The Value of Data and the Value of Questions: Achieving Improvement in Hospital Pharmacy and Medication Safety.

Medication safety incidents are one of the major patient safety issue faced across all healthcare services and one that is very challenging to tackle. To make progress, data about the supply and use of medicines that is generated and made available in clinical systems can serve both the purposes of patient safety and service quality improvement. This paper shows how the value of data for these purposes can be framed in terms of the value of questions. This theme is developed based on an interview with a quality and safety pharmacist working in a large hospital pharmacy unit.

Delivering Digital Drugs: An Exploratory Study of the Digitalisation of Supply and Use of Medicines.

Medicines' supply and use is incresingly reliant on digital means and information. This poster presents exploratory research over five episodes of digitalisation of medicines across the supply network. We 'follow the drug' through this emerging field, providing an initial map of this new territory.

The Role of Technology in Medication Safety Incidents: Interpretative Analysis of Patient Safety Incidents Data.

This is a study of medication safety incidents reported to the NHS in England (UK) associated with the use of digital technology. An interpretative analysis of 888 incidents reports offers insight into uses and features of this technology associated with medication errors and potential patient harm.

Networking Hospital ePrescribing: A Systemic View of Digitalization of Medicines' Use in England.

Medicine management is at the core of hospital care and digitalization of prescribing and administration of medicines is often the focus of attention of health IT programs. This may be conveyed to the public in terms of the elimination of paper-based drug charts and increased readability of doctors' prescriptions. Based on analysis of documents about hospital medicines supply and use (including systems' implementation) in the UK, in this conceptual paper electronic prescribing and administration are repositioned as only one aspect of an important wider transformation in medicine management in hospital settings, involving, for example, procurement, dispensing, auditing, waste management, research and safety vigilance. Approaching digitalization from a systemic perspective has the potential to uncover the wider implications of this transformation for patients, the organization and the wider health care system.

e-Literacy in health care.

This paper explores notions of e-Literacy (otherwise IT literacy or digital literacy) in health care. It proposes a multi-dimensional definition of e-Literacy in health care and provides suggestions for policy makers and managers as to how e-Literacy might be accounted for in their decisions.

The fungibility of time in claims of efficiency: the case of making transmission of prescriptions electronic in English general practice.

OBJECTIVES: This paper presents a study of the effects of the implementation of the NHS Electronic Prescription Service (EPS) on time spent on repeat prescribing in English general practice. EPS is a new network service for the electronic transmission of primary care prescriptions, principally between GP practices and community pharmacies. This service is promoted on the basis of the importance of safe and timely supply of medicines, and the level of medicines use by many patients with treatable chronic conditions. The service is also based on presumptions of significant time-savings and efficiency gains for general practices and GPs. Our objective was to assess the time-related changes (including time savings) conditioned by digital transmission of prescriptions, specifically for repeat prescribing activity in primary care practices. METHODS: As part of the official evaluation of EPS in the English NHS we undertook a qualitative research design with field studies in four of the first GP practices adopting EPS. This research was based on interviews with clinical and administrative staff, and non-participant observation of repeat prescribing related activities. RESULTS: We found that the use of EPS reduced turnaround time and conditioned changes in the workflow, with time-savings found mainly in relation to administrative tasks. But the use of this technology also created additional tasks and shifted existing tasks and responsibilities. Thus elimination of tasks did not automatically correspond to potential staff savings or cost savings. Tasks that were eliminated and new tasks that were created were not equivalent in terms of time spent, quality of attention required, and roles involved. CONCLUSIONS: The wider claim that healthcare information technology saves time and increases efficiency is often based on assumptions of the fungibility of time and people - i.e. that units of time added or saved on different steps of the workflow can be summed up as if they were all of the same kind, and thus reveal any net efficiency gain. But workflow time savings involve changes in the quality of tasks, redistribution of work and responsibility that mean that time can hardly be added or subtracted to obtain 'efficiency totals'.

Clinical Computer Systems Survey (CLICS): learning about health information technology (HIT) in its context of use.

Successful health information technology (HIT) implementations need to be informed on the context of use and on users' attitudes. To this end, we developed the CLinical Computer Systems Survey (CLICS) instrument. CLICS reflects a socio-technical view of HIT adoption, and is designed to encompass all members of the clinical team. We used the survey in a large English hospital as part of its internal evaluation of the implementation of an electronic patient record system (EPR). The survey revealed extent and type of use of the EPR; how it related to and integrated with other existing systems; and people's views on its use, usability and emergent safety issues. Significantly, participants really appreciated 'being asked'. They also reminded us of the wider range of administrative roles engaged with EPR. This observation reveals pertinent questions as to our understanding of the boundaries between administrative tasks and clinical medicine - what we propose as the field of 'administrative medicine'.

Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems.

BACKGROUND: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. METHODS: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS). RESULTS/DISCUSSION: We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. SUMMARY: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals.

OBJECTIVES: To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England. DESIGN: Theoretically informed, longitudinal qualitative evaluation based on case studies. SETTING: 12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years. DATA SOURCES: Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. RESULTS: Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. CONCLUSIONS: Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Learning lessons from electronic prescribing implementations in secondary care.

This paper reports a study undertaken in the UK to gather lessons learned from hospital sites that have implemented electronic prescribing systems. The work was commissioned by NHS Connecting for Health, the UK Department of Health agency responsible for the implementation of the National Programme for Information Technology. The aim was to capture front-line experience of the project and systems implementation, and to share it with staff who will in the future participate in other implementations. Data were drawn from detailed interviews with staff and a survey in 13 hospitals in England, as well as a review of published studies of implementations. The study output is a report and six user-facing briefing documents targeted at key stakeholder groups; nurses, pharmacist, doctors, senior executives, implementation team members and IM&T staff.

Exploring control in health information systems implementation.

Health information systems promise opportunities for improved healthcare. However, these opportunities may become challenges and obstacles to practice. This research reflects on the outcomes of implementing healthcare information systems in three English hospitals. In each case qualitative methods were used to observe and interview doctors, nurses and pharmacists as they carried out their daily healthcare routines. The changes that the implementation of health information systems brought for both the clinical encounter, as well as health care professionals' work flow, were explored. We argue that such technologies have become a central orchestrator of the clinical setting, to the extent that they often impose control on healthcare practices. Using a socio-technical approach we seek to understand how information systems technology and healthcare professionals can work together rather than apart, or around one another.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation.

OBJECTIVES: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. DESIGN: A mixed methods, longitudinal, multisite, socio-technical case study. SETTING: Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a "middle-out" approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. CONCLUSIONS: Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations' perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

Sociotechnical changing in healthcare.

This paper discusses a conceptual approach to the study of the implementation of ICTs in healthcare organizations. The paper uses some fundamental concepts from sociotechnical studies to address the complex process of change--the changing--that accompanies ICT innovations. The paper argues for the importance of the perspective of changing as a way to account for the dynamics as technology and people, organizations and institutions co-constitutively work-out their future together.

Medication errors with electronic prescribing (eP): Two views of the same picture.

BACKGROUND: Quantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods. METHODS: The study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. QUANTITATIVE: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. QUALITATIVE: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review. RESULTS: The two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines. CONCLUSIONS: The qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and could be used to supplement information from anonymous error reporting schemes.

Evaluating monitoring systems in the European social fund context: a sociotechnical approach.

In contrast to the prevailing image of monitoring systems as technical systems, it is proposed that they should rather be conceived of as social endeavors at exchanging information. Drawing on the monitoring and evaluation framework of Cornford, Doukidis, and Forster, the concept of information agreement is suggested as a way of assessing the quality of monitoring systems in context. Preliminary implications are discussed with regard to the quality of information, the information agreement being conceptualized as a tacit, and/or explicit agreement between and among participating government partners about the quality of information.

Qualitative evaluation of an electronic prescribing and administration system.

OBJECTIVE: To provide a formative socio-technical evaluation of a pilot implementation of an integrated electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on one ward. DESIGN: A qualitative observational approach using discourse analysis within a socio-technical evaluation framework addressing systems functions, human perspectives and organisational context. SETTING: Surgical ward in a teaching hospital. PARTICIPANTS: Staff on study ward and in pharmacy. INTERVENTION: Implementation over time of an integrated electronic prescribing, automated dispensing, barcode patient identification and EMAR system. MAIN OUTCOME MEASURES: Assessment of technical performance, developed attitudes to the new system, changes to delivery of care and work practices. RESULTS: The system was successfully implemented on the ward, and remained in operation for over 2 years. Many of the technical components of the system initially showed problems, but the system evolved, with increased functionality and improved performance. Attitudes to the system in the early stages were mixed. Over time, and with experience of making the system work for them, staff attitudes changed to become more balanced and the potential benefits of the system became clearer to most. The system structured the work of staff, sometimes unexpectedly. CONCLUSIONS: Electronic prescribing systems need to be seen as occasions for change and learning rather than as black-boxed technical solutions to identified problems. The evaluation framework allows understanding as well as hypothesis testing, and is recommended for future evaluations of electronic prescribing systems.