Managing the Gradual Transition from Paper to Electronic Patient Record EPR A Case Study By Nina Bou

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Managing the Gradual Transition from Paper
toElectronic Patient Record (EPR) A Case
StudyByNina Boulus Thesis submitted as part of
the Masters degree in Dept of Informatics, UiO

• Dr.Zubeeda Quraishy
• Department of Informatics
• University of Oslo, Norway

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I wish to thank Nina Boulus.

• whose thesis I am using as a teaching material
  to highlight the different challenges a large
  scale project faces in implementing the
  electronic patient record in Rickshospitalet, a
  national hospital in Norway.

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Why I chose the above case study for the class?
Reasons

• The case study is discussed using many frameworks
  and theories particularly ANT which describes
  how, where and to what degree the technology
  influences human behaviour (Monterio,2000) thus
  giving us a deeper understanding of how
  technology is interlinked to its context

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Reasons..

• b. particularly when trying to understand the
  roles and meanings of artifacts in social world
  or in work then this perspective creates a light
  on how human and non-human elements are
  intertwined and together creates heterogeneous
  socio-technical network. This is important from
  the anthropological perspective.

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Reasons.

• The above thesis / case study also helps us to
  develop a deeper understanding of the socio
  technical aspects of the complexities and
  challenges that emerge from the implementation of
  the EPR
•  
• Also the above case study describes / delineates/
  outlines the strategies to manage the gradual
  transition to digital record from the manual
  paper based records.

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What is an EPR?

• An Electronic Patient Record (EPR) is an
  electronic medium for storing clinical
  information.
• Most of the electronic patient records replicates
  the structure that is used in the paper based
  record and
• It accumulates all the information that is
  relevant for the treatment and nursing of a
  patient.

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Why an EPR?

• Seen as a solution for various problems in the
  health care organization
• b. Increased demand for efficiency and quality as
  transformation is taking place from Public
  sector to Business culture.
• c. Increased focus on costs saving and
  documenting activities, efficient use of
  resources and benefits.
• d. Not only to reduce the physical size of the
  paper records but to centralise and merge the
  paper based records into EPR.
•  

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Main reason for doing the above case study by the
researcher

• For last three decades implementation of EPR has
  proved to be a highly challenging and complex
  task in spite of huge funding spent on the
  process of implementation by national and
  international agencies.
• EPR had great visions To support managed care
  logic, redesign of work processes and improved
  quality of care ( Nilsson, Grissor and
  Aanestad,2002).

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Contd..

• EPR were expected not only to replace the old
  fashioned, messy and inadequate paper records but
  to fundamentally transform and improve medical
  care ( Dick Steen,1991 in Nilsson et
  al,2002,p2).
• Provides an opportunity to study the issues of
  scaling large information infrastructures

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Theoretical framework for the study

• Analytical framework that was used by the
  researcher in this case study is consisted of
  Actor Network Theory (ANT) which is also used as
  a methodological theory to view information
  infrastructures

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Brief Introduction of Actor Network Theory

• ANT as a methodological theory has been used in
  this case study to understand information
  infrastructures (IIs) .
• Main reason for choosing ANT according to
  author of the study is that
• Provides a framework for the socio-technical
  aspects and views the technology as an actor on
  par with other actors
• provides theoretical concepts for documenting a
  complex and heterogeneous socio-technical work
  practice with many actors.

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Advantages of Using ANT)

• Brings forth to light how new technology
  affects and interacts with the various actors and
  vice versa indicating a mutual interaction
  process.
• ANT has the advantage of viewing both the
  human and non human actors as linked elements in
  the networks (heterogeneous actor networks) and
  also the focus is on the interplay and relations
  between these elements.

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Contd..

• ANT provides a better understanding of the
  networks complexity, helping us to see how
  borderline issues and inscriptions are hidden in
  the links between the various actors..
• Also, the theory provides a deeper understanding
  of the process of translations and motivations of
  heterogeneous actors

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How is an alignment achieved in the network ?

• The alignment is obtained through a process
  whereby the actors interests are translated in to
  an agreeable expressions that are supported by
  several actors( Callon,1991, Law,1992 and
  Latour,1991)
• The interests of the different actors are
  translated into technological and social
  arrangements of material form.
• And this translation once inscribed into an
  artefact (register or agreement) and
  institutionalized becomes so powerful that it
  enforces a desired behaviour( Calon, 1991)

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Then, what is an Artefact?

• An artefact can be a paper or a computer based
  document (reading and writing artefacts),lists,
  whiteboards, progress notes and forms which is
  more than a static carrier of information.
• A paper document can be replaced electronically.
• Both the reading and writing artefacts can be
  active participants in work practice as they
  accumulate inscriptions and coordinate
  activities .

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(contd..) What is an Artefact?

• Medical record for instance, is an artefact that
  feeds in to the content of the medical decisions
  made, into the doctor-nurse relation-ship, into
  the organisation of medical work and in to the
  figuration of the patient.(Berg,1999,p.375).

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(Contd..)

• Medical record for instance, is an artefact that
  feeds in to the content of the medical decisions
  made, into the doctor-nurse relation-ship, into
  the organisation of medical work and in to the
  figuration of the patient (Berg,1999,p.375).

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Why the Artefacts are not static?

• The artefacts triggers activities (Hanseth and
  Lundberg (2001)
• The artifact becomes dynamic as it not only
  provides interactions between different actors
  but also when new entries are constantly added .
  Examples of an order given by the doctor to
  collect blood test shows how the order form
  coordinates activities of several interrelated
  heterogeneous entities
• Yates(1989),Heath and Luff studied the role of
  the patient record in medical practice and showed
  how the role of the paper documents are central
  in the work and the interactions between doctors
  and patients.

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Advantages and disadvantages in Using the paper
and computer based artefacts

• While both the forms of artefacts mediate the
  practices of which they become a part, the paper
  based artefacts have special properties that make
  suitable in both synchronous and asynchronous
  collaboration.
• A paper is a portable artefact that has micro
  mobility, meaning it can be manipulated and
  easily reordered( Luff and Heath, 1999,p 307). At
  the same time there is a limitation to a paper
  artefact that is, it can be present in one
  location at a time.

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Contd

• Paper based artefacts become invisible when they
  become electronic.
• Computer based artefacts (reading and writing
  artefacts) have the possibility to collect and
  assimilate inscriptions and to rapidly
  interconnect locations that are geographically
  separated .
• Computer based order forms can prompt messages to
  the appropriate individual.
• In short, artefacts have various important roles
  in the medical history as they coordinate
  activities and accumulate inscriptions.

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Different perspectives adopted to view EPR

• EPR viewed from the perspective of Information
  infrastructure systems
• What is an Information infrastructure Systems?
• Information infrastructures are more than just
  the physical facilities that are used to
  transmit, store, and process information ( data
  ,voice and images).
• In Websters dictionary Infrastructure is
  defined as
• A substructure or underlying foundation
  especially, the basic installations and
  facilities on which the continuance and growth of
  a community ,state etc, depends as roads,
  schools, power plants, transportation and
  communication
• systems etc,(Garlanik,1970)

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What is an Information Infrastructure System?

• Information infrastructure is a vast field that
  covers all kinds of use and use areas.
• It involves political, social, organisation,
  human aspects and issues from the development
  of industrial at national, regional or even the
  global level. (Hanseth and Monteiro,1997, chap 1)
• Unlike in the past where isolated information
  systems were developed IIs will encompass the
  integration of large number of systems.

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Reason for selecting the above perspective to
view EPR

• It helps to understand the patient record in a
  broader framework than the traditional
  information systems.
• Rather than understanding the systems as single
  elements in an isolated fashion which are
  developed for specific purposes and are used by
  homogeneous group they are described as elements
  in a larger infrastructure, including both
  technological and social actors.
• Infrastructures are heterogeneous in the sense
  that they include elements of different
  qualities, humans and computers.

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Reasons for selecting to view EPR

• A key characteristic of infrastructure is that
  they evolve continuously through extensions and
  improvements without any time frame and over a
  period the infrastructures develop the scope of
  including new applications and the number of
  users and use areas increases giving it the
  feature of being open and scaled..
  (Hanseth,2002)
• In other words infrastructures are never built
  from scratch but rather developed by
  interrelating and inter connecting existing
  components.
•  

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Reasons for selecting to view EPR

•     The aspect that IIs are shared by
  heterogeneous users along with the fact that
  their development is heavily influenced by
  installed base and standards is generally taken
  for granted makes the author of the study discuss
  below the implications for change and the role of
  the installed base in relation to change

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Implications for Change

•        Traditional IS design is different from
  the design of IIs in several perspectives.
• Unlike in traditional information systems there
  is complexity and unpredictability in IIs.
• Traditional ISs design methodologies focus on the
  development of a closed systems meaning single,
  isolated and stand alone systems (Hanseth, 2002)
  and design phase follows a closed time frame
  which is supposed to have pre-defined start and
  ending time frame(Orlikowski,1996)..
•  As a result, the role of the installed base
  becomes crucial as it heavily influences the
  design of the new elements.
• When implementing complex Information
  infrastructure it is best to adopt an
  evolutionary approach.

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Implication of adopting evolutionary approach

• In evolutionary approach the installed
  base is seen as a design starting starting
  point(Hanseth,1996).Thereafter, sub-networks are
  being changed following step-wise incremental
  changes at alignment, while aligning the new
  components with the rest of the network.
• This increases the chances for a
  successful transition over time between stability
  and flexibility(change) for the different
  components(Hanseth, Monteiro, Halting 1996)
• It has been proved that re-designing existing
  components or introducing new components produce
  unintended side effects.
• Therefore when one of the components is
  extended or re-designed this often has the
  consequences for other components in the entire
  network (Hanseth, Ciborra and Braa,2001).

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Importance of Transition Strategies

• In order to meet the new requirements IIs have to
  gradually evolve and scale through extensions and
  improvements, in order to meet the new
  requirements.
• But scaling an information infrastructure is
  neither trivial nor automatic but a process
  caught in a dilemma.(Monteiro,1998,p 230)
  involving pressure for change and at the same
  time demanding negotiation and balance against
  the conservative influence of the existing
  installed base.

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Importance of Transition Strategies

• Changing a large and complex infrastructure, such
  as the medical information infrastructure is
  profoundly challenging.
•  

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Why it is challenging?

• The challenge lies not in changing paper- based
  records in to electronic media but how the
  process of change and the evolution itself will
  be managed.
• Thus a transition strategy should be a
  descriptive plan which outlines each evolutionary
  step including negotiations about how big changes
  can or have to be made, where to make them, and
  when and which sequence to deploy them
  (Monteiro,1998,p.230)

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Implications of implementing II and rather than
just present II as a challenge.