Medication Reconciliation as Repair Work.

In Norway, the process of developing a national shared medication list has been underway for several years. The shared medication list provides an overview of all the medications used by a patient. However, its proper use requires that it be maintained regularly through so-called medication reconciliation processes in which health personnel clarify - and ask patients - what and how much medication they use. We explore the work embedded in the bedside medication reconciliation process at a hospital, the health personnel conducting this work and the implications for the shared medication list. We argue that reconciliation processes can be conceptualized as collective repair work that needs to be continued after the shared medication list is implemented.

Configuring Secretarial Workflows in the Epic EHR Suite.

The primary goal of large-scale electronic health record (EHR) suites is to meet the needs of a broad range of users in healthcare institutions. EHR suites are extensively configurable, which makes it possible to tailor them to diverse professional practices and users. However, while users such as physicians and nurses may have clearly defined responsibilities, clerical personnel (i.e. secretaries) conduct "in-between" or invisible work that is not as easily defined. Therefore, it may be more difficult to tailor EHR suites to their needs. Moreover, because secretaries are quite low in the hospital hierarchy, it is difficult for them to obtain satisfactory solutions. In this paper, we explore the challenges of configuring the EHR suite for secretary workflows in the Health Platform program in central Norway.

Implementing Large-Scale Electronic Health Records: Experiences from implementations of Epic in Denmark and Finland.

BACKGROUND: With the still larger scale of electronic health records (EHRs), their implementation has become increasingly complex. In this study, we focus on one large-scale EHR - Epic. PURPOSE: We analyze the Epic implementations in Denmark and Finland to understand how healthcare professionals experience this large-scale EHR. METHOD: The study is based on documentary analysis. The analyzed documents include user surveys, assessment reports, material from project partners, and research papers. RESULTS: The Danish and Finnish Epic implementations are still troubled five and three years, respectively, after the first go-live. In Denmark, the business case and implementation process have been sharply criticized. The correction of usability problems and unstable system integrations have been slow, the time required to perform common clinical tasks has increased, and 32% of the users remain dissatisfied or very dissatisfied with the system. In Finland, the physicians and nurses experience improved technical performance but inferior usability and reduced work support compared to the EHR they used before Epic; only 4.7% (physicians) and 7.3% (nurses) agree that patient information is easy to access, and only 9.3% (physicians) and 26.2% (nurses) agree that Epic helps improve the quality of care. CONCLUSION: The post-implementation experiences from the two implementations contradict pre-implementation expectations. Specifically, the consequences of using Epic have become salient only after go-live. As a result, the implementing organizations and their users have predominantly found themselves in a reactive mode of fending off problems rather than a proactive mode of realizing benefits.

Large-Scale EHR Suites and Path-Dependence.

Large-scale electronic health record (EHR) suites are expected to cover a broad range of use scenarios for healthcare workers in hospitals, nursing homes, home-care services, and general practitioner (GP) clinics. However, preparation for the implementation of EHR suites requires years of detailed planning and consumes considerable financial and human resources. A key problem, then, is that there is less room for decision-makers to consider promising alternative solutions both before and after the implementation of EHR suites. On this basis, we explore how past decisions on EHR suites limit future technological alternatives. Empirically, we focus on the Health Platform program in Central Norway, where the goal is to implement the U.S. Epic EHR suite in 2022, following similar implementations in Denmark in 2016 and Finland in 2018.

A Common Electronic Health Record for Norwegian Municipalities.

Large-scale electronic health record (EHR) systems have increasingly become a staple of the European healthcare market. The Norwegian health care authorities are planning for the acquisition of a common large-scale EHR system for 291 of Norway's 356 municipalities. This has resulted in much controversy among the stakeholders. We explore the key contested areas.

Scaling AI Projects for Radiology - Causes and Consequences.

Artificial intelligence (AI) for radiology has the potential to handle an ever-increasing volume of imaging examinations. However, the implementation of AI for clinical practice has not lived up to expectations. We suggest that a key problem with AI projects in radiology is that high expectations associated with new and unproven AI technology tend to scale the projects in ways that challenge their anchoring in local practice and their initial purpose of serving local needs. Empirically, we focus on the procurement of an AI solution for radiology practice at a large health trust in Norway where it was intended that AI technology would be used to process the screening of images more effectively. Theoretically, we draw on the information infrastructure literature, which is concerned with scaling innovative technologies from local settings, with a limited number of users, to broad-use contexts with many users.

Introducing Lightweight IT - A Way to Build Flexibility for Healthcare Organizations?

The paper addresses socio technical relations of implementing a lightweight IT app in Norway. The focus is on how such technology will influence the possibilities for an organization connected to a large-scale heavyweight IT infrastructure to provide more rapid changes in line with healthcare worker's needs. The research question is therefore: How can lightweight IT support rapid organizational changes? The empirical site is one of the first health trusts in Norway implementing lightweight technology integrated to their Electronic Health Record (EHR). The lightweight technology is a nursing app for registering early- warning score (NEWS) bedside the patients. The paper is based on a qualitative interpretive approach, and the results are discussed in line with information infrastructure theory.

National Integration Components Challenge the Epic Implementation in Central Norway.

Electronic health record (EHR) suites cover a broad range of cross-sectoral use scenarios. Thereby, they streamline information flows but also require that healthcare professionals with diverse responsibilities must adapt to one and the same system. In the region of Central Norway, the EHR suite from Epic is being implemented at hospitals as well as in municipal healthcare. However, the 64 municipalities in the region are increasingly exploring the option of bypassing Epic by supplementing their existing systems with national integration components. These components provide integration and data exchange across systems for selected healthcare information. We discuss whether they are a viable alternative to Epic. The three components are the summary care record, the shared medication list, and the national welfare technology hub.

The Rising Importance of e-Health in Norway.

Drawing on three central sources of data on the development in e-health use in Norway (studies from the Norwegian Centre for e-Health Research, studies from Statistics Norway, and the Tromsø 7 Study), we describe the rising importance of e-health. Originally restricted to a limited use within the health services, in recent years the use of e-health has gained momentum both in the general population and within the traditional health services, as the Internet has offered easy access to health information as well as a range of other health-related services.

The Tension between National and Local Concerns in Preparing for Large-Scale Generic Systems in Healthcare.

Large-scale generic systems are typically adapted to local practice through configuration. This is especially important in healthcare, which involves a plurality of institutions and users. However, the decision to acquire a generic system in public healthcare is typically founded on regional and national health policy goals, which often are translated into various forms of standardization. As a result, national and regional health policy interests may stand in contrast to interests on the local level. Therefore, we analyze how national and local concerns are weighed against each other in the preparations for implementing large-scale generic systems in healthcare. We explore what role configuration plays and what the prospects are for long-term development. We contribute with insight into how the organizational consequences of generic systems are formed already in the preparation phase and point to how configuration easily results in standardization, thereby basically privileging national and regional health goals at the expense of local needs. Empirically, we focus on the preparations for implementing the Epic electronic health record in Central Norway.

Persuasion Tactics in the Implementation of Large-Scale EHR Suites in Public Healthcare.

Large-scale electronic health record (EHR) suites have the potential to cover a broad range of use needs across various healthcare domains. However, a challenge that must be solved is the distributed governance structure of public healthcare: Regional health authorities regulate hospitals, municipalities are responsible for first-line healthcare services, and general practitioners (GPs) have an independent entrepreneurial role. In such settings, EHR program owners cannot enforce municipalities and GPs to come on board. Thus, we examine what tactics owners of large-scale EHR suite programs apply to persuade municipalities to participate, how strongly these tactics are enforced, and the consequences. Empirically, we focus on the Health Platform program in Central Norway where the goal is to implement the U.S. Epic EHR suite in 2022. Theoretically, the paper is positioned in the socio-technical literature.

Drivers of expectations: Why are Norwegian general practitioners skeptical of a prospective electronic health record?

While expectations are well-known drivers of electronic health record (EHR) adoption, the drivers of expectations are more elusive. On the basis of interviews with general practitioners (GPs), we investigate how the early implementation process drives their expectations of an EHR that is being implemented in Norway. The GPs' expectations of the prospective EHR are driven by (a) satisfying experiences with their current system, (b) the transfer of others' experiences with the prospective EHR, (c) a sense of alignment, or lack thereof, with those in charge of the implementation process, (d) uncertainty about the inclusion of GP needs, and (e) competing technological futures. To manage expectations, starting early is important. Mismanaged expectations produce a need for convincing people to reverse their expectations. This appears to be the situation in Norway, where the GPs are currently skeptical of the prospective EHR.

The Master Study in Telemedicine and E-health at the University of Tromsø, Norway, 2005-2018.

In this paper we describe the Master Study in Telemedicine and E-health at the University of Tromsø, Norway. The study enrolled its first students in 2005 and was closed in 2018. We describe and discuss the background of the programme, its development and accomplishments and why it was closed. Hopefully, this narrative will be of use to other programmes focusing on e-health.

User Requirements Meet Large-Scale EHR Suites: Norwegian Preparations for Epic.

Electronic health records (EHRs) are becoming the norm in healthcare. Typically, these EHRs are large-scale suite systems. The up-front presence of ready-for-use EHR suites changes the role of user requirements and the conditions for deciding which requirements to include in the final contract. In this paper, we investigate how user requirements are negotiated in the ongoing preparations for the implementation of Epic throughout the region of Central Norway. User requirements shape vendor selection but they are also shaped by the vendors' existing EHRs and by the requirements of the selected vendor's other customers.

Preconditions for Enabling Advanced Patient-Centered Decision Support on a National Knowledge Information Infrastructure.

In Western healthcare, an important goal is to provide clinical decision support "for the right healthcare personnel, in the right situation, at the right time". In this poster, we use a qualitative approach to outline the preconditions for enabling such advanced patient-centered decision support. This study indicates that establishing a national knowledge information infrastructure demands well-defined national standards, codes, and terminologies, as well as structured clinical data. An extensive governance structure is also required.

From Free-Text to Structure in Electronic Patient Records.

We report from the initial steps of a collaboration project between two post-doctoral projects, both using a qualitative action research approach to address challenges related to shifting from a free text to a structured EPR system constituting important preconditions for establishing advanced decision support and reuse of healthcare data. We have started to explore three areas that may influence this process related to: 1) Legislative challenges of getting access to all relevant healthcare data. 2) Challenges of exchanging data between silo systems and open platform systems. 3) Replacing a free text silo EPR with an open platform system - and the practical challenges of defining the content of the context sensitive structured EPR. Hence, we ask the following research questions: How to address challenges related to the shift from free text to structured EPR systems? How will the need for semantic interoperability between different EPRs influence the goal of advanced clinical decision support? Empirically, we draw on the regional FRESK program (2017-2022), in the North Norwegian Health Region, which includes implementing both a new regional open platform based EPR system, and a proprietary medical chart system.

The implementation of an electronic health record: Comparing preparations for Epic in Norway with experiences from the UK and Denmark.

BACKGROUND: The implementation of electronic health records (EHRs) requires careful preparations but may still cause trouble. In this study we focus on one EHR - Epic. PURPOSE: We compare the experiences from implementing Epic in the UK and Denmark with the preparations for implementing it in Norway. METHOD: The study is based on document analysis (UK and Denmark) and interviews (Norway). RESULTS: Epic had a troubled start in both the UK and Denmark with malfunctions in the interfaces to other clinical systems, disruptions in the continuity of care, and drops in performance. While the state of routine use has subsequently been reached in the UK, the transition process is still ongoing in Denmark. In Norway experiences from, especially, Denmark are heeded in planning the implementation of Epic, which is expected to deliver better care more efficiently. We discuss six pitfalls to achieving these benefits. CONCLUSION: Experiences from, especially, Denmark inform the Norwegian preparations, but these experiences point toward more challenges than solutions. The implementation of Epic in Norway is currently in a state of considerable uncertainty.

Data work: A condition for integrations in health care.

Integration and interoperability between different information and communication technology (ICT) systems are crucial for efficient treatment and care in hospitals. In this article, we are particularly interested in the daily local work conducted by health-care personnel to maintain integrations. A principal aim of our article is, therefore, to contribute to a sociotechnical understanding of the "data work" that is embedded in the integration of health-care systems. Theoretically, we draw on the concepts of "information infrastructures" and "articulation work," and we discuss how social status may influence the invisible articulation work. Furthermore, we show how historical decisions and existing systems both nationally and regionally have impacts on the daily work of local actors. Empirically, we have studied the formative stages of a large-scale electronic medication management system project in the Northern Norway Regional Health Authority.

Evaluating Model-Driven Development for large-scale EHRs through the openEHR approach.

PURPOSE: In healthcare, the openEHR standard is a promising Model-Driven Development (MDD) approach for electronic healthcare records. This paper aims to identify key socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals. More specifically, key fundamental assumptions are investigated empirically. These assumptions promise a clear separation of technical and domain concerns, users being in control of the modelling process, and widespread user commitment. Finally, these assumptions promise an easy way to model and map complex organizations. METHODS: This longitudinal case study is based on an interpretive approach, whereby data were gathered through 440h of participant observation, 22 semi-structured interviews and extensive document studies over 4 years. RESULTS: The separation of clinical and technical concerns seemed to be aspirational, because both designing the technical system and modelling the domain required technical and clinical competence. Hence developers and clinicians found themselves working together in both arenas. User control and user commitment seemed not to apply in large-scale projects, as modelling the domain turned out to be too complicated and hence to appeal only to especially interested users worldwide, not the local end-users. Modelling proved to be a complex standardization process that shaped both the actual modelling and healthcare practice itself. CONCLUSION: A broad assemblage of contributors seems to be needed for developing an archetype-based system, in which roles, responsibilities and contributions cannot be clearly defined and delimited. The way MDD occurs has implications for medical practice per se in the form of the need to standardize practices to ensure that medical concepts are uniform across practices.