A Qualitative Exploration of Workarounds Related to the Implementation of National Electronic Health Records in Early Adopter Mental Health Hospitals

Aims To investigate the perceptions and reported practices of mental health hospital staff using national hospital electronic health records (EHRs) in order to inform future implementations, particularly in acute mental health settings. Methods Thematic analysis of interviews with a wide range of clinical, information technology (IT), managerial and other staff at two early adopter mental health National Health Service (NHS) hospitals in London, UK, implementing national EHRs. Results We analysed 33 interviews. We first sought out examples of workarounds, such as delayed data entry, entering data in wrong places and individuals using the EHR while logged in as a colleague, then identified possible reasons for the reported workarounds. Our analysis identified four main categories of factors contributing to workarounds (i.e., operational, cultural, organisational and technical). Operational factors included poor system integration with existing workflows and the system not meeting users' perceived needs. Cultural factors involved users' competence with IT and resistance to change. Organisational factors referred to insufficient organisational resources and training, while technical factors included inadequate local technical infrastructure. Many of these factors, such as integrating the EHR system with day-to-day operational processes, staff training and adequate local IT infrastructure, were likely to apply to system implementations in various settings, but we also identified factors that related particularly to implementing EHRs in mental health hospitals, for example: EHR system incompatibility with IT systems used by mental health–related sectors, notably social services; the EHR system lacking specific, mental health functionalities and options; and clinicians feeling unable to use computers while attending to distressed psychiatric patients. Conclusions A better conceptual model of reasons for workarounds should help with designing, and supporting the implementation and adoption of, EHRs for use in hospital mental health settings.

[1]  Barriers and strategies for improving communication between inpatient and outpatient mental health clinicians , 2011, BMJ quality & safety.

[2]  D. Coplen.  Types of Unintended Consequences Related to Computerized Provider Order Entry , 2007 .

[3]  A. Sheikh,et al.  Archetypal trajectories of social, psychological, and spiritual wellbeing and distress in family care givers of patients with lung cancer: secondary analysis of serial qualitative interviews , 2010, BMJ : British Medical Journal.

[4]  Jennifer Lai,et al.  Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis , 2007 .

[5]  Stephan Poelmans.  Workarounds and distributed viscosity in a workflow system: a case study , 1999, SIGG.

[6]  Anselm L. Strauss,et al.  Basics of qualitative research : techniques and procedures for developing grounded theory , 1998 .

[7]  Blackford Middleton,et al.  Barriers to Electronic Health Record Use during Patient Visits , 2006, AMIA.

[8]  Ronald M. Salomon,et al.  Research paper: Openness of patients' reporting with use of electronic records: psychiatric clinicians' views , 2010, J. Am. Medical Informatics Assoc..

[9]  Yogesh Kumar Dwivedi,et al.  The Diffusion of Research on the Adoption and Diffusion of Information Technology , 2008, Open IT-Based Innovation.

[10]  Philip J. Kroth,et al.  Do electronic health records affect the patient-psychiatrist relationship? A before & after study of psychiatric outpatients , 2010, BMC psychiatry.

[11]  V Szabo,et al.  Secondary analysis of qualitative data. , 1997, ANS. Advances in nursing science.

[12]  Lisa A. Petrides,et al.  Costs and benefits of the workaround: Inventive solution or costly alternative , 2004 .

[13]  C. Anandan,et al.  The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview , 2011, PLoS medicine.

[14]  Aziz Sheikh,et al.  Integration of a nationally procured electronic health record system into user work practices , 2012, BMC Medical Informatics and Decision Making.

[15]  Ana M. Bernardos,et al.  Open IT-Based Innovation: Moving Towards Cooperative IT Transfer and Knowledge Diffusion IFIP TC 8 WG 8.6 International Working Conference, October 22-24, ... Federation for Information Processing) , 2008 .

[16]  V. Braun,et al.  Using thematic analysis in psychology , 2006 .

[17]  A. Strauss,et al.  Basics of qualitative research: Grounded theory procedures and techniques. , 1993 .

[18]  Leslie Woods.  Reworking qualitative data Janet Heaton Reworking Qualitative Data Sage 176 £18.99 0761971432 0761971432 [Formula: see text]. , 2005, Nurse researcher.

[19]  Gregory Makoul,et al.  Research Paper: The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters , 2001, J. Am. Medical Informatics Assoc..

[20]  Norman Sartorius,et al.  Stigma and mental health , 2007, The Lancet.

[21]  Dimitra I. Petrakaki,et al.  Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation , 2010, BMJ : British Medical Journal.

[22]  Tosha B. Wetterneck,et al.  Technology Evaluation: Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety , 2008, J. Am. Medical Informatics Assoc..

[23]  A. Dobbie,et al.  Electronic health records in outpatient clinics: Perspectives of third year medical students , 2008, BMC medical education.

[24]  Hani Safadi,et al.  International Conference on Information Systems ( ICIS ) 1-1-2010 THE ROLE OF WORKAROUNDS DURING AN OPENSOURCE ELECTRONIC MEDICAL RECORD SYSTEM IMPLEMENTATION , 2013 .

[25]  Yan Xiao,et al.  Work coordination, workflow, and workarounds in a medical context , 2005, CHI Extended Abstracts.

[26]  M. Patton,et al.  Qualitative evaluation and research methods , 1992 .

[27]  J. L. Gannon,et al.  Understanding Patient Safety , 2007 .

[28]  R. Silverman.  Understanding Patient Safety , 2008 .

[29]  D. Bates,et al.  The rise and fall of England's National Programme for IT , 2011, Journal of the Royal Society of Medicine.

[30]  Polly Sobreperez,et al.  Technological Frame Incongruence, Diffusion, and Noncompliance , 2008, Open IT-Based Innovation.

[31]  Peggy Nygren,et al.  Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis , 2006, The Annals of Family Medicine.

[32]  D. Bates,et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. , 1998, JAMA.

[33]  Les Gasser,et al.  The integration of computing and routine work , 1986, TOIS.

[34]  J. Heaton.  Reworking Qualitative Data , 2004 .

[35]  Elaine H. Ferneley,et al.  Resist, comply or workaround? An examination of different facets of user engagement with information systems , 2006, Eur. J. Inf. Syst..

[36]  D. Detmer.  Information technology for quality health care: a summary of United Kingdom and United States experiences , 2000, Quality in health care : QHC.

[37]  J. Heaton.  Secondary Analysis of Qualitative Data , 2003 .

[38]  Aziz Sheikh,et al.  The case study approach , 2011, BMC medical research methodology.

[39]  Dean F. Sittig,et al.  Computerized Provider Order Entry Adoption: Implications for Clinical Workflow , 2008, Journal of General Internal Medicine.

[40]  Gregory Makoul,et al.  The Use of Electronic Medical Records , 2001 .

[41]  Alissa L. Russ,et al.  Exploring the persistence of paper with the electronic health record , 2009, Int. J. Medical Informatics.

[42]  Marc Berg,et al.  Viewpoint Paper: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors , 2003, J. Am. Medical Informatics Assoc..

[43]  J. Dow.  Mental Health Act 2007 , 2008 .

[44]  C. Burt,et al.  Which physicians and practices are using electronic medical records? , 2005, Health affairs.

[45]  Dimitra I. Petrakaki,et al.  Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from a prospective national evaluation in 'early adopter' hospitals , 2011 .

[46]  Niall Hayes,et al.  Work-arounds and Boundary Crossing in a High Tech Optronics Company: The Role of Co-operative Workflow Technologies , 2000, Computer Supported Cooperative Work (CSCW).

[47]  M. Patton.  Qualitative evaluation and research methods, 2nd ed. , 1990 .

[48]  Katherine Vestal,et al.  Nursing and the Art of the Workaround , 2008 .

[49]  Aziz Sheikh,et al.  Information technology for patient safety , 2010, Quality and Safety in Health Care.