Cresswell Kathrin, Morrison Zoe, Crowe Sarah, Robertson Ann, Sheikh Aziz
Centre for Population Health Sciences, University of Edinburgh, UK.
Inform Prim Care. 2011;19(4):191-206. doi: 10.14236/jhi.v19i4.814.
The absence of meaningful end user engagement has repeatedly been highlighted as a key factor contributing to 'failed' implementations of electronic health records (EHRs), but achieving this is particularly challenging in the context of national scale initiatives. In 2002, the National Health Service (NHS) embarked on a so-called 'top-down' national implementation strategy aimed at introducing commercial, centrally procured, EHRs into hospitals throughout England.
We aimed to examine approaches to, and experiences of, user engagement in the context of a large-scale EHR implementation across purposefully selected hospital care providers implementing early versions of nationally procured software.
We conducted a qualitative, case-study based, socio-technically informed, longitudinal investigation, purposefully sampling and collecting data from four hospitals. Our data comprised a total of 123 semi-structured interviews with users and managers, 15 interviews with additional stakeholders, 43 hours of non-participant observations of meetings and system use, and relevant organisation-specific documents from each case study site. Analysis was thematic, building on an existing model of user engagement that was originally developed in the context of studying the implementation of relatively simple technologies in commercial settings. NVivo8 software was used to facilitate coding.
Despite an enduring commitment to the vision of shared EHRs and an appreciation of their potential benefits, meaningful end user engagement was never achieved. Hospital staff were not consulted in systems choice, leading to frustration; they were then further alienated by the implementation of systems that they perceived as inadequately customised. Various efforts to achieve local engagement were attempted, but these were in effect risk mitigation strategies. We found the role of clinical champions to be important in these engagement efforts, but progress was hampered by the hierarchical structures within healthcare teams. As a result, engagement efforts focused mainly on clinical staff with inadequate consideration of management and administrative staff.
This work has allowed us to further develop an existing model of user engagement from the commercial sector and adapt it to inform user engagement in the context of large-scale eHealth implementations. By identifying key points of possible engagement, disengagement and re-engagement, this model will we hope both help those planning similar large-scale EHR implementation efforts and act as a much needed catalyst to further research in this neglected field of enquiry.
终端用户缺乏有意义的参与，一再被视为导致电子健康记录（EHR）“实施失败”的关键因素，但在国家层面的倡议背景下实现这一点尤其具有挑战性。2002年，国民医疗服务体系（NHS）开始实施一项所谓的“自上而下”的国家实施战略，旨在将商业采购、集中管理的电子健康记录引入英格兰各地的医院。
我们旨在研究在有目的地选择的医院护理提供者中，大规模实施电子健康记录的背景下，用户参与的方法和经验，这些提供者正在使用国家采购软件的早期版本。
我们进行了一项基于案例研究的定性、社会技术知情的纵向调查，有目的地从四家医院抽样并收集数据。我们的数据包括对用户和管理人员的123次半结构化访谈、对其他利益相关者的15次访谈、对会议和系统使用的43小时非参与观察，以及来自每个案例研究地点的相关组织特定文件。分析采用主题分析法，基于现有的用户参与模型，该模型最初是在研究商业环境中相对简单技术的实施背景下开发的。使用NVivo8软件辅助编码。
尽管一直致力于共享电子健康记录的愿景，并认识到其潜在好处，但从未实现有意义的终端用户参与。在系统选择过程中未征求医院工作人员的意见，这导致了他们的沮丧；随后，他们认为定制不足的系统的实施进一步使他们疏远。尝试了各种实现本地参与的努力，但实际上这些都是风险缓解策略。我们发现临床倡导者在这些参与努力中发挥着重要作用，但医疗团队中的等级结构阻碍了进展。结果，参与努力主要集中在临床工作人员身上，而对管理和行政人员的考虑不足。
这项工作使我们能够进一步发展商业领域现有的用户参与模型，并对其进行调整，以便为大规模电子健康实施背景下的用户参与提供参考。通过确定可能参与、脱离参与和重新参与的关键点，我们希望这个模型既能帮助那些计划类似大规模电子健康记录实施工作的人，又能成为这个被忽视的研究领域进一步研究的急需催化剂。
