Medical and Nursing Staff Perspectives on an Electronic Health

Record Implementation in Hospital Outpatient Departments

A Qualitative Study in Four English Hospital Trusts

Kate Marsden

, Tony Avery

, Sarah P. Slight

Nicholas Barber

Division of Primary Care, University of Nottingham, Nottingham, U.K.

School of Pharmacy, UCL, london, U.K.

Keywords: Hospital Outpatient Departments, Electronic Health Records, Qualitative Study, Implementation.

Abstract: Objective: The authors sought to investigate the attitude of the staff using computers in outpatient

departments and whether their perceptions altered as a result of the NHS Care Record Service (CRS)

implementation. Design: Qualitative study using semi-structured interviews and observations. Participants:

A total of 70 interviews were undertaken representing a broad range of staff involved in the outpatient

department including doctors, nurses, managers, medical records staff, clerks and IT staff. In addition, 361

hours of observations were carried out in the outpatient departments over a six week period. Setting: UK

Results: This study highlighted the dependence that outpatient department staff placed on IT and the

complexity of issues surrounding their use of computer systems. All outpatient staff used a computer to

some degree in their work and were relatively computer literate but recognised that there were problems

with the technology such as the length of time it took to get information from the system, the number of

times it crashed and the lack of interoperability between different systems. The implementation of the NHS

in one trust created additional problems for the outpatient staff, especially during the rather protracted

bedding-in time. As the software was more complex than the previous system, it required a greater number

of clicks to find the information needed. The added scale and complexity of the NHS CRS was perceived to

have resulted in an overall slower system, with problems finding relevant patient information on the screen.

The clinic booking system configuration created difficulties with double or triple booking of clinics or

clinics cancelled. During this process, staff did not feel that senior managers were listening to their

concerns. Conclusions: The outpatient department has different and unique requirements which must be

considered during the development stage of any new electronic health record system. IT development

processes must acknowledge that new software systems require a degree of maturity and undergo testing in

the different departments prior to the implementation process. Staff need to feel part of the software

implementation process and their problems addressed to reduce stress and anxiety. The software design

flaws described decreased the acceptance of the NHS CRS by staff but it is important to recognise that staff

opinions and views may change over time as the system becomes embedded and matures.

1 INTRODUCTION

Many hospital staff now use computers for at least a

part of their work and the hospital outpatient

department is no exception in being dependent on

some IT. Outpatient departments provide care to

enormous numbers of people and for most of those

patients, it is their principal care providing

department in the hospital. The number of patients

seen is rising year on year; between 2008/09 and

2009/10, activity had risen 12% to 19,746,222

appointments. (Audit Commission, 2009)

There have been several studies exploring the

barriers and frustrations associated with the

implementation of the Electronic Health Record

(EHR) in hospitals (Moody et al., 2004); (Dillon et

al., 2005); (Scott et al., 2005); (Kossman, 2006);

(Firth et al., 2008); (Holden, 2009); (Boonstra and

Broekhuis, 2010) although few have concentrated on

the outpatient department (Joos et al., 2006) or

explored the attitudes of staff when confronted with

a change over from a known computer system to a

different one. Staff acceptance is now recognised as

394

Marsden K., Avery T., P. Slight S. and Barber N..

Medical and Nursing Staff Perspectives on an Electronic Health Record Implementation in Hospital Outpatient Departments - A Qualitative Study in

Four English Hospital Trusts.

DOI: 10.5220/0004321803940398

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2013), pages 394-398

ISBN: 978-989-8565-37-2

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

integral to the organisational change process and is

considered crucial for any successful

implementation of Information Technology (IT).

(Miller and Sim, 2004); (Jensen and Aanestad, 2007)

This study was part of a larger programme of

research to evaluate the implementation of the

National Health Service Care Record Service (NHS

CRS), the central plank of England’s NHS’

ambitious National Programme for Information

Technology (NPfIT). The NPfIT sought to leverage

the potential of IT to provide better quality, safer

and sustainable healthcare. (Robertson et al., 2011);

(Robertson et al., 2012) The key aim of the

Programme was to replace paper records with life-

detailed digital records, which can be shared across

healthcare organisations. (Robertson et al., 2010);

(Cresswell et al., 2011); (Sheikh et al., 2011).

In the context of undertaking the wider

evaluation of the implementation and adoption of the

NHS CRS, (Sheikh et al., 2011) we sought to (i)

explore the completeness of medical records in the

outpatient department (forthcoming separate paper),

and (ii) investigate the attitude of the staff to using

computers in the outpatient department, and

whether their perceptions altered as a result of this

implementation.

2 METHODS

The qualitative study was undertaken at four English

trusts, which had expressed an interest in

implementing NHS CRS, and it encompassed eight

hospital outpatient departments.

2.1 Data Collection and Analysis

Data collection took place in the outpatient

departments of participating trusts between May

2010 and December 2010. If a trust had more than

one hospital site, then the main (adult) outpatient

departments were selected.

Semi-structured interviews were undertaken with

a range of key stakeholders who were purposively

sampled and included doctors, managers, nurses, IT

staff and clerical staff. Interviews ranged in length

from five minutes to an hour, were audiotaped (with

permission), and transcribed verbatim. An

information sheet explaining the purpose of the

study and a consent form were supplied to all

participating staff. The researcher also undertook

observations and took field notes in the outpatient

departments.

Interview transcripts were imported into NVIVO

9, a data analysis and visualization tool designed to

assist with qualitative analysis (Bazeley, 2007)

where they were coded and then thematically

analysed. Major themes common to different groups

of interviewees were identified and explanations

built for recurring patterns and associations.

Because of substantial delays in the

implementation of the NHS CRS, only one trust

actually implemented the outpatient department

software module and the researcher was able to

obtain the perspectives of staff five months after the

implementation of the system.

3 RESULTS

Seventy interviews in total were undertaken and, in

addition, 361 observation hours were carried out

over a six week period.

Whilst staff understood that the computer system

was a tool to improve the outpatient department

work-flow and assist them in their work routine,

those interviewed frequently expressed frustration in

the problems they faced with using the computer.

This section will highlight the key issues that

impacted on staff in all four trusts using their current

computer systems. It will then explore the effects of

the implementation of the NHS CRS in the

outpatient department of the one trust that deployed

the new system.

3.1. Staff Perception of Their Current

Systems

All the hospitals in this study already used a

computer for one or more processes and, in general,

the outpatient staff considered themselves computer

literate. However, paper-based medical records still

dominated in all four trusts and the lack of

interoperability between different software systems

meant that patient information was accessed only via

several different and separate systems. Frequently,

this resulted in all computer based information being

printed out and placed in the medical record when

preparing each clinic.

Many staff complained that, at times, the system

was unreliable. In one trust, the computer was

known to freeze suddenly which was not only

frustrating for the staff, but had the potential to

disrupt the clinician-patient consultation. The staff

expressed exasperation when the system failed and

crashed, as ‘everything is dependent on your PAS

system’ (Interview8). Staff also complained that the

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Departments-AQualitativeStudyinFourEnglishHospitalTrusts

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systems, at times, were ‘frustratingly slow’

(Interview15).

3.2 Following Implementation

of the New System

During the course of the research study, one trust

implemented elements of the NHS CRS which

included the outpatient department module. This

section will briefly examine some of the issues that

staff in the outpatient departments experienced when

confronted with changing over from one computer

system that was well established to a newer and

more complex one. Initially, the staff had been

positive about the changeover to the NHS CRS but

the software problems affected their attitude and

confidence in the new system. One manager spoke

for others stating ‘the trust has lost a big opportunity

in terms of capturing the moment.’ (Interview51).

Whilst not every person was negative, there was

little praise for the new system ‘I think the

principle’s a good idea […] but I just don’t feel as

confident as I once did.’ (Interview50)

3.2.1 Training

Whilst some staff believed that the training they had

received had been adequate, others felt it has been

too soon and did not help them with what they

needed to know.

The staff required crib sheets and step-by-step

guides but at the time few were available. Within

each outpatient department, the staff tended to

support each other through the difficult period

following go live. As one nurse explained ‘if

somebody finds something out they actually all tell

each other and they’ll actually work together.’

(Interview44) This support structure enabled many

to carry on despite the stressful situation they were

faced with during the implementation period.

3.2.2 Issues with the New System

This new system was considered even slower than

the previous one, it crashed frequently and took so

long to retrieve information. Staff complained that

the complexity of the system challenged their work

processes and that interoperability between systems

remained a problem. More clicks were needed to

retrieve the desired information which was then

difficult to view, ‘the screens are badly laid out, the

data is badly laid out across the tabs on the screen’

(Interview56). In addition, the terminology on the

new system was changed for common clinic

expressions such as ‘peg board’ instead of ‘screen’

and ‘withdrawn’ instead of ‘cancelled’ causing

further confusion for staff.

3.2.3 Clinic Booking Information

Fundamental to the outpatient department is an

efficient booking system for outpatient

appointments. The configuration of the new system

meant that the staff who booked the clinic saw

different information to the outpatient department

staff. This created confusion, sometimes resulting in

patients arriving for clinics that did not exist or

clinics being double or treble booked with all

patients arriving at the same time or no patients

arriving for a clinic.

3.2.4 Senior Management Support

Staff in the outpatient department tried to alert

senior management of the problems they were

having but they felt that no one was listening to

them, ‘nobody seems to be hearing us so we’re

either not speaking the same language, we’re

speaking a foreign language, or we’re not being

heard for a reason’ (Interview47).

3.2.5 Professionalism Attacked

As a consequence staff felt that their professionalism

was being attacked, ‘We were trying desperately

hard to keep the clinics running, get the patients

seen, be there with the patients whilst they’re being

examined and being seen and we can’t do that if

we’re chasing round after […] a computer system

that won’t deliver what we’re looking for’

(Interview47).

3.2.6 Safety Issues

With the implementation of the NHS CRS some of

the clinical staff expressed concern that the

confusion with the new system created potentially

unsafe issues for the patients. As one nurse said,

‘safety mistakes are being made which weren’t

before,’ (Interview49).

One of the consultants also complained that he

was very concerned about the safety aspect of the

new system, ‘The system is not working to some safe

way and we have to find ways around it to make

things safe’ (Interview42).

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4 DISCUSSION

4.1 Main Findings

This study highlighted the dependence outpatient

department staff placed on IT and the complexity of

issues surrounding the use of computer systems.

Whilst papers have studied clinicians’ attitudes

relating to the implementation of software, (Dillon et

al., 2005); (Whittaker et al., 2009) few studies have

explored the practical problems experienced by the

staff (Boonstra and Broekhuis, 2010) during any

implementation period.

All outpatient staff expressed frustration that the

poorly designed software often impacted negatively

on their workload and this decreased the acceptance

of the NHS CRS by staff. They raised concerns

about (i) the length of time it took to get information

from the system, (ii) the number of times it crashed

and (iii) the lack of interoperability between

different systems.

Staff found that they had to alter their work

practices, rather than the technology fitting into their

work processes (Cresswell et al., 2012). According

to Buntin, (2011) the human element is crucial to a

successful software implementation. Although staff

in this study appeared willing to embrace the new

system, the implementation process brought with it a

number of challenges altered their attitude to the

new system.

5 STRENGTHS

AND LIMITATIONS

One of the main strengths of this study was the

large number of different staff involved, who

provided a wealth of information and knowledge

about the practices and procedures undertaken in

each trust. Data was collected across a number of

different speciality outpatient departments, thus

providing a more complete picture in the different

research sites. This helped to provide a

comprehensive picture of the issues staff faced when

using the hospital electronic systems.

The main limitation to this research was that the

implementation of the new NHS CRS took place in

only one trust, this being due to the well-publicised

delays in the NPfIT. The lack of benefits may have

been unique to the site as the trust was still

undergoing a transitional period of implementation.

It is therefore important to recognise that staff

opinions and views may change over time as the

system becomes embedded.

6 CONCLUSIONS

Staff expressed their frustration that computer

systems did not assist the effective running of the

clinics. The implementation of the new computer

system in the one trust studied appeared to cause

additional delays and problems for the staff in the

outpatient department and placed extra stress on

them.

Sheikh et al (2011) acknowledged how the

political pressure to implement the NHS CRS meant

timelines were rushed and therefore software was

implemented prematurely. A greater maturity of the

new system may have prevented some of the

problems experienced by staff at this trust.

Many of the issues raised here have been

mirrored in other studies (Kossman, 2006);

(Boonstra and Broekhuis, 2010) thus demonstrating

the importance of learning from previous

implementations. Jensen and Aanestad (2007) stated

whilst the benefits to EHR can be considerable, the

implementation of any new system can be erratic

especially when the system fails to meet the need of

the healthcare professionals. This study

complements those results and highlights that with

any major change in software, staff need to be

involved throughout the process.

The outpatient department has different and

unique requirements which must be considered

during the development stage. It is essential that

there are adequate test runs prior to any major

implementation to identify potential problems and, if

necessary, the software not implemented until all

such problems are satisfactorily dealt with. Should

any occur during the initial stages of implementation

then they must be given top priority for

development.

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