Received: 27 August 2010 Accepted: 19 January 2011 early interview study in one hospital reported user pre- Published: 19 January 2011 ference for PACS over traditional films because of References improved ability to share images between clinicians 1. The World Health Report 1999: Making a Difference. Geneva: The World (RI), faster reporting times (CI), and potential benefit Health Organisation; 1999. for patients (IW) [51]. 2. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006, 144(10):742-52. 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BMC Med Inform We thank Trudi James for undertaking the interviews for CS3. We are very Decis Mak 2008, 8:47. grateful to all our interviewees for their time and candour, and Rick Iedema 14. Yarbrough AK, Smith TB: Technology acceptance among physicians: a for constructive criticism of an earlier version of this paper. We thank the new take on TAM. Med Care Res Rev 2007, 64(6):650-72. Service and Delivery Organisation (SDO) for funding the study. This article 15. Mair F, May C, Murray E, Finch T, O’Donnell C, Anderson G, et al: presents independent research commissioned by the National Institute for Understanding the implementation and integration of e-Health Services. Health Research (NIHR) SDO programme. The views expressed in this Report for the NHS Service and Delivery R and D Organisation publication are those of the author(s) and not necessarily those of the NHS, (NCCSDO). London: SDO; 2009. the NIHR, or the Department of Health. The NIHR SDO programme is funded 16. 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Finch TL, Mair FS, May CR: Teledermatology in the UK: lessons in service and take full advantage of: innovation. Br J Dermatol 2007, 156(3):521-7. 40. Cross M: Will Connecting for Health deliver its promises? BMJ 2006, • Convenient online submission 332(7541):599-601. 41. Ritchie J, Spencer L: Qualitative data for applied policy research. In • Thorough peer review Analysing Qualitative Data. Edited by: Bryman A, Burgess R. London: • No space constraints or color figure charges Routledge; 1994:173-94. • Immediate publication on acceptance 42. Barry CA, Britten N, Barber N, Bradley C, Stevenson F: Using reflexivity to optimize teamwork in qualitative research. Qual Health Res 1999, • Inclusion in PubMed, CAS, Scopus and Google Scholar 9(1):26-44. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Implementation Science Springer Journals

Why is it difficult to implement e-health initiatives? A qualitative study

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References (129)

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Springer Journals
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Copyright © 2011 by Murray et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Health Promotion and Disease Prevention; Health Administration; Health Informatics; Public Health
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1748-5908
DOI
10.1186/1748-5908-6-6
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21244714
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Abstract

Background: The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers – the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives. Methods: We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with ‘on the ground’ experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT). Results: Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to ‘normalize’ where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization. Conclusions: Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners’ attention to potential problems with a view to addressing them during implementation planning. Background resources [1]. Although each country is pursuing indivi- The challenges facing healthcare systems in the twenty- dual solutions to these challenges, some common first century have been well described: an aging popula- approaches are clearly apparent, including the use of tion; increasing prevalence of long-term conditions; information and communication technology (ICT) [2]. improving health technologies leading to better survival; The use of ICT is expected to lead to improvements in and rising expectations of healthcare all combine to put healthcare quality (e.g., through better communication) ever increasing pressure on available healthcare and efficiency (e.g., through reduced duplication of investigations) [3]. Australia, New Zealand, and the UK have been at the forefront of attempts to embed ICT * Correspondence: elizabeth.murray@ucl.ac.uk into routine healthcare [4], with the UK investing £12.4 e-Health Unit, Department of Primary Care and Population Health, University College London, Royal Free Campus, Rowland Hill Street, London billion over 10 years [5]. However, despite political com- NW3 2 PF, UK mitment and substantial investment, there has been Full list of author information is available at the end of the article © 2011 Murray et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Murray et al. Implementation Science 2011, 6:6 Page 2 of 11 http://www.implementationscience.com/content/6/1/6 significant variability in the success of different e-health were interested in taking a social action approach to implementations across the British National Health Ser- implementation, rather than focusing on socio-technical vice (NHS) [6]. Many projects have been subject to con- relations or higher-level theories of structuration. We siderable delay, increasing budget deficits, and in some wanted to understand the work that implementers did, cases, severely negative impacts on the quality and effec- and our approach was informed by the analysis of col- tiveness of care [7,8]. lective action, a core construct of Normalization Process Difficulties in e-health implementation are an interna- Theory (NPT)[28], whichweusedtoprovideageneral tional phenomenon, with similar problems being widely framework for this study. In particular, we focused on reported [9-12]. This work has taken many forms and, those of its components [29] that support the analysis of importantly, it has raised questions about what ‘success- enacting implementation and other social processes. ful’ implementation actually means. For example, de NPT focuses on the work that individuals and groups Bont and Bal [13] have described how a telemedicine have to do foranewtechnologyorpracticetobecome service met organizational criteria for ‘success’ and yet embedded and sustained in routine practice. failed to normalize in practice. Despite this critical con- We were interested in exploring the application of ceptual problem, much research has focused on issues four of NPTs concepts: interactional workability (IW); of efficacy or effectiveness, with trials addressing the relational integration (RI); skill set workability (SSW); ‘can it work/does it work?’ questions [2,3]. How new and contextual integration (CI) (Figure 1). IW refers to systems are ‘implemented’ remains a problem, and an the impact that a new technology or practice has on important theme in much recent work has been the interactions, particularly the interactions between health problem of ‘resistance’ or refractory behaviours of pro- professionals and patients (consultations). RI refers to fessionals – and the assumption that their ‘attitudes’ to the impact of the new technology or practice on rela- e-health are the root problem [14]. Studies exploring the tions between different groups of professionals, and the views of senior staff charged with implementing an degree to which it promotes trust, accountability, and e-health innovation are rare [15]. This is surprising, responsibility in inter-professional relationships. SSW because these people (henceforth referred to as ‘imple- refers to the fit between the new technology and exist- menters’), with their direct experience of planning and ing skill sets. An example of poor SSW would be a tech- managing implementations, are likely to have useful per- nology that required clinicians to do clerical work, or spectives on the factors contributing to the success or conversely, required administrative staff to take clinical failure of new systems, which might contribute to brid- decisions. CI, which refers to the fit between the new ging the gap between research and its wider implemen- technology and overall organisational context, including tation into practice [16,17] organisational goals, morale, leadership, and distribution Although there is a considerable body of work on fac- of resources. tors promoting successful implementation in healthcare The assumption that informed our analysis was that [18,19], implementation research within healthcare has technologies that are understood by their users to been described as a ‘relatively young science’ [20]. This have a positive impact on consultations (IW), inter- is reflected in vigorous debates about how to understand professional relationships (RI), and which fit well with implementation processes and about the theoretical existing skill sets (SSW) and organisational context (CI) tools that can be used to do this [21]. These offer us are more likely to normalize than those with a negative generalisable frameworks that can apply across differing impact or poor fit [30]. settings and individuals; the opportunity for incremental This study had two aims: first, to determine imple- accumulation of knowledge; and an explicit framework menters’ views of factors which promote or inhibit suc- for analysis [21]. There are a number of theoretical fra- cessful normalization (implementation, embedding, and meworks that have been applied to studies of technolo- integration) of e-health innovations; and secondly, to gical change in healthcare and informatics, and explore whether the collective action components of important contributions have been made to understand- Normalization Process Theory (NPT) provided an ade- ing the role of attitudes [22], and social transmission of quate explanation for different perceived degrees of nor- innovations between [23] or interactions within [24,25] malization. Although NPT was derived from a large actor-networks. More recently, Greenhalgh et al. have body of empirical work, at the time this study was offered a high level and abstract theorization of designed (2006), there were relatively few studies which ICT programmes from the perspective of Structuration had attempted to test NPT’s power as an explanatory Theory [26]. model across a range of technologies [31-33]. We Like de Bont and Bal [13], Berg [24], and Greenhalgh adopted a case study methodology as the most effective and Stones [26], our study falls within the general frame way of addressing these two aims because case study of science and technology studies [27]. However, we methods are appropriate for studying complex systems Murray et al. Implementation Science 2011, 6:6 Page 3 of 11 http://www.implementationscience.com/content/6/1/6 Figure 1 Constructs of the collective action component of normalization process theory. which are in a state of flux [34] and for exploring why case, the implementation had occurred between 2004 to and how particular outcomes occurred, rather than sim- 2006, with data collection undertaken 2007 to 2008. ply describing what happened [35]. Case study methods Case study one (CS1) was the implementation of the are distinguished by their in-depth focus on a relatively Choose and Book (C&B) system in a hospital trust ser- small number of units or ‘cases’ [36], and benefit from ving an inner city population in a large metropolitan prior development of theoretical propositions to guide area in England and the lead Primary Care Trust provid- data collection and analysis [37]. ing referrals to that hospital. C&B was a national elec- tronic service that provided patients with the Methods opportunity to choose which hospital their general prac- Design titioner (GP) referred them to for a particular problem, We report case studies of three e-health innovations. and to book the time and date of their first appoint- Data were collected using semi-structured interviews ment. C&B was a flagship project for the multi-billion with implementers and analyzed using the Normaliza- pound programme for improving use of information tion Process Model. technology in the English NHS, known as Connecting for Health [40]. Implementation involved three main Setting stakeholders: the hospital receiving referrals, the Primary Our theoretical framework, as well as previous research Care Trust (PCT) commissioning out-patient appoint- conducted by members of the team [38,39], led us to pos- ments, and the GPs making referrals. tulate that the characteristics most likely to influence the Case Study two (CS2) was the implementation of the success or failure of an implementation were the clinical Picture Archive and Communication System (PACS) in context (primary, secondary, or community care) and the one acute hospital trust, which included several hospi- nature of the e-health technology [29]. In addition, we tals at different sites, located in a largely rural area of wished to ensure that the implementation was recent England. PACS was a system for digitizing images, such enough to remain alive in respondent’s memories, while as X-rays, scans, or photographs. The digitized images sufficiently established to allow for assessment of the could be stored online, and accessed simultaneously extent to which the initiative had become embedded and from different locations. integrated into routine practice (normalized). These cri- Case Study three (CS3) was the implementation of a teria led to the selection of three cases (Table 1). In each Community Nursing Information System (CNIS) for Murray et al. Implementation Science 2011, 6:6 Page 4 of 11 http://www.implementationscience.com/content/6/1/6 Table 1 Summary of Case Study characteristics Case Study Choose and Book Picture Archiving and Community Nurse Information System Communication System Health care Primary/Secondary care interface Secondary care Community care setting Aim of Allow patients to book first Digitise x-rays and other images so Electronic record system that also allows patient technology outpatient appointment at they can be stored and viewed registration, clinic and visit scheduling and access to hospital of choice electronically clinical algorithms. Professionals Primary care: GPs, administrative Doctors, radiologists, radiography Community nurses affected by staff. administrative staff technology Secondary care: Consultants, outpatient administrative staff Data collection district nurses in an urban area in Scotland. The CNIS Semi-structured interviews were used to determine not consisted of hand-held wireless enabled Personal Digital Assistant devices (iPAQs). District Nurses could use them only ‘what happened’ but also participants’ explanations to record clinical assessment information while out in the of ‘why it happened’ in that way. Interviewees were community, and download the information to the central asked for a description of the e-health implementation server once back at base. The system also included some process from their perspective, their views about factors decision support in the form of standardized assessment which had promoted or impeded implementation and tools with associated care algorithms. The system had ori- their assessment of how normalized (embedded into ginally been intended to form a single shared assessment routine care) the e-health initiative had become. Inter- that could be shared between district nurses and social views were tape-recorded and transcribed verbatim, with services; however, social services had been unable to pur- the interviewer keeping additional field notes. sue their side of the implementation and so this function had not become available by the time of data collection. Data analysis Data were analyzed using the framework method pro- Participants posed by Ritchie and Spencer [41] according to four com- Participants were staff with responsibility for planning ponents of the collective action construct of NPT (May and/or executing an e-health initiative (’implementers’ 2006): IW, RI, SSW, and CI (Figure 1). Data were coded to as defined in Figure 2). We purposively recruited a the four constructs and overall degree of normalization. maximum variety sample, aiming to include senior Initial interviews were coded by the interviewer (JB) and chief investigator (EM) in order to develop a coding Department of Health or Connecting for Health staff framework. This framework was then tested and refined with responsibility for a number of e-health projects at a two-day multidisciplinary data analysis clinic invol- across multiple organizations, senior staff from within ving all authors. The revised coding frame was reapplied the Trust or Health Board with lead responsibility to the previously coded interviews and all subsequent for implementing a number of e-health systems within their organization (such as chief executive officers), and interviews by three authors independently (JB, EM, middle management with day-to-day responsibility for CM). There were no significant disagreements in apply- the implementation under study. Recruitment within ing the coding framework. each case study continued until we reached saturation, Data are presented in the text with each quotation fol- i.e., until no new data were emerging from subsequent lowed by case study number and role of interviewee. interviews. Based on previous experience, we estimated Where quotes include remarks by the interviewer, the that up to ten interviews per case study would be interviewer is denoted by ‘I’ and the participant by ‘P.’ needed [38]. Results Twenty-three interviews were undertaken: ten for CS1, five for CS2, and eight for CS3. Our intended sampling In this study, an implementer is any person charged with assisting with an e-health system implementation. Depending on the policy level, sponsor implementers may be frame was achieved, with interviewees including regional found at national, regional, and/or local levels, and may include health service tsars, chief executives, clinical directors, senior healthcare managers, ICT staff, health leads for the cluster (CS2) or local service provider (CS1), professionals, local NHS managers, staff involved in training, and staff working for Chief executives for the trust or health board for all three private companies contracted to supply, facilitate, or support technology implementations. Although our focus was not health professionals, some health case studies, and clinical or IT leads and a range of mid- professionals with a lead role in an e-health implementation were interviewed. dle management with ‘on the ground’ responsibilities Figure 2 Definition of implementers. (Table 2). Data saturation was achieved quickly in the Murray et al. Implementation Science 2011, 6:6 Page 5 of 11 http://www.implementationscience.com/content/6/1/6 Table 2 Roles of Interviewees Case Study Choose and Book (CS 1) PACS (CS 2) CNIS (CS 3) Regional Level Lead for Local Service Provider Regional Implementation Director for Cluster Chief Executive CEO of Trust CEO of Trust Managing Director of provider company; General Manager of Health Board Senior Management Clinical Lead for Hospital Trust Clinical Lead for Hospital Trust IT Manager Health Board; Clinical Services Manager Middle Management or “on the GP and clinical lead in PCT; Radiology Manager; Lead Project Nurse; ground” Consultant; IT Manager IT training manager Health Board; Senior Practice Manager; Nurses x 2 Project Manager for Hospital Trust; Outpatient Manager; Primary Care Director for Hospital Trust two case studies (CS2 and 3), which were located in a understand that they have been started last May, and single context, but took longer in C&B, where there were they’re only 80% on the system.’–CS3 senior nurse very different perspectives emerging from the three dif- ‘It’sa newgadgettoshowoff amongsttheir friends ferent groups of stakeholders in the hospital, the primary and stuff like that.’–CS3 IT trainer care trust, and individual general practices. Thepicture in CS1(C&B) wasmorecomplex.It Assessments of normalization appeared that there had been a high degree of normaliza- For each case study, we explored interviewee perspec- tion in the hospital, with references to it as ‘away of life tives of the degree to which the e-health innovation had here’ (CS1 hospital chief executive officer) or ‘completely become normalized. Data were triangulated across the embedded in standard operational workings’ (CS1: project different interviewee perspectives. The three case studies manager for C&B in the hospital). In primary care, there demonstrated a wide range of normalization (Table 3). was variable (and often low) normalization with certain For example, CS2 (PACS) had completely normalized practices contributing the bulk of the electronic referrals: and was totally embedded into routine practice: ‘Yeah, well most GPs don’tuse it!’–CS1 hospital ‘It’s just taken for granted that you come in and you chief executive officer use PACS and that’s how your images are that’sit... Just normal practice now.’–CS2 IT training manager Even in those practices that were high users of C&B, it was considered problematic, and had not become part In contrast, CS3 (CNIS) had at best, only partially of routine practice: normalized, and provided a good example of the differ- ence between adoption and normalization. Although ‘Right you are saying within my 10-minute slot and some 80% of the district nurses were using it, many you have said Choose and Book will take a couple of teams were still running dual systems (old paper-based minutes – it doesn’t – what, even two and a half and new electronic), and it was evident that not all years on it takes at least four and is not even work- nurses felt comfortable using it, with the hand-held ing properly today. So it took me 10 minutes to do devices still seen as new or strange: one this morning.’–CS1 GP early adopter ‘Ithink it’s fair to say it’s not integrated into normal This variability in perceived normalization was further routines very much at all in my area, but the previous analyzed using NPT as an explanatory framework (Table 3). area that they were in before, they, I mean, I Where implementers perceived good levels of CI, IW, RI, Table 3 Summary of factors affecting normalization of study technologies Case Study C & B (hospital) C & B (primary care) PACS CNIS Degree of normalization ✓✓✓ ✗/✓ ✓✓✓ ✓ Interactional Workability (impact on consultations) ✗ ✗✗✗ ✓✓✓ ✓ Relational Integration (impact on inter-professional relationships) ✗ ✗ ✓✓ ✗/✓ Skill Set Workability (fit with existing skill sets) ✓ ✗✗ ✓ ✗✗✗ Contextual Integration (fit with organizational context) ✓✓✓ ✗/✓ ✓✓✓ ✓ Murray et al. Implementation Science 2011, 6:6 Page 6 of 11 http://www.implementationscience.com/content/6/1/6 and SSW, high levels of normalization had occurred. How- was no way of getting the information to them.’–CS ever, where implementers perceived problems in one or 3; Clinical Services Manager more of these areas, the level of normalization was lower. In contrast, C&B had a negative effect on IW in gen- Interactional workability eral practice, with interviewees commenting adversely Data were considered to refer to IW if they reported the on thetimerequiredtomakeaC&B referraland the impact of the new technology on health professional – negative impact this had on patient consultations. C&B patient interactions or consultations. PACS was per- had little impact on IW in hospital, except where the ceived as having a very positive impact on doctor- system allowed patients to be booked into the wrong patient relationships on two grounds. The first was that clinic, which led to unsatisfactory consultations. images were always available when needed, allowing clinicians to make decisions in a timely manner: Relational integration Data were coded to RI if they referred to the impact of ‘The biggest advantage is in having images available the new technology on relationships between groups of all the time to everyone. So as soon as I take a picture professionals. of you, somebody can see it. In fact, everybody can PACS was reported as promoting communication and see it. So where, if you were come into A and E and trust between different professional groups because it you’ve broken an arm and you have to be referred to enabled multiple users to view the same image from dif- the orthopaedic surgeons, there is no backwards and ferent locations. This was felt to have improved working forwards of one piece of film following you around or relations between for example, orthopaedic surgeons and not as the case may be. The fact that you have a pic- radiologists, or within multidisciplinary team meetings ture that any doctor can see, the orthopaedic surgeon for planning complex cancer care for individual patients: can see; it can be in the theatre if you get up there in 10 minutes time. It can be on the ward if you are ‘Yes and I think its aiding clinicians to have a better admitted to the ward, it can be in the department for conversation if you put it in the cancer or renal unit specialist, um, review of it and report being done – ...the multidisciplinary team meeting.... I can remem- all at the same time.’–CS2 radiology manager ber, my senior pathologist has just retired and she said sitting in some of these meetings now and Second, doctors liked being able to show patients their you’ve got the pathology there and you’ve got the images, and found this easier to do with PACS than images there and she said the quality of the clinical with film: conversation that’s going on around what’sbestfor an individual patient and their circumstances has ‘you did get good doctors saying ‘it’ssonicebeing moved on and is a higher quality clinical discussion able to point things, and rotate things, and show which I would then argue must lead to better treat- things more easily,’ because you can magnify and ment planning and clinical decision making and things like that I suppose, so you can do that sort of therefore must lead onto better outcomes for thing, and share that with the patient.’–CS2 IT patients.’–CS2 chief executive officer training manager ‘And I think, particularly with the interaction between say one of the clinicians and one of the The datasuggested that theCNIShad apositive radiologists, that’s improved because the consultant impact on IW. The iPAQ devices were cheap, robust outside knows that the consultant radiologist inside and portable, allowing nurses to feel comfortable carry- has access to those images – and has probably ing them around as they visited patients, and hence pro- already seen them, probably already done a report – viding access to the patient record during home visits: so what they are doing is they are starting off from another point. In the old days, if a CT scan was ‘You’ve seen how streamlined they are quite you done and it went to the ward, the consultant on the know petite. You can put them in your pocket.’ ward wouldhaveto pickit upand bringitdownto –CS3 IT trainer the radiologist and that would be the first time the ’[Before the CNIS] if you needed information about radiologist was seeing it. Because it had never come someone whose condition had deteriorated, perhaps down from the ward before. Whereas now, he rings on a Friday afternoon, you then had to write a dif- him up and say –‘you’ve seen so-and-so, and said ferent set of documentation and drive it to the place so-and-so – what about this little bit over there?’ that the patient needed to be seen, otherwise there And then he looks up and ... Or they still come Murray et al. Implementation Science 2011, 6:6 Page 7 of 11 http://www.implementationscience.com/content/6/1/6 down to the department to talk because they like the that task themselves. However, the advantages of PACS interaction, but it is not the first time the radiologist swiftly won them over: is seeing that scan.’ CS2 radiology manager ‘And the orthopaedic surgeon said ‘What happens The CNIS had been intended to have a positive when I go on the ward and the nurse can’tget the impact on inter-professional relationships because it was image up on the screen?’‘The nurse can’tget the originally intended to form the basis for a joint record image up on the screen – you’re going to!’ And off held by both social services and community nurses. he went, mumbling that he didn’twant PACSintro- However, problems within social services led to exten- duced until he retired. He’s now on that DVD that sive delay, and at the time of data collection, social ser- wasdoneasachampion of it.’–CS2 radiology vices were not using the system, preventing any positive manager impact of the system on RI. The impact of C&B on relations between professional Ease of use was seen as essential for the CNIS, where groups was most marked for the relations between hos- the nurses started from a low level of IT literacy. Many pital consultants and GPs, with both groups regretting were alarmed that poor IT skills could jeopardize their the loss of personal contact between referring doctor future employment: and specialist (negative impact on RI): ‘It’s basically nurses who don’t even have a computer ‘I think one of the points about Choose and Book in their own homes and they haven’t actually come was to basically - is part of a systematic disenfranch- across this sort of technology and they’re having to isement of clinicians basically - so that we now refer face it at work and sometimes you get that sort of to a generic gastroenterologist or a generic chest nervous reaction that they maybe might feel a bit physician.’–CS1 GP early adopter inadequate in the sense that that oh this is really ‘I think it is all a bit more distant. Because it used to daunting. I’ve never used a computer system before. be the GPs referred to their main buddies. And they Will this mean I’ll be out of a job?’–CS3 IT trainer can’t really do so much anymore. What we hope is we substituted for that theconfidencethatthey Trainers had to spend a great deal of time on one-to- patients will be seen the first time by someone who one training and emotional reassurance: can deal with the problem.’–CS1 consultant and clinical lead for C&B in hospital ‘I must say, to be honest, they we do hold their hand quitealot andwe’ve probably spoilt them in a sense that we tend to go out to the health centres and actu- Skill set workability ally do the training rather than tell them to come out Data were coded to SSW if they referred to the fit to an unfamiliar environment.’–CS3 IT trainer between the new technology and existing skill sets, or efforts made to teach the requisite skills to users. C&B fit well with the skill sets in hospital, where In many ways PACS fit well with existing skill sets. It administrative and IT staff tended to deal with it. In was seen as relatively intuitive to use, and intensive efforts general practice, C&B had a poor level of SSW because were put into training clinical staff before implementation: GPs were expected to make the C&B referral within a consultation. They perceived this as a clerical function ‘... and basically there were a number of sessions set that was a poor use of their clinical skill: up by our training department with five or six web browsing terminals, andtheyjustwentinand they ‘I think the doctors would say that they are doing a [clinical staff] were shown how to get into their bit more with Choose and Book administration than patient; they were shown how to pick an image, and they used to. They are not happy about that. Really. how to adjust and image and read a report. I think And that is why that brings out the worst headlines we probably got about 60% of the clinical staff in the in the comics - ‘Iamnot atravelagent’ sort of trust trained before go-live. thing...’–CS1 GP early adopter I: Before go-live. Oh fantastic. P: Which was bad. And the other 40% very quickly Contextual integration learnt afterwards.’–CS2 radiology manager Data were coded as pertaining to CI if they reported on Some clinicians were used to nurses displaying images the fit between the technology and the overall organiza- for them, and were initially reluctant to have to take on tional context, including organizational goals, the quality Murray et al. Implementation Science 2011, 6:6 Page 8 of 11 http://www.implementationscience.com/content/6/1/6 of leadership within the organization, resources allocated over in...toberolledout... But also – andthisisthe to the implementation, and overall morale. other driver was – that as the rest of the world, all PACS was perceived as a way of meeting several orga- the other service providers that they were engaging nizational goals, including national targets for shorter with, were increasingly becoming... conducting their waiting times for investigations, increased efficiency business through, through the electronic medium, if within the hospital, and the chief executive officer’sper- they had... if at the very minimum, if you get them sonal goal of encouraging clinical engagement with IT. onto a platform, if I use that expression, to get them PACS helped the organization achieve their goals by onto something which would enable a, a transfer eliminating the problem of x-ray films that had been maybe at some future date, to, to another potential ‘lost’ or were unavailable at the time and place they system, depending on what their various service part- were needed: ners may, may develop, because if you’re simply not on anything, then it becomes quite difficult to, to be ‘they were never in the right place at the right time. part of an information technology strategy for, for the Well, never is too strong a word, but I think there wider sector... It would introduce them to - as indivi- were times when we were running up to about 20% duals, as professionals - to this world of electronic lost films. And what I mean by ‘lost films’ is just not record-keeping and information sharing, which they being in the right place at the right time.’–CS2 radi- just simply had no experience of.’–CS3 director, ology manager. community health and care partnership This had considerable knock-on costs in terms of On the negative side, there had been significant orga- repeat X-rays, delays to consultations or treatments, and nizational change locally, which had absorbed staff time staff time in looking for films. PACS eliminated this and energy, distracting them from the e-health imple- inefficiency: ‘throughPACSwebecomemore efficient, mentation: more productive’–CS2 consultant radiologist The chief executive officer was very committed to ‘It’s a huge piece of change, re-organizational change introducing PACS and provided strong leadership for at the time we were trying to introduce this, coupled the implementation process, ensuring that sufficient with the Agenda for Change, means we’dthree big resources, including time, senior staff and funds were things that did create issues, and we just had to kind available for the implementation to go well and com- of manage our way around it.’–CS3 joint services plete on time: manager ‘A lot of the nurses just feel it’s been one constant ‘Well I drove it, I chaired the project board...It’s about change after another.’–CS3 lead project nurse change and the way we do things, changing the cul- ture. So I chaired the project board and brought the Possibly related to this organizational change was a relevant people, so the lead radiologist who was my perceived problem with leadership, including the dis- key clinical champion was there. My head of IT was banding of the dedicated implementation group after there. There were other people involved and in a the first year and inadequate allocation of resources for sensewedoeverythinghere byproject management training and support, leaving nurses without the input methodology. That’s the way we make sure we deliver needed to build their confidence and expertise with the things.’–CS2 chief executive officer system: The data from CS3 (CNIS) demonstrated both positive ‘Um, I think a couple of years ago, there was a steer- and negative features about CI. On the positive side, the ing group set up to move this forward. And there system was seen as a way of achieving the policy goal of was also a reference group set up to look at what sharing assessment information between community should be on the system. Um, because of organiza- nursing and social services. This enabled funds to be tional change, more than anything, I think we’ve lost identified and targeted on this implementation, while the implementation group... I think, really, what’s also achieving a long-term goal of engaging a profes- been happening in [city] is that some training has sional group that had little experience of IT: been given to nursing staff, but there’sbeennofol- low-up within that area to make sure it’s happening.’ ‘This was a, a group of staff who had no access to –CS3 senior nurse electronic record-keeping at all. And there had been ‘not having help out of hours. I’mnot sure if that’s a series of efforts to do this over the years, and over resolved yet; they hadn’t resolved it when I moved in the previous decade, all of which had failed to... failed 2007 because there was no helpdesk out of hours. Murray et al. Implementation Science 2011, 6:6 Page 9 of 11 http://www.implementationscience.com/content/6/1/6 They would train the staff and support them but normalization of these technologies from their perspec- they only worked nine till five, Monday to Friday.’ tive of being involved in service implementations. NPT –CS3 clinical services manager – with its emphasis on the degree to which a new tech- nology fits with professional-patient interactions, rela- CI of C&B varied according to context. The hospital we tionships between staff groups, existing skill sets, and studied was in competition with 3 or 4 others located organisational context – provided a good explanation within a few miles, including highly regarded teaching hos- for the observed variability in normalization of three pitals. The overall number of referrals from primary to sec- contrasting technologies in different contexts. ondary care was decreasing, and the study hospital could Strengths of this study include the use of case study only survive financially if it could attract an increasing pro- methodology with case studies selected to include a range portion of a decreasing pool of referrals. C and B became a of healthcare contexts and types of e-health initia- central part of this hospital’sbusinessplantomaintain tives. Identifying ‘implementers,’ apreviouslyunder- inward referrals and hence overall financial viability: studied group, proved straightforward, and they did provide data from a perspective that differed to clinicians. ‘So I wanted to make it so easy to book an appoint- The multidisciplinary nature of the research team, the ment in this hospital that people would start to use convening of a data clinic to refine the coding framework, this hospital for booking.’–CS1 hospital chief execu- and the independent coding by three authors all added to tive officer the reflexivity and rigour of the research [42]. Weaknesses include the relatively small number of case studies due to Awareness of this overwhelming importance of C&B resource constraints and the low number of interviews. A to the organization’s survival plan had permeated every wider range of case studies would have been useful in con- level of management, leading to considerable investment sidering the common features of ‘successful’ implementa- of energy and resource into the implementation: tion. At the time that this study was performed, the collective action components of NPT were those that were ‘we had very strong executive leadership so it was best developed and had survived robust processes of con- always top of the priority. We had quite a strict pro- struct validation. We therefore focused analysis through ject methodology in terms of the meeting structures that lens. However, as the study continued other con- that we had. And we had a project board that met structs of NPT also reached construct validation stage consistently and was chaired by chief execs.’–CS1 [43]. We do not think, however, that more interviews per project manager for C&B in the hospital case study would have materially strengthened our find- ings. It could be argued that the study is weakened by our During the study period, however, C&B bore little rela- reliance on interview data, which must of necessity present tionship to the goals of the Primary Care Trust or the subjective interpretations of activity and observed phe- general practices, apart from an awareness of the govern- nomena. Observation is the ‘gold standard’ of socio-tech- ment promotion of policies aimed at improving patient nical studies (STS) research but in practice is hard to choice. Some individual general practices saw the electro- accomplish in studies like this without large numbers of nic booking component of C&B as a way of cutting down fieldworkers and privileged access to often contentious on administrative time spent chasing appointments in and complex settings. We hadtodothe best we could secondary care for their patients, but this advantage was with resources and ethics committee permissions available often offset by the amount of administrative time taken to us. The latter was an important restriction on our work, sorting out problems caused by C&B: since it was a condition of ethical committee approval that all respondents in this study were given 24 hours to con- ‘because we felt there would be real advantages to it sider and make informed consent before we interviewed and it would hopefully streamline the process of them. Documents would have been useful to us, but much referring patients to hospital and from the whole of what we were interested in did not reside in documents starting point here through to when the patient was but rather in knowledge in transit (emails, telephone con- actually seen at the other end. That was what we versations, ad hoc conversations, and meetings) that are initially thought.’–CS1 practice manager hardly ever available to the researcher. Our ethics commit- tee approval made it impossible for us to pursue ad hoc conversations; therefore, interviews were the only window Discussion onto events that happened far from the researcher’s gaze. Senior staff with responsibility for implementing new We note that they seem to be more frequently and inten- e-health technologies in the NHS had clear views sively used in STS studies generally, perhaps reflecting the about factors that promoted or inhibited perceived increasing complexity of fieldwork arrangements as STS Murray et al. Implementation Science 2011, 6:6 Page 10 of 11 http://www.implementationscience.com/content/6/1/6 Author details work like ours shifts into the more distributed social e-Health Unit, Department of Primary Care and Population Health, spaces of ‘whole systems.’ University College London, Royal Free Campus, Rowland Hill Street, London Our qualitative data on normalization of two of the NW3 2 PF, UK. Primary Care Research Network for Greater London, London South Bank University, 103 Borough Road, London SE1 0AA, UK. Faculty of case studies fits with published quantitative data. The Health Sciences, University of Southampton, Southampton SO17 1BJ, UK. problems with C&B that were occurring at the time of 4 5 Institute of Health and Society, University of Newcastle, UK. Academic Unit our data collection are well documented, with just 63 of General Practice and Primary Care, Centre for Population and Health Sciences, College of Medical, Veterinary and Life Sciences, University of referrals made using C&B in the first year [44], and Glasgow, 1 Horslethill Road, Glasgow G12 9LX, UK. Primary Care Trusts only halfway to the C&B target in 2007 [45]. A questionnaire study found that the major- Authors’ contributions All authors have made substantial contributions to the conception and ity of GPs were not in favour of C&B, citing problems design of the study, have been involved in drafting and revising the with time constraints and the inflexibility of the system manuscript and have approved the final version. JB collected the data for [46], reflecting our finding that poor IW impeded nor- case studies one and two; EM, JB and CM coded the data. EM is the guarantor of the paper. FM was PI on the grant that funded this work. malization in primary care. In contrast, the literature on PACS suggests that this has been widely adopted Competing interests internationally [47], accompanied by marked improve- CRM led on developing NPT, and all authors have made important contributions to its development. ments in workflow [48], reporting times, productivity [49], and reduced requests for repeat x-rays [50]. An Received: 27 August 2010 Accepted: 19 January 2011 early interview study in one hospital reported user pre- Published: 19 January 2011 ference for PACS over traditional films because of References improved ability to share images between clinicians 1. The World Health Report 1999: Making a Difference. Geneva: The World (RI), faster reporting times (CI), and potential benefit Health Organisation; 1999. for patients (IW) [51]. 2. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006, 144(10):742-52. 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Implementation ScienceSpringer Journals

Published: Jan 19, 2011

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