Understanding variation in departmental adoption of Electronic Health Records: an embedded case study [post]

2019 unpublished
Electronic Health Records (EHR) are integrated software applications used by healthcare providers to create, share, retrieve, and archive patients' health status information. Especially for large healthcare organizations, implementing Electronic Health Records organization-wide is a complex endeavour. The EHR literature generally suggests that contextual factors play a major role in adoption. We demonstrate how the work context in uences adoption at the departmental level in a situation where
more » ... a situation where each department has its own medical specialty or patient stream, clinical authority, and accountability. Here, the achievement of full adoption by all departments is not self-evident. Drawing on EHR implementation in a Dutch hospital, this study explores how the clinical departments' work context characteristics contribute to their pre-implementation intended adoption and their post-implementation EHR uptake. Methods: This embedded case study allowed us to examine the EHR adoption of eight diverse clinical departments in terms of their work and socio-political context. Data collection entailed semi-structured interviews, observing meetings, document analysis, and feedback sessions to check our interpretations. We examined the context and adoption intentions before implementation and the adoption level approximately half a year after the Go Live. The comparative case analysis iterated between holistic department-level descriptions and structured data displays based on inductive and deductive coding. Results: We identi ed three departmental types that varied both in adoption intention and postimplementation uptake: (1) departments oriented towards the organization with an enthusiastic or compliant adoption; (2) internal-oriented departments with a selective or conditional adoption; and (3) externally oriented departments with no or low adoption with workarounds. Conclusions: We conclude that work context characteristics contribute to individual departments' adoption of an EHR. By acknowledging departmental types that will vary in adoption intention, and Research site and department selection To explore how the particular contexts of clinical departments affect the adoption of organization-wide EHR, we conducted an embedded case study within a large hospital in the Netherlands. A case-study approach allowed us to study departmental adoption in its natural setting and so understand its nature and the complexities involved [27, p. 78]. The Dutch healthcare system is in transition from a supply-side oriented, government-regulated approach towards managed competition [28] . The Netherlands has 77 hospitals [29] . Since 2006, hospitals have increasingly been allowed to negotiate with health insurers over treatment prices and quantities. The number of negotiable treatments has risen from 20% in 2008 to 70% in 2018. Increasing pressure from insurance companies to lower prices has resulted in competition between hospitals [30] . In order to lower prices while maintaining quality, hospitals are increasingly specializing, which requires negotiations between hospitals and specialties. Partly as a consequence of this specialization, hospitals are still expected to collaborate with each other in networks to maintain accessibility and increase the quality of care [31] . This development is enabled through demands for transparency in terms of price and quality imposed by government, insurers, and patients, a process that represents a strong push towards EHR use. In many hospitals in the Netherlands, clinical departments enjoy a fair degree of autonomy if only because the medical specialty is professionally accountable for the patient care delivered. Often, medical specialties are organized in legally separate entities that negotiate with the hospital management. The focal hospital of our research had initiated a program directed at purchasing and then implementing an organization-wide EHR to improve cross-departmental work ows, patient safety, and e ciency of care. Top management had decided to implement, through a big-bang approach, a uniform system, with hospital-wide functionality, that left little room for customization. The focus was on internal hospital processes and reimbursement for services rather than on information exchange with external actors. The system was expected to replace numerous stand-alone applications and integrate all the existing paper-based and electronic records. The case study in this paper covers the pre-implementation stage that lasted 2.5 years (Autumn 2012 -Spring 2015 and the subsequent uptake between December 2017 and Spring 2018, complemented with a snapshot of the realized adoption for each department a year later. The preimplementation stage was divided into two phases, in each of which we gathered data. Phase 1 focused on project preparation, requirements speci cation, the tendering procedure, and vendor selection. Phase 2 involved the subsequent system design, system integration, training, and testing. The implementation strategy from December 2017 onwards was plateau-oriented and is still in progress. The level of customization will be increased at each successive plateau. The analysis of the realized adoption concerned the implementation of the rst plateau. Given our study's comparative nature [32] , eight departments were selected to allow theoretical replication [33] . The departments (coded A -H) were selected in consultation with the EHR's project management to ensure variation on three selection criteria: (1) the department's existing patient administration and
doi:10.21203/rs.2.17193/v1 fatcat:ys7sluqc65cflo2ds6wq57mw7u