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jo u r n alho m e p a g e :w w w . i j m i j o u r n a l . c o m

Evaluation ofuser adoptionduring three module deployments of region-wideelectronicpatientrecord systems

RebeckaJanols^∗,ThomasLind,BengtGöransson,BengtSandblad

UppsalaUniversity,DepartmentofInformationTechnology,Lägerhyddsvägen2,75237Uppsala,Sweden

article info

Articlehistory:

Received13June2013 Receivedinrevisedform 18December2013 Accepted15February2014

Keywords:

Medicalinformatics Medicalhealthrecord, Computerized Organisationalchange Technologyadoption Hospitalinformationsystems Humancomputerinteraction

abstract

Background:InSwedentherearemodularregion-wideEPRsystemsthatareimplemented atvarioushealthorganisationsintheregion.ThemarketisdominatedbyfourITsystems thathavebeenprocuredanddeployedin18outof21regions.

Methods:Ina2.5-yearresearchstudy,deploymentsofthreeregion-wideEPRmodules:a patientadministrationsystem,eReferralmoduleandeMedicationmodulewerefollowed andevaluated.Healthprofessionals,EPRmaintenanceorganisation,ITandhealthcare managerswereobserved,interviewedandrespondedtoquestionnaires.

Results:Althoughthesamedeploymentprocesswasusedduringthethreedeployments, largevariationsintheunits’adoptionswereobserved.Thevariationsweredueto:(1) expec-tationandattitude,(2)managementandsteering,(3)end-userinvolvement,(4)EPRlearning, and(5)usabilityandthepossibilityofchangingandimprovingtheEPR.

Conclusions:Ifchangesinworkprocessesarenotconsideredindevelopmentand deploy-ment,thepotentialbeneﬁtswillnotbeachieved.ItisthereforecrucialthatEPRdeployment isconceivedasorganisationaldevelopment.Usersmustbesupportednotjustbeforeand duringthego-livephase,butalsointhepost-period.Aproblemoftenencounteredisthatit isdifﬁculttomakelatechangesinaregion-wideEPR,anditisanopenquestionwhetherit ispossibletotalkaboutasuccessfuldeploymentiftheusabilityoftheintroducedsystem islow.

1. Introduction

InSweden,responsibilityforhealthandmedicalcareisshared betweenthreeindependentgovernmentlevels:thenational governmentallevel,21self-governedcountycouncils/regions andthe290municipalities.Thesebodiescaneitherchoose

∗Correspondingauthor.Tel.:+6421810093.

E-mailaddresses:rebecka.janols@it.uu.se,rebecka.janols@gmail.com(R.Janols),thomas.lind@it.uu.se(T.Lind), bengt.goransson@it.uu.se(B.Göransson),bengt.sandblad@it.uu.se(B.Sandblad).

to deliver thecare themselvesoruse privatecompanies, cooperativesornon-proﬁtorganisations.FordecadesSweden hasbeenoneoftheleadingeHealthcountriesintheworld [1] andoverthe lastten yearseHealthdevelopment has movedtowardsusingregion-wideelectronicpatientrecord (EPR)systems.Region-wideEPRmeansthatthesystemis sharedbetweenallcareproviders(i.e.,primaryandhospital

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care)withinthesamecountycouncil/region.Themarketis dominatedbyfourITsystemsthathavebeenprocuredand deployedin18out of21 counties.Thefour¹ vendorsare:

Cambiohealthcaresystems(CambioCosmic),Compugroup (Takecare),Evry(EvryCross)andNorrbotten’scountycouncil (VAS).Eventhoughthesamevendorsupportsseveralcounty councils,theyeachhavetheirowninstances,terminology andconﬁgurations[2].Allsystemsaremodulebasedand provideclinicalcaresupportandpatientadministration func-tionalities.Thismeansthatin18countycouncilsthepatient information(notesmadebyallcareproviderswithinthesame countycouncil)isstoredinthesameEPR.Thecountycouncils’

motivationsforusingregion-wideEPRare:(1)increased acces-sibility–allpatientinformationwithinthecountycouncilshouldbe accessibleforallcareproviderswithinthesamecountycouncil,(2) samestructure–easiertoshareandaccessinformation,(3)cost reductions–lessdoubledocumentation,re-usetestresultsetc., and(4)betterinformedhealthprofessionals–fewer unneces-sarymeetingswithpatients.Althoughthecountycouncilsshare aregion-wideEPRsystem,theystillhavemorethan30other ITsystems(i.e.,radiology,laboratoryandorderingsupplies)to supporttheirneeds.SomeoftheITsystemscanbeaccessed fromtheEPR,whileothersrequireanotherlogin.Inorder tomakesharingofinformationpossiblebetweenthecounty councilsandmunicipalities,anational“patient overview”-systemhasbeendevelopedbutnotyetfullyimplemented throughoutthecountycouncils/regionsandmunicipalities.

Thispaperisbasedona2.5-yearresearchprojectofone ofthecountycouncilsandtheuniversity.The participat-ingcounty councils areresponsibleforthe care ofmore than300,000citizens.Theyhave13,000employeesdistributed acrossauniversityhospital,asmallerhospitaland40primary carecentres.Theyareusingoneofthementioned region-wideEPRsystemtoshareinformationwithinandbetweenthe differentunits/organisations.Duringtheresearchprojectthe deploymentofthreeregion-wideEPRmoduleswereevaluated anddifferentstakeholderswereinterviewedandobserved.

Analysesin ourprevious studies,performedinthe same countycouncil[3–5],showthatthehealthprofessionals(i.e., nurses,physicians,assistantnursesandparamedics) consid-eredtheregion-wideEPRsystemtoincreaseaccessibilityand readability.Accessibilitymeansthateverypatienthasone electronicrecordthatisimmediatelyaccessibleforallcare providersinthesameregion.Readabilitymeansthatwiththe region-wideEPRsystemthehealthprofessionalsnolonger needtosearchformissingpaperrecords,andthe computer-basedrecordsarealwayseasytoread.Despitethebeneﬁts experienced,allparticipantsagreedthattheregion-wideEPR didnotprovidesufﬁcientsupport,andtheyarguedthatthe systemhadlowusabilityandwastime-consumingtouse.

Thehealthprofessionals,bothnursesandphysicians, con-sideredtheEPRsystemtohavemajorusabilityproblemsand tobenon-intuitive,andmostusersexperiencedthatusing thesystemhadincreasedtheircomputertimeanddecreased

1Thereisaﬁfth:Siemens(Melior),whichhasalargemarket share.However,becauseMeliorisusedinhospitalsandnotshared betweenprimarycareandhospitalcare,ithasnotbeenincluded asaregion-wideEPR.

theirpatienttime[5].Theuseradoptionproblemshadslowed downthedeploymentprocess;however,themanagerswere convincedthat,ifthehealthprofessionalsfollowedthe pro-cessesthesystemwasbuilton,manyoftheusabilityproblems woulddisappear[6].Previousstudies[3–5]discusshow physi-ciansandnursesexperiencesdeployingandusingEPR[4,5]

andhowtime,usageandcontexteffectedthePASdeployment [3].

Theaimofthispaper istoidentifyareasthatcanbe, dependingonhowtheyaremanaged,perceivedasbarriers and/orsuccessfactorsforuseradoptionwhiledeployingand usingaregion-wideEPRsystem.Thepaperisbasedona cross-analysisofevaluationsofthreeregion-wideEPRmodule deploymentswithinthesameSwedishcountycouncil.

1.1. Region-wideEPRvs.enterprise-wideIT

Region-wideEPRsystemsthataredevelopedbyvendorand sharedbetweenseveralhealthorganisationshavemany sim-ilaritieswithtraditionalenterprise-wide(EW)ITsystems[7].

AccordingtoDavenport,EWsystemsarecommercialsoftware (oftenmodulebased)thatpromisesaseamlessintegrationof allinformationﬂowingthroughtheorganisation[8].Markus andTanishavea similar deﬁnitionthatEW systemsare

“commercialsoftwarepackagesthatenabletheintegrationof transactions-orienteddataandbusinessprocesses through-outanorganisation”[9](p.176).TheEWsystemisageneric solutionthatisbuilttosolvethefragmentationof informa-tioninorganisations.Thesystemsarebasedonthevendor’s assumptionsofbestpractice.Definingbestpracticeis con-tentious;e.g.,clinicalbestpracticeandITbestpracticemay notalignwell[8].Intheory,enterprisesystemsaregreat.The benefitofhavingallinformationseamlesslyintegratedmakes iteasiertoaccessandshareinformationwithinthe organi-sation.Inreal-lifeEWsystemshowever,researchhasshown thatthereisahighfailurerateondeploymentofEWsystems [8–10].InordertosucceedwithEWsystems,itiscrucialtohave cleargoalsaboutwhatthesystemsshouldsupport.Reworking theorganisation’sprocessesisnecessaryinordertoachieve anidealmatchbetweenthesystemandthecontext. Usu-allysomedegreeofcustomisationispossible.Customisation ofthesoftwarecan,however,beexpensiveandoftena hin-drancetoachievementoftheaimofinformationseamlessly flowingthroughtheorganisation[8].Despitethebenefits,a commonargumentfornotselectingEWsolutionsisthatthe processesonwhichtheITsystemisbased(oftencalledbest practice,accordingtothevendors)donotrepresentthe pro-cessesusedintheorganisations.So,theusersneedtochange theirprocessesinordertoworkeffectivelywiththesystem [10].

1.2. Deploymentsanduseradoption

Theaimofourstudywastoinvestigatetheprocessinwhich theIT systemisdeployed.This meansthatwehavenot studiedthetechnicalimplementation;insteadwewere inter-estedintheprocessinwhichtheITsystemisintroduced andadoptedbytheorganisationandusers.Toemphasise ourfocus,wechosetousethetermdeploymentinsteadof implementation.In previous researchboth deploymentand

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implementationareusedfortheprocessthatwerefertoas thedeployment.However,wefeelthataseparationbetween the terms is necessary to emphasise that it is not just thetechnicalpartsthatareimportant:organisationaland behaviouralaspectsareequallyimportantastechnologyto achieveaneffectiveandefﬁcienthealthITadoption[11–13].

Withdeploymentwerefertotheprocesswhenthesystemis introducedandadoptedbytheorganisationandusers,while withimplementationwerefertothetechnicalinstallations etc.FordecadesresearchabouthealthIThasshownthatit isdifﬁculttosucceedwithdeploymentofhealthIT[11–24].

Manyresearchershaveidentiﬁedcriticalsuccessfactors(CSF) forsucceedingwithhealthITandEWdeployments[25,26].

AccordingtoPoonandWagner[27],CSFsare“theconditions thatneedtobemettoassuresuccessofthesystem”(p.395).

Theyareoftenpresentedasshortcutstoasuccessful deploy-mentandusage.ResearchonCSFshasbeencriticisedasbeing deterministicandexcludingsituationalandcontextual fac-tors[7,28].

PinelleandGutwin[29]arguethatoneofthegreatest chal-lengestohealthITdeploymentsisthestructureofthehealth careorganisation.Westernhealthcareorganisationsareoften diversewithspecialiseddivisionsandunits,withdifferent administrativeandmanagementorganisationsonlyloosely coupledtogether.Thedifferentunitshavehighautonomyand arespecialisedindifferentareasofthecaredelivery.Pinelle andGutwin[29]arguethatthestructureoftheorganisation isbothadriverandabarrier.Thestructureoflooselycoupled unitsincreasestheneedforITthatsupportssharing informa-tionandcollaboration.Thecomplexorganisationalstructure makesithard todeploynewtechnologysuccessfully.The problemsbecomenoticeablewhentheorganisationaimsto deploythesameregion-wideIT,andthedifferentunits,with theirtraditionofhighautonomy,haveadifferentideaabout howtheworkshouldbecarriedout.Theauthors[29]suggest ﬁvestrategiesforintroducinghealthITsystemsintoloosely coupledhealthcaresettings.

• Usefocusgroupstobringrepresentativesfromdifferent unitstothetabletoconfrontdifferencesandbuild consen-sus

• Use bottom-up deploymentstrategy; directdeployment effortsfromtheoperationalunitandnotfrom administra-tiveunitsormanagement

• Identifylocalchampionsintheoperationalunitswhocan helpbuildconsensusamongcolleagues

• Alignrolesandresponsibilitiestominimiseroleconﬂicts

• Addressinequity early,employ user-centreddesignand involveusersinthedeploymentplanningsession[29](pp.

562–566).

Theﬁvestrategiesemphasisetheimportanceofincluding andengagingtheend-usersinthedeploymentactivities. Pre-viousresearchshowsthatitisnotjustimportanttoinvolve theend-usersinthedeploymentactivitiestheyshouldbe involvedthroughoutthewholedevelopmentprocess[30].The importanceofend-usersparticipationinhealthIT develop-menthasbeen studiedby[31].Theauthorscometo the conclusionthatthe powerbalancebetween the stakehol-ders(ITorganisation,clinicalorganisation,managementand

vendor)hasamajoraffectoniftheend-users(health profes-sionals)becomerealparticipantswiththepowertochange andimproveorjustbeingclinicalconsultants.Realend-user participationisessentialforthesuccessfuloutcomeofHIT development.Kanstrup[32]isemphasisingtheimportanceof notjusthavinglocalITsupportsthatareinvolved;itiscrucial tohaveparticipatoryITsupports.Theauthorsareproviding amethodforidentifyingqualiﬁedcandidatesforthesupport position.

1.3. Sociotechnicaltheoriestoexplaindeployment outcome

Using theories about sociotechnical systems to explain deploymentoutcomeanduseradoptionhasbecomemore andmore common in thelast decade[11,12,21,22,33–38].

Asociotechnicalapproachmeansthatexplanationsofthe deploymentoutcomeanduseradoptionhaveorganisational, technological and behavioural explanations. According to LorenziandRiley[21,22],thereasonsforasystemfailurehave differentcharacters:communication,culture,anunderestimation ofcomplexity,scopecreep,organisational,technological,trainingand leadershipissues(p.118).Berg[12]arguesthatasuccessfulIT deploymentissociallynegotiated.Forexample,whatis con-sideredtobeasuccessfuldeploymentforhealthprofessionals mightnotbethesameforthehospitalmanagementortheIT managerandviceversa.Theseissuesareoftennotrealised withintheorganisations,andBergarguesthattobegina dis-cussionaboutwhatasuccessfuldeploymentprocessiswill opentheeyesoftheorganisationtothecomplexmeaningof successandfailure.Thisdiscrepancycouldbeexplainedby thefactthattheymeasuresuccessdifferently[12].Forsome stakeholderseconomicaspectsarethemostimportant mea-surement,andforotherstheusageisthemostimportant.

Thesuccessorthefailureofthedeploymentcanalsochange overtime;forexamplethedeploymentcanbeconsideredto beasuccessbytheusersinthebeginning,andthenaftera fewmonthstheusersfeelthatthesystemisnotsupporting themandatthattimeconsiderittobeafailure.Berg[12]

arguesthat,evenifonecancomeupwithameasurement forthesuccessofanITdeploymentitisimpossibletouse thesameperspectiveinanothercontextconcerninganother organisation.Organisationshavedifferentcontexts,sizesand formsofleadershipthataffecthowtheyreacttothesame ITsystemandthesamedeploymentstrategy.Inourstudy, weadoptthehealthprofessionals’perspectivewhenweare analysingtheEPRdeploymentanduseradoption.MariaLluch [37]conductedaliteraturereviewaboutpreviousresearch(31 sourcesbetween1995and2009intotal)abouthealthcare pro-fessionals’organisationalbarrierstohealthIT.Thefocuswas onsociotechnicalaspectsofhealthITimplementationor post-implementationinhealthcaresettings.LluchusedGalbraith’s starmodeltoidentifyfivecategoriesofbarriersamongthe research.Thebarriersare:(1)structureofhealthcare orga-nisations,(2)tasks,(3)peoplepolicies,(4)incentives,and(5) informationanddecisionprocesses.EventhoughLluchsorted thebarriersinto fivecategories,sheemphasisesthatthey arenotstand-alonecategories.Instead,theyareall interre-latedwitheachother.Inourresearchstudy,thefivecategories mentionedcanbeobserved,butwearguethattheycanbeseen

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asbarriersand/orreasonsforsuccess.Inourstudy,twofactors thatarenotmentionedinLluch’sliteraturereviewhavebeen added:usabilityandthepossibilityofchangingand improv-ingtheITsystem.Usabilityaspectsareoftenmentionedin healthITresearch,butincombinationwithasociotechnical approachforanalysingeHealthdeploymentsandusage,they areoftenignored,exceptinafewexamples[11,12,39].

1.4. Thestudieddeploymentprocess

Theevaluateddeploymentsfollowedthesamedeployment process.Thedeployment processwas both centrally and locallymanaged.Thecentraldeploymentgroupconsistedofa projectleader,anumberofpeoplefromtheEPRmaintenance organisationandoneEPRcoordinatorfromeachdivision(the groupconsistedofupto15individuals).Thecentral deploy-mentgroupwas responsiblefor:(i)centrally steeringthe deployments,(ii)informingtheEPRcoordinatorsabout strate-giesandnewworkprocesses,and(iii)creatingaforumin whichtheEPRcoordinatorsreceivedsupportandguidance duringthedeployments.Thecentraldeploymentgroupwas responsibleforcentral steeringofthe deployments.They hadregularmeetingsbeforeandduringthedeployment.In thosemeetingstheEPRcoordinatorsdiscussedprogress,and theEPRmaintenanceorganisationspreadinformationabout sharedstrategiesandclinicalroutines.

MostEPRcoordinatorswereeducatedhealthprofessionals thatworkedfulltimewithEPR-relatedissues.Their responsi-bilitiesweretomanagethedeploymentsandsupporttheunits intheireverydayEPRusage.Theclinicaldivisionsselectedthe EPRcoordinatorsandtheirrolewastobethelinkbetween theITorganisationandtheend-users.Theirresponsibility duringthedeploymentswastolocallymanageandsteerthe divisions’deploymentprocess.TheEPRcoordinatorswerein chargeofagroupofsuper-userswhorepresentedeachofthe division’sunits.Togethertheywereresponsiblefor identify-ingexistingandnewworkprocesses,andteachingthehealth professionalstousetheITsystemaccordingtothenewwork processes.

2. Methods

Inthispaper,deploymentsofthreeregion-wideEPRsystem modulesareevaluated.Theaimistoidentifyareasthatcan, dependingonhowtheyaremanaged,beperceivedas barri-ersand/orsuccessfactorsforuseradoptionwhiledeploying aregion-wideEPRsystem.Thethreemoduledeployments evaluatedarePAS,eReferralandeMedication.Allthree mod-ulesare,togetherwithcaredocumentation,cornerstonesin aregion-wideEPRsystem.Theevaluationswerepartofa 2.5-yearresearchprojectofthecountycouncilandthe uni-versity.Theaimofthe projectwas toﬁnd methodsand processesthatwouldhelptheorganisationstoworkmore effectivelywiththeircoreIT systems.Duringthestudies, bothqualitativeandquantitative methodswere used(see Table1).

Duringthedata gathering, thefocus wasondifferent aspectsofuseradoption:

• Userparticipation:dotheusersparticipateindeployment activities?Ifyes:whatkindofactivitiesdotheyparticipate in?Ifno:whathinderstheuserstoparticipate?

• LearntousetheITsystem:wheredidtheuserslearnto usethesystem?Howdidtheyexperiencetheactivitiesthat wereorganisedbythecentraldeploymentgroupandthe super-users?

• Preparefornewworkroutines:howdidthemain stake-holdergroupsworkwithpreparingnewworkroutinesand changedmanagement?

• Supportfortheusers:whatkindofsupportdidtheusersget duringthedeployment?Whoprovidedthesupport?How didtheusersexperiencethesupport?

Afterandduringtheevaluations,theﬁndingswere dis-cussedindifferentseminarsandworkshopsatthehealthcare organisation.Theaimofthosemeetingswastodiscussthe evaluationwiththeminordertoimprovetheirdeployment process.Wegiveamorethoroughdescriptionoftheactivities duringthethreedeploymentsbelow.

2.1. FromoldPASsystemtoPASmodule

Thepatientadministration system(PAS) deployment was studiedinthreeuniversityhospitalunits,aninfection dis-easeward,agynaecologywardandanorthopaedicopencare unit.Bothquantitativeandqualitativemethodswereused beforeandduringthego-liveanduptotwoyearsafterthe deployment.Tomeasureusability,avalidatedquestionnaire calledAvI(abbreviationforAnvändbarhetsindexinSwedish) wasused.ThegoalwithAvIwastodescribetheprocesses behindusability.Thequestionnairecontained16questions thatweredividedintosixsubscales:(1)systemdevelopment,(2) usage,(3)utility,(4)competence,(5)stressandhealthand(6) rela-tions[40].TheﬁrstquestionnaireconcernedtheoldPASsystem andwasdistributedbeforethedeploymentofthenewsystem.

Thesecondquestionnairewasdistributedaftertwomonths ofusageandthethirdaftertenmonthsofusage.To comple-mentthequestionnaires,interviewsandobservationswere performedduringthethreemeasurementpointsandduring thego-live.Intheopencareunit,theyreceivemanynew patientseveryday,afactthatmeantthatnursesand assis-tantnursesusedthePASfunctionalitiesforseveralhoursa day.Inthewards,thePASfunctionalitieswerejustusedwhen anewpatientarrivedorwhenapatientwasdischarged.In bothwards,theoldPASwasjustusedbytheclerks,a situ-ationwhichmeantthatmoststaffrarelyusedit.Deploying thenewPASaffectedthestaffinthethreewardsdifferently.

Forthestaffintheopencareunit,itmeantthattheywere goingtoperformthesametasksinanewsystem,whilein thewardsusingthenewPASmeantchangesinpractice.The newtasksrequiredthatthePAStasksbedistributedamong allstaffinsteadofbeingjusttheclerks’responsibility.More detailedinformationaboutthePASdeploymentcanbefound in[3].

2.2. Frompaper-basedreferralstoeReferral

ThebeneﬁtswiththeeReferralmodulewerethatallreferrals wereelectronicinsteadofonpaper.Thispracticemeantfaster

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Table1–Informationaboutthethreedeployments.Wheretheevaluationtookplace,whatdatamethodsthatwereused andwhotheend-userswere.

PASmodule(2008) Referralmodule(2009) Medicationmodule (2010–2011) Aboutthemoduleandthe

deployment

FromanoldPASsystem(usedfor 10years)toaPASmodulethatwas integratedwiththeexisting region-wideEPRsystem

Frompaper-basedreferrals toaneReferralmodulethat wasintegratedwiththe existingregion-wideEPR system

Frommedicationlistson papertoaneMedication modulethatwasintegrated withtheexisting region-wideEPRsystem Themoduleincludessupportfor:

Schedulingandresourceallocation, bookingform,plannedactivities, appointmentletters,consultation referrals,bedmanagement,agreement management,registrationof inpatients,admissionoverview, invoicingandregistrationoverview

Themoduleincludes:

referralmanagement,support forthereferringdoctorsand thereceivingparty

Themoduleincludes:

medicationandprescription overview,decisionsupportand continuousdocumentation

Wheredidtheevaluations takeplace?

Usersandsuper-usersfromthree units(i.e.,infectiousdiseases ward,gynaecologywardandan orthopaedicopencareunit)were observedandinterviewedbefore, duringanduptotwoyearsafter thego-live.Theaimwasto evaluatethepreparations, expectationsanduseradoption

Theprimarycarecentres andcentraldeployment projectgroup’spreparations andactivitieswere evaluated.Theaimwasto evaluatethepreparations andexpectations

Usersandsuper-users, fromtwounits(i.e., medicationandsurgery units)wereobservedand interviewedbefore,during andafterthego-live.The aimwastoevaluatethe preparations,expectations anduseradoption

Datagatheringmethods Interviews Interviews Interviews

Observations Observations Observations

Participationinlearning sessions

Questionnaires Questionnaires

Theend-users Physicians Physicians Physicians

Nurses Nurses Nurses

Clerks Clerks

replies,amoresecureprocessandeasiertraceabilityof refer-ralsandanswers.Beforeourevaluation,theeReferralmodule hadalreadybeendeployedandusedintheprimarycare cen-tres.Thismeantthattheprimarycarecentresorderedthe referralsintheEPR,butsentaprintedversiontothespecialists atthehospital.DuringtheeReferraldeployment,thecentral deploymentgroup’sactivitiesandtheprimarycarecentres’

preparationswereevaluated.Duringtheevaluation,we par-ticipatedasobserversduringthecentraldeploymentgroup’s meetingsandwhenthesuper-usersandEPRcoordinators learnedtousetheeReferralsystem.Inadditiontothese occa-sions,managersfromsixprimarycarecentreswereaskedto participateinashorttelephoneinterviewabouthowthey pre-paredtheirorganisationforthenewprocessoforderingand receivingreferralselectronicallyinsteadofonpaper.Usersin twoprimarycarecentreswerealsoobservedandinterviewed whiletheyusedtheeReferralsystem.

2.3. Frompaper-baseddrugliststoeMedication

ThedeploymentoftheeMedicationmodulewasevaluatedin twohospitalwards,amedicalwardandasurgicalward.The deploymentatthehospitalwasapartofthecountycouncil’s larger“bigbang”deployment.Allhospitalunitsandwards, withafewexceptions,weregoingtoadopttheeMedication module.TheeMedicationmodulehadbeendeployedinafew wardsattheuniversityhospital.Someofthewards consid-eredittobeaneffectivetoolwhileothershadinterrupted

thedeploymentandgonebacktotheoldroutines.During theevaluation, bothqualitativeandquantitativemethods were used.Thequantitative methodwasa questionnaire thatwassenttoallend-usersbetweenthelearningsessions andgo-live.Thisquestionnairehadthesamestructureas thequestionnaireconductedduringthePASdeployment[40].

Before,duringandafterthego-live,nursesandphysicians inthetwowardswereobservedandinterviewed.The obser-vationsinthewardswereconductedduringclinicalrounds, when thelevel of medication-related work activitieswas highest.Wealsoparticipatedasobserversduringthecentral andlocaldeploymentgroup’sactivities,whensuper-users wereintroducedtotheeMedicationmoduleandduringthe end-users’learningsessions.

2.4. Thecross-caseanalyses

Inthispaper,weperformedacross-caseanalysisofthethree evaluations.Theanalysesweredividedintofoursteps:(1) thewrittenreportsfromeachofthethreeevaluationswere reviewed;(2)theempiricaldata(e.g.,interviewtranscripts, notesandquestionnaireresults)fromthethreeevaluations werereviewed;(3)thedatafromthefirstandsecondsteps werecondensedtomaincategoriesforbarriersandreasons forasuccessfuluseradoption;and(4)theidentifiedcategories were compared with previous research about implemen-tation/deploymentanduseradoptionofeHealth.Thefive categoriesare:

In document Change and Resistance to Change in Health Care (Page 55-69)