Managing the Gradual Transition from Paper to Electronic Patient Record (EPR) – A Case Study By Nina Boulus –Thesis submitted as part of the Masters degree in Dept of Informatics, UiO Dr.Zubeeda Quraishy Department of Informatics University of Oslo, Norway

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.

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

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.

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.

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.

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.

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).

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

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

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.

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.

Contd.. ANT provides a better understanding of the network’s 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

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)

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.

(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).

(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).

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.

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.

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.

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 Webster’s 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)

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.

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.

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.

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

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.

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).

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.

Importance of Transition Strategies Changing a large and complex infrastructure, such as the medical information infrastructure is profoundly challenging.

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)

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