IN
DEGREE PROJECT MEDICAL ENGINEERING, SECOND CYCLE, 30 CREDITS
STOCKHOLM SWEDEN 2020,
Implementation of a Mobile
Healthcare Solution at an Inpatient Ward
SIRI RÖNNLUND ULRIKA OTTOSSON
KTH ROYAL INSTITUTE OF TECHNOLOGY
SCHOOL OF ENGINEERING SCIENCES IN CHEMISTRY, BIOTECHNOLOGY AND HEALTH
A Master Thesis Project in Collaboration with Cambio Healthcare Systems AB.
Implementation of a Mobile Healthcare Solution at an Inpatient Ward Implementation av ett mobilt informationsstöd
på en sjukhusavdelning
Siri Rönnlund & Ulrika Ottosson
Master of Science Thesis in Medical Engineering Advanced level (second cycle), 30 credits Supervisor at Cambio: Towe Andrén Supervisors at KTH: Björn Fischer & Fangyuan Chang Examiner: Sebastiaan Meijer TRITA-CBH-GRU-2020:080 KTH Royal Institute of Technology School of Engineering Sciences in Chemistry, Biotechnology and Health http://www.kth.se
Abstract
Healthcare is a complex system under great pressure for meeting the patients’ needs.
Implementing technology at inpatient wards might possibly support healthcare pro- fessionals and improve quality of care. However, these technologies might come with issues and the system might not be used as intended.
This master thesis project investigates how healthcare professionals communicate at an inpatient ward and how this might be affected by implementing a Mobile Healthcare Solution (MHS). Further, it sought to question why healthcare profes- sions might, or might not, use the MHS as a support of their daily work and what some reasons for this might be. Research methods were of qualitative approach.
Field studies were performed at an inpatient ward and further, two healthcare pro- fessionals were interviewed. Grounded Theory (GT) was chosen as a method to process the data and obtain understanding for communication at the inpatient ward.
The results showed that healthcare professionals communicate verbally, written and by reading, using different tools. The most prominent ways of communication were verbally, where it was common to report or discuss about a patient. The means for communication did not get drastically affected by implementing the MHS and rea- sons for this were of social, technical and organizational types. Some reasons for not using the MHS were habits and due to healthcare professionals perceiving the MHS as more time consuming than manual handling. However, a specific investigation of whether this might affect the usage of the MHS is yet needed.
Keywords: Mobile Healthcare Solutions, Electronic Health Records, Healthcare Innovation System, User and Implementation, Ethnography
Sammanfattning
Sjukv˚arden ¨ar ett komplext system med stor press att tillgodose patientens behov.
Att inf¨ora teknik p˚a sjukv˚ardsavdelningar kan m¨ojligg¨ora st¨od f¨or v˚ardpersonalen och f¨orb¨attra v˚ardkvaliteten. Emellertid kan dessa teknologier komma med problem och systemet kan komma att anv¨andas annorlunda ¨an avsett.
Detta masterexamensarbete unders¨oker hur h¨also- och sjukv˚ardspersonal kommu- nicerar p˚a en sjukv˚ardsavdelning och hur detta kan p˚averkas genom att imple- mentera ett mobilt informationsst¨od. Vidare ifr˚agasattes varf¨or v˚ardpersonal anv¨ander, eller inte anv¨ander, informationsst¨odet i sitt dagliga arbete samt orsaker till detta. I projektet anv¨andes kvalitativa metoder d¨ar f¨altstudier samt intervjuer genomf¨ordes p˚a en sjukv˚ardsavdelning. Grundad teori valdes som en metod f¨or att bearbeta data och f˚a f¨orst˚aelse f¨or kommunikation p˚a sjukv˚ardsavdelningen.
Resultaten visade att v˚ardpersonalen kommunicerar muntligt, skriftligt och genom att l¨asa, med hj¨alp av olika verktyg. Den fr¨amsta kommunikationen skedde muntligt, d¨ar det vanligaste var att rapportera eller diskutera om en patient. Kommunikatio- nen p˚averkades inte drastiskt av implementeringen av det mobila informationsst¨odet och sk¨alen till detta var av sociala, tekniska och organisatoriska orsaker. N˚agra an- ledningar till att det mobila informationsst¨odet inte anv¨andes var dels vanor samt att v˚ardpersonalen upplevde applikationen som mer tidskr¨avande ¨an ett manuellt utf¨orande. Ytterligare kunskap om huruvida detta p˚averkar anv¨andningen av det mobila informationsst¨odet beh¨ovs.
Nyckelord: Mobilt informationsst¨od, Elektroniska journaler,
H¨alsov˚ardsinnovationssystem, Anv¨andare och implementing, Etnografi
Acknowledgements
We would like to acknowledge and thank the people who have helped and supported us, to only some of whom it is possible to mention here. It is a great pleasure to thank those who made this possible and supported us, not only during the work of this master thesis but throughout our whole engineering degree.
First of all, we would like to thank our amazing supervisors Bj¨orn Fischer, Fangyuan Chang and Towe Andr´en for their unwavering support. Your great advice, knowl- edge and funny stories have guided us through this thesis. We will always remember to look out for cowboy wallpapers and to bring candy to any meetings.
We would like to give the most sincere thank you to our families, for your love and unconditional support, including Heidi for all the cuddles and walks.
A special shout out goes out to all board members of BPC, thank you for these amazing years and for all the laughter’s. Thank you for all the memories that will stick with us forever. We would also like to thank our close friends for always supporting us, you know who you are. Without you, it would not have been possible.
Lastly, we would like to acknowledge how fun it has been to write this master thesis together in a pair. This has been by far the funniest thing during our engineering degree and we are proud to have accomplished this together.
Sincerely,
Siri R¨onnlund & Ulrika Ottosson
KTH Royal Institute of Technology, May 2020
Distribution of Work
This master thesis project has been carried out together in cooperation between the two authors, Siri and Ulrika. However, Chapter 2 was mainly overseen by Ulrika and Chapter 4 by Siri. Apart from this, the authors did not observe the same healthcare staff during the field studies. Further, the data analysis was performed independently on each set of data obtained. Later, the data was switched and hence analyzed by each author.
Contents
1 Introduction 1
1.1 Research Questions . . . 2
2 Background 3 2.1 Healthcare Innovation System . . . 3
2.1.1 Electronic Health Records . . . 3
2.1.2 Mobile Healthcare Solutions . . . 4
2.2 Digitizing Healthcare . . . 5
2.2.1 Human and Technology Interaction . . . 6
2.2.2 User and Implementation . . . 6
3 Methodology 9 3.1 Grounded Theory . . . 9
3.1.1 Case Selection . . . 10
3.1.2 Quality of Thesis . . . 10
3.2 Data Collection . . . 11
3.2.1 Field Study . . . 11
3.2.2 Expert Interviews . . . 12
3.3 Data Analysis . . . 12
3.3.1 Data Processing . . . 12
3.3.2 Development of Model for Communication . . . 14
3.3.3 Discussion and Final Results . . . 14
4 Results 15 4.1 Communication at the Inpatient Ward . . . 15
4.1.1 Board . . . 17
4.1.2 Electronic Health Records . . . 17
4.1.3 Notes . . . 18
4.1.4 Phone Calls . . . 19
4.1.5 Reporting . . . 20
4.2 Usage of the Mobile Healthcare Solution . . . 21
4.3 Reasons for Double Documentation . . . 23
4.4 Communication after Implementation . . . 23
4.4.1 Board . . . 24
4.4.2 Electronic Health Records . . . 24
4.4.3 Notes . . . 24
4.4.4 Phone Calls . . . 24
4.4.5 Reporting . . . 25
5 Discussion 26
5.1 Implications for Academia . . . 26
5.2 Implications for Mobile Healthcare Solution . . . 28
5.2.1 Improvements for the Mobile Healthcare Solution . . . 29
5.3 Limitations . . . 30
6 Conclusion 31 References 32 A Appendix 36 A.1 Interview Questions . . . 36
List of Figures
3.1 Flowchart of the research design . . . 10 3.2 Visual presentation of how the field notes were labelled during data
processing . . . 13 4.1 Model for framework of communication at the inpatient ward . . . 16 4.2 Types of activities that occurred with the EHR and the distribution
of these before the implementation of the MHS (n=101) . . . 18 4.3 Activity flow of reporting at the inpatient ward . . . 20 4.4 Types of activities that occurred with the EHR and the distribution
of these after the implementation of the MHS (n=250) . . . 24
Chapter 1 Introduction
The demands and needs from patients have never been as high as they are today [1], where digital developments within healthcare are a prerequisite to ensure easily ac- cessed healthcare with efficiency, quality and patient involvement [2]. Each patient produces information to a large extent, which must be available for all healthcare professionals involved with the patient [3]. This information is overwhelming for healthcare professionals not only due to the volume of it, but also because of its diversity such as clinical data, physician notes, prescriptions and medical imaging.
Knowing where to find all of this information is hard for healthcare professionals.
It could be written on a paper note, in a medical record at the workstation on the doctor’s office or in another physicians memory. Information accessibility and com- munication within healthcare is of great importance for patient safety and could possibly be aided by digital tools [4]. However, the digital systems available in healthcare today are problematic as they are slow and not well integrated [5]. This often leads to manual duplication as well as unnecessary communication for the healthcare professionals, which is time consuming and results in insufficient access to available information as well as increased administration. Insufficient access and information getting lost might result in a lower patient safety and lower the quality of care for the patient.
These problems could possibly be solved by using mobile tools for the daily work of the healthcare professionals. Mobile Healthcare Solutions (MHS) holds certain promises for new ways of sharing and transferring information [6]. MHS as part of this master thesis is defined as an application on a tablet used by healthcare pro- fessionals at inpatient wards. The particular MHS solely works in connection to a specific Electronic Health Record (EHR) which has to be in place at the inpatient ward for the MHS to work. This application could contribute to a more efficient healthcare process and ease the workload for healthcare professionals [7].
Previously, there has been two case studies made for the specific MHS at one hospital in Enk¨oping [8] and in V¨axj¨o [9], both indicating benefits in terms of time savings.
It is beyond knowledge whether, and how, the MHS impacts the social settings in practise which is to be investigated in this master thesis project. Existing literature refers to high failure rates of social types when implementing technical solutions to an inpatient ward [10], since already existing technology and arrangements matter and might affect the usage of the new technology [11]. There are studies made on
implementation of telecare, mostly in home environment, where concepts for user and implementation are investigated. However, it has not been investigated when implementing an MHS and it is therefore of interest to study how communication and interactions at an inpatient ward is affected by this. Further, it is of interest to understand behaviours of members of the staff to understand why, or why not, the system is of benefit for work at the inpatient ward. This master thesis project contributes to the field of area by understanding how MHS might impact commu- nication for healthcare professionals. Swedish government offices give support for advances within medical technology and its possibility to increase survival as well as health of patients [2].
This master thesis project was conducted under exceptional times during the out- break of the pandemic Covid-19. Due to the spread of the virus and uncertain cir- cumstances, the project got affected since it was performed at an inpatient ward and therefore needed to get changed in settings.
1.1 Research Questions
This thesis aims to understand how the implementation of a MHS might affect communication for healthcare professionals at an inpatient ward and to answer the following research questions:
• What are some reasons for members of the staff to use, or not use, the MHS?
• Why do healthcare professionals transfer information from digital to non- digital and vice versa?
• Have the means for communication changed after the implementation of the MHS? If so, how?
The following chapters include Background containing relevant information about healthcare innovation system along with user and implementation, Method describ- ing and justifying the chosen research approach, Results with the outcome of the investigation, Discussion with implications for academia as well as the mobile health- care solution and finally a Conclusion of the thesis.
Chapter 2 Background
2.1 Healthcare Innovation System
To meet the patients’ needs, there is an increased interest in understanding how healthcare can develop and improve [12]. One of the most discussed areas are how innovation processes could solve challenges within healthcare. Innovation is a de- manding ability which could be used to make healthcare less expensive and more efficient, but is a scarce field within healthcare [13].
Healthcare can be seen as a complex system in many ways, in terms of diversity of patients involved, the different professionals involved or because it is involved in different sectors and worldwide [14]. On the other hand, each of these systems could possibly be described as a system on its own, such as the hospitals booking system could be described as a system in this context. This system, and the system as a whole, will be affected by integrating new technical objects both in and between the systems [15]. It is important to understand that the social setting within the system, the organization, will be affected as well as it will affect the technical object introduced. When integrating a technical object in a social setting, the two systems might shape each other and this might possibly create a new system.
Being that healthcare is a complex system, the effects of innovation are relative and perspective-dependent [14]. Due to the numerous different elements within health- care, such as the number of different diseases a patient can have, or when a patient has co-morbidity, there is no single solution to resolve the problems. Literature on innovation within the public sector has emphasized the need for joined innova- tion for complex organizations like healthcare, such as collaborations or innovation in partnerships between different healthcare organizations [16]. Within healthcare, benefits of innovation processes have appeared inter-organizational, since different healthcare practitioners frame problems differently [17].
2.1.1 Electronic Health Records
Healthcare innovation is a broad concept and could refer to many different topics, one of which is Electronic Health Records (EHRs) [18]. EHRs are evolving more as an important matter for healthcare, this due to increasing costs within healthcare as well as regulations changing promptly [19]. Further, globalization and digitalization
has influenced the importance of keeping records of a patient electronically, in order to keep track of a patient’s medical history.
As it is an information technology system, it come with a need for implementation as well as it might come with complications and an adoption process. When un- derstanding of this implementation phase and factors for successful adoption within an organization is lacking, IT systems within healthcare often fail and are being abandoned by the users [20]. Particularly challenging problems when implementing health information systems are of social, technical and organizational types [21].
These barriers of adoption could for example be implementation process and train- ing, costs as well as the compatibility with already existing systems [22].
The modern environment for healthcare consists of connected and integrated IT systems, which is a new foundation of digital tools available to meet the needs for healthcare professionals as well as the patient [5]. However, healthcare environment is insufficient in terms of IT systems being slow and not integrated, hence having a need of development. This often leads to insufficient access to important information and an increased need for administration, which is time consuming. Better means for information sharing might lead to a higher efficiency for healthcare professionals.
As healthcare processes are increasing in complex and getting more complicated, more opportunities for EHRs are seen by patients as well as by society [23]. EHRs stand as an important foundation to ease communication and daily work for health- care professionals [24]. EHRs are used by many different types of people and pro- fessions, such as by doctors, nurses, assistant nurses, administration coordinators as well as by patients. This makes EHRs a very complex system, both for users and developers. Previously, however, there has been positive outcomes when studying patients’ attitudes of EHRs [6].
2.1.2 Mobile Healthcare Solutions
Just as EHRs are a way of adopting innovation in healthcare, so are Mobile Health- care Solutions (MHS). MHS are digital tools which could be used to improve health- care flow and increase patient safety, as well as helping staff at inpatient wards to create efficiency in administration [25]. MHS is a broad concept that exists in many different versions and which might fulfill different functions. Some solutions that exist today work in connection to an EHR, while some MHS are stand alone solu- tions [26]. These mobile devices allow for healthcare professionals to access EHRs remotely, which could contribute to increased efficiency [27].
In this research project one specific MHS will be investigated. MHS as part of this master thesis project is being defined as an application on a tablet used at inpatient wards in connection to an EHR. This application is a software solution solely used by healthcare professionals such as nurses, doctors and assistant nurses.
The application works solely in connection with a specific EHR, which has to be installed at the inpatient ward beforehand. As a system, they are integrated in such ways that what is being put in at the MHS appears in the EHR, and vice versa.
Patient information might be handled manually on paper by taking notes and print- ing out test results and lists of medication for each patient [25]. This manual han- dling of information increases the administration for healthcare professionals, which is time consuming as well as there is a risk of information getting lost. Both aspects could results in a lower quality of care for the patient. MHS might enable new work- ing methods for how information is being shared and handled at inpatient wards [5].
With the intended MHS, all information is at hand on a tablet stored in the pro- fessionals pockets, which might result in less paper notes and less efforts [25]. This might enable for every healthcare professional to access information in one place which could imply for a better information sharing between members of the staff.
When healthcare professionals put less efforts in searching for information, they could put more efforts in helping a patient. Further, the specific MHS holds pos- sibilities for customization, which could solve inter-organizational problems since every healthcare professional might use the MHS as desired.
However, a new product demands for an implementation phase where both train- ing and technical equipment such as tablets and computers has to be in place [13].
As with all technical devices and applications, systems might come with technical issues. One issue could be loss of internet connection, lack of battery or broken tablet due to item being dropped. Beyond these technical issues, there could be functionality issues with the product. Further, there could be issues of social types when implementing technical solutions to an inpatient ward, where failure rates have shown to be high in a study where a mobile application was introduced to home care in Sweden [10]. The social settings are not as investigated as technical aspects and could therefore be considered when implementing a MHS, such as interactions and practices of healthcare workers and how already existing technology is being used. Problems in social settings might arise when the new technology is not well integrated with already existing systems and arrangements [11]. Already existing arrangements matter because workers are used to these and will continue putting efforts in maintaining them. When implementing a new system it is therefore im- portant to recognize these arrangements and consider how they will integrate, to support the already existing arrangements. If these implementations and arrange- ments fail in integration the product might not be used as intended. To address and solve these issues, one solution might be to recognize the changes healthcare is going through, such as the digitizing of healthcare.
2.2 Digitizing Healthcare
In order to be able to provide better healthcare, IT systems have to be redesigned and digitized [28]. Healthcare systems face an increasing demand due to growing population, chronic diseases and elderly population [29]. Investments for digitizing healthcare are being made and the promises for what digitizing within healthcare can do are huge, such as the potential of medical technology [2]. Digitizing health- care can be done in several ways and might possibly affect different people and systems. Therefore, there are few aspects which could be taken into consideration when digitizing healthcare. One example of how healthcare has been digitized is in
the region of Dalarna, where the health center has been digitized, saving time for both the patient and healthcare professional [30].
2.2.1 Human and Technology Interaction
Connected technology and real-time monitoring is today the very heart of digitizing healthcare and an integrated part in modern hospitals [31]. These kinds of tech- nologies produce data with the aim to ease information shared between patient and doctor, as well as fortifying a decision-making system for doctors. The development of these systems and technology within healthcare infers for healthcare professionals to interact with technology in their work. This means that interaction that formerly occurred face-to-face are altering more to being machine-based. Further, face-to-face communication has been presented as being the most powerful way of accomplishing intelligibility. Therefore, when developing new interaction systems, it is a challenge for the developer to ensure for the system to respond to both the user’s action but also for the system to mediate the information correctly [32].
Not only are interactions between human and technology important but also the interactions between humans, especially within healthcare where communication is important for the safety [33]. Interactions between nurses have shown to have an important role for patient safety and care damages. A big part of communication between nurses is occurring while performing practical tasks and due to this, mis- understandings might emerge. These misunderstandings and insufficient transfer of information is one of the main factors for damages within care. To assure care of high quality, communication and human interactions are essential [34].
Technology has exceedingly shaped us in the way we interact, both with each other and with the world [31]. Not only has it changed our ways of communicating or in terms of mobility but we are constantly provided with information and impres- sions from technology. Digitizing healthcare does not only come with promises and potential, it might also come with a risk for humans to loose contact with their en- vironment. This could happen if the connection to the technology and information is too heavy and could result in humans not observing their surroundings in detail.
However, digital technology tools have been shown to be useful for organization and coordination within healthcare and hold promises for further developing healthcare.
These concepts and knowledge is important to keep in mind when implementing MHS at inpatient wards to ensure that the quality of care is not affected by this.
2.2.2 User and Implementation
When developing new technologies, it is of great importance to consider the user in the development phase [15]. The user and the development of technology has to go hand in hand in order to develop a well functioning product. Therefore, the design process is a continuous process of going back and forth between configuration and the actual user. There is a difference between the designers projected user and the real user, as well as there is a difference between the world described in the tech- nology’s displacement and inscribed in the object. Implementing new technologies will always lead to new arrangements between people and things. By carefully con-
sidering the user in the development phase, the user’s actual environment will have a greater possibility to take part in the finished product and in the implementation phase. Considering the user during the implementation phase also has an influence on how the technology is used for future purposes.
The designer adjusting the imagined user with the real user is very important for the value of the final product [35]. If the real environment for the final user is not being considered, the constructed product could be of no use. This is often the case when the user is excluded in the designers process. Further, choosing the subjected user could affect the final product, since every user is individually behaving [36]. It is therefore of interest for the developer to get to know the actual user and their behaviour. By doing this, it is possible to understand the user from within. This is because users might believe that they are behaving in a certain way, while actually practising it in totally different ways. This might also stand as a warning for the developer, since the users don’t necessarily always know best and might not always be sure of what their actual requirements for the product are.
One concept for understanding the relationship between user and technology is called the concept of Script, which is an approach where the configuration of the user is central [35]. This is an important and well used concept when designing technology designated for the daily work of humans. Script is trying to capture how relation- ships between humans are affected by technical objects and how technology forms different systems and settings in which humans are acting in [15]. The concept of script argues that the developer could consider the user’s behaviours, interests, skills as well as their motives for using the technology during the design process for the technical object. By doing this, the technical object would result as an attribute to the users and help transforming their work to the better rather than going to waste.
This concept is important for successfully implementing new technical objects at inpatient wards.
It is discussed how the user might affect the implementation and integration of the technology [15]. The difficulty of understanding the real user from within is discussed, still the importance of this is stressed [36]. There is a greater problem with trying to interpret the relationship with users and technology in a setting where technology already is existing, where there is not only issues with how the user will interact with the new technology but how well integrated the new systems will be.
An existing system will have its impact on the user and the new systems will inte- grate in some means, which will have its impact on both systems and the usage of the technology [11]. Depending on the intention of the developed technology, it might replace existing technology but it might also be a supportive system [35]. If the real user and its environment and needs are not taken into consideration carefully, the newly developed technology might not do any of the mentioned and therefore not be used as intended. However, it might not always be enough to perform a config- uration of the user and this might result in the user rejecting the embodied image within the technology [37]. These problems might arise when there are misleading interpretations on the user, which results in the wrong values in the technology.
When this is the case, the user might reject the technology and a dialogue has to take place between user and designer for the possibility for finding new solutions.
When considering users and implementation, there is a discussion of whether the user can be seen as existing before the implementation of technology, or whether the user is produced along the implementation [38]. This has been investigated in a study where telecare services were implemented, where it was found for the users to be created along the implementation phase instead of there being a co-construction of users and technology. Further, it was found that the implementation phase might be arranged for so that conditions for the user is allowing for functions beyond the actual technology, such as focusing on relationships with the user. Further, in an- other case when implementing telecare to healthcare, it was found for interaction between humans and things to be dependent on the place for the usage of technology [39]. How the technology is used is affecting the dynamic interactions and might either enable or hold back for actions. This implies for the understanding of how and why the place for implementation of a new technology might redefine the already existing settings. Further, it infers for why some settings allows for incorporation of new technologies while other might resist it.
Previous pilot studies when implementing a MHS have shown to have less resis- tance for usage of the MHS when the staff has been involved in the selection of the MHS and in such ways, engaging the healthcare professionals [27]. In the same study, it was shown for IT support to be important and that many healthcare pro- fessionals acquired additional IT training for the usage of the MHS. After the study, it was clear that MHS are of benefit for healthcare professionals, but that they come with barriers when implementing and adopting to the new ways of working.
There are many studies made on implementation of telecare in healthcare and many concepts are derived from these. Many of these studies include implementations that have been made in home environment. However, it would be of interest to see how the settings might be redefined when implementing a MHS at an inpa- tient ward, which is to be investigated in this thesis. It is of interest to explore whether this affects the social settings and how as well as create understanding for how communication at an inpatient ward might be affected by implementing a new technology. Further, discussions about why it is changed have not been made as well as the understanding for why healthcare professions might use, or not use, the newly implemented technology. How the implementation of an MHS at an inpatient ward might influence its setting could contribute to the previous works and is to be investigated in following chapters.
Chapter 3
Methodology
Research methods were of qualitative approach consisting of both ethnographic re- search and qualitative interviews. The research methodology is inspired by using Grounded Theory (GT), however with some adaptations and the approach for cre- ating the model was inductive research.
3.1 Grounded Theory
GT was chosen as a method to gain in-depth knowledge to understand the con- cept that was being studied, how the means for communication at an inpatient ward might be affected by implementing a MHS. By applying GT it was possible to explore and understand the behaviour, interaction and relationships between in- dividuals at the inpatient ward. One reason for adopting the method of GT was that the method helps form a theory about the collected data, without having prior knowledge to it. MHS as an application on a tablet used at inpatient wards can be considered as a quite new area to study, since it is lacking data as well as lacking theory and understanding. This means that the gap of knowledge is wide and that knowledge is needed for this research.
GT is a qualitative research method with central components in the simultane- ous collection and organization of data [40]. It is a method which is generated by its own process, by using empiric data and not neglecting or adding any theory, thus having an open mindset for the results obtained [41]. In other words, GT is using the empiric data for generating data analysis without prior knowledge of the outcome. This is one of the main benefits of using GT, since it provides an in-depth perspective, new theories can emerge from coding the data into categories [42]. This methodology allows for data collection and analysis to stand in close relationship to theory within the studied concept [43]. This creates opportunities for theory and theoretical ideas to emerge from the collected data.
The following figure illustrates the research design.
Figure 3.1: Flowchart of the research design
3.1.1 Case Selection
This master thesis project was conducted at one surgical inpatient ward at one pri- vately held hospital in Stockholm. This case was selected because terms of timing for the research project aligned with the planned implementation process of the MHS at the inpatient ward. Further, the case was selected due to theoretical reasons such as the case was likely to offer insights for understanding and identifying relationships and interaction at one inpatient ward. The inpatient ward offered a setting complex enough but also with an ideal number of professionals, all willing to be observed and contribute to the research. This allowed for the theory to emerge from clinical settings. To select the case for theoretical reasons is called theoretical sampling [40].
The chosen case selection, interactions at the surgical inpatient ward, could pos- sibly represent other contexts as well, such as other inpatient wards in Sweden.
How the staff work and interact at the chosen inpatient ward is not expected to differ drastically between other inpatient wards in Sweden. However, the research is a case study and should not be generalized.
3.1.2 Quality of Thesis
Reliability, internal validity, construct validity and external validity has been con- sidered in this study, by for example performing member check and by the use of a variety of methods to collect data [44]. Further has the research process been performed with high internal reliability since both researchers have agreed about what has been observed and heard [43].
3.2 Data Collection
In order to answer the research questions, a data collection was conducted. The data collection consisted of an ethnographic field study as well as expert interviews.
Since the research questions were to understand how staff at inpatient wards inter- act and communicate, qualitative methods were chosen. Qualitative methods are chosen when the aim is to collect data of in-depth character from few resources [45].
Therefore, to create in-depth knowledge in the field of study, qualitative methods was the most suitable choice for research method.
GT has two central features, which are the development of theory from data col- lections as well as an iterative, simultaneous, approach. This process, where both collection and processing of data assign back to each other, is continuous until data analysis is complete. Due to this, several field studies were performed at the same time as the obtained data was processed.
3.2.1 Field Study
A field study of ethnographic approach was performed in order to obtain data.
Ethnography is a method and a tool for an extended user to observe the life of the feature of interest [43]. Studies of ethnographic approach refers to the researcher observing behaviours, people and relationships in their usual environment in order to give detailed information and descriptions. This is usually done by the researcher becoming a part of the environment that is to be studied, which was applied as part of this master thesis project. The purpose of this was to observe the users without impacting on their ways of interacting with each other and the technology. It is of big importance for the researcher to not infer with the environment, in order to be able to observe the natural environment itself. With the inside perspective that the researcher obtains, understanding of how and why groups or organizations works a certain way can be created. These habits usually do not reflect how individuals would personally explain their way of working and is therefore crucial for in-depth understanding.
The working behaviours and interactions of two doctors, three nurses and one as- sistant nurse were chosen to be observed. In order to understand how members of the staff work and interact at inpatient wards and since the MHS is a software solution for nurses, doctors and assistant nurses, all three professions were chosen to be studied. All three professions were selected because they would use the MHS after implementation and thus be affected by its implementation. The field studies were performed during one full working day for the nurses and the assistant nurse, between 06.45-15.00. For the doctor, the observation was performed between 09.00- 11.00 since this was the time doctors were present at the inpatient ward and had access to the MHS. In total, six field studies were performed and the main source of data was field notes. These notes were taken on a note pad at the inpatient ward and were noted at least every 15 minutes in order to notice the time for each event.
Further, these notes were transcribed to documents on a computer, where each day resulted in 5-6 A4 sheets.
3.2.2 Expert Interviews
Interviews were the chosen method for validation of the model since the experts were expected to be able to confirm how they work and interact and to some extent also why they do so. Questions regarding the situation at the inpatient ward and to what extend the implemented MHS had changed their ways of communicating and interacting were asked. The interview questions can be found in Appendix A.
The interviews were based on the findings from the data processing and analysis.
The interviews questions were compiled together to a semi-structured interview, where some questions were formulated beforehand and some questions were asked as to follow up on the interviewees replies and varied in order [43]. Semi-structured interviews were chosen to achieve rich and detailed answers but not being too time- consuming. The interview questions were both open-ended and close-ended, depend- ing on whether the questions had the aim of validating the model or whether it was to understand reasons for a certain behaviour. All of the six professions observed were asked for an interview and two accepted, one nurse and one assistant nurse.
The interviews were held in Swedish via remote video conference in a distinct con- ference room and were partially verbatim transcribed, in terms of the information getting written down during the interviews. The duration of the interviews were 40 minutes and the transcribed documents were locked in one file in the author’s laptop. The password was only known by the two authors.
When the interview questions were stated, two test interviews were performed to ensure that the interviews would result in functional data. These test interviews were also for preparation before the actual interviews to gain better understanding of how the actual interview would be executed. After the test interviews, questions were formulated differently, some questions were added and some taken away to obtain an interview that would gain understanding for the healthcare professional.
3.3 Data Analysis
The process of collecting data to generate a theory from it as the data is being simultaneously analyzed is part of using the method of GT [40]. By doing this, the researcher can further find out what settings and data to collect next. The constant comparison of the findings from data collected and analyzed data with existing literature helps to create an in-depth understanding of the studied phenomena.
3.3.1 Data Processing
When processing the data and coding the text based on what was in the field notes, categories for in which the data could be categorised into emerged from the data itself while processing it. The data was processed on paper sheets, using coloring pens and Post-it Notes. Different categories were assigned to different colors and actions and sets of data were labeled with color for each category. Whenever a category contained many actions and patterns, a new label arose which was further analyzed. Further, each label was compiled and analyzed in order to find patterns and actions within the data.
Coding was the first step of the data processing and was performed shortly after the first field notes were conducted. Coding is in this context intended as naming different events from the data, such as different behaviours. By doing this, the data can be categorized and codes can be compared with each other to see what concepts fit best together [43]. Coding can be done in three steps which are open coding, axial coding and selective coding [46]. Open coding is about breaking down the data and is done with the purpose of breaking through bias, subjectivity and any preconceptions. In this step are events, behaviours and actions compared in terms of difference or similarity and further categorized into categories and sub-levels. In the step of axial coding is the data from open coding being put together again to test the data once more. This is done in order to look for new actions or possible categories. In the last step, selective coding, the categories are being put together again in order to study the data as a whole and to see what the data represents in terms of the phenomenon of interest. This step is usually the last step of coding to obtain knowledge of the final results.
Labels that emerged from the field notes were:
Figure 3.2: Visual presentation of how the field notes were labelled during data processing
3.3.2 Development of Model for Communication
A model was developed from the categories shown in Figure 3.2 to understand the conceptual framework of communication at the inpatient ward before the implemen- tation of the MHS. This model was then further used as a foundation of commu- nication in order to understand how and why the MHS affects interactions at the inpatient ward. A model is a simplified attempt to describe a real phenomenon and assumptions for reality can therefore be made [47]. Developing a model can be done both deductively and inductively. The approach differs and is based on phenomenon of interest, whether the research is of qualitative or quantitative approach, but it is also based on previous research and literature. The development of a model is a dynamic, continuous process.
In this master thesis project, an inductive approach was used and the development of the model was based on data collected from the field study. The empirical data was analyzed with a grounded theory approach to find similarities and differences in behaviours in order to develop concepts which would create a theoretical framework for the organization. These concepts were labeled and described for the practice situation to understand the phenomenon. The labels can be found in Figure 3.2.
When following this process, it is possible for researchers to develop a model and linkages between concepts [48]. These labels were written on paper sheets and cut into individual pieces, such as ”Board”, ”EHR”, ”Phone calls” and ”Questions”.
When having these pieces of paper, the linkages between the labels were searched for. As an example, both phone calls and notes could include verbal communication such as a healthcare professional was talking on the phone and talking to another professional about information that was found on a note, but they could also include written communication in such ways that a professional could write information on a paper note when receiving a phone call.
In this master thesis project, the model was developed to understand how health- care professionals communicate at an inpatient ward and further used to understand how the implementation of the MHS would affect on these means for communication.
The observed means for communication and important tools used for communication found in Figure 3.2 were used to develop the model by figuring out how commu- nication was carried out at the inpatient ward. These labels from data processing and analysis were found to all include communication in terms of written, read and verbal. These means for communication were therefore the main foundation for the model found in Figure 4.1. The different tools that the healthcare professionals used to communicate is also found in this figure.
3.3.3 Discussion and Final Results
As the model became clear after the field studies, the interview questions encom- passed the identified components of the model. Firstly, the interview data was categorized according to their relevance to each component in the model and was then compared to the data from the field studies. Further, data was collected from a database about how members of the staff at the inpatient ward were using the EHR after the implementation of the MHS. Finally, the obtained data led to discussion and final results.
Chapter 4 Results
As an engineer, being at an inpatient ward can be both stressful and scary, but also very interesting. There are a lot of different things going on at the same time and there is always some kind of noises, both alarms and patients in pain. The surgical inpatient ward offers 24 beds, plus two extra beds when necessary. Each nurse working a morning shift at the inpatient ward has responsibility for six patients. The staff at this inpatient ward were busy most of the time, with tasks such as providing medication to patients, nursing or documentation such as writing or reading EHR.
The patients at this inpatient ward were very varying, both in a broad age range from young adults to elderly people, but also in their different diseases. All patients had been through severe operations, or were to undergo one, and most commonly it was related to the abdominal area. Due to this, the visits to the surgical inpatient ward could include everything from feces on the floor and puking patients, to death.
In other words, no two moments were alike.
4.1 Communication at the Inpatient Ward
Communication was found to be a big part of the work at the inpatient ward and in order to understand how communication has changed and to answer the stated research questions, understanding of how communication was performed before im- plementation had to be obtained. Therefore, a model for the means by which the healthcare professionals communicate was developed. The purpose for developing the model in Figure 4.1 was to conceive understanding for how members of the staff communicated and interacted with each other at the inpatient ward. The model aims to describe the means by which members of the staff communicated and interacted with each other in the inpatient ward. This, in order to further understand how and why the implementation of the MHS affected communication and interactions at the inpatient ward. The model for framework of communication at the inpatient ward was used to analyze the rest of the findings in such ways of how different means for communication could impact on other means of communication, but also for why the MHS might not have impacted on different elements of the model. In order to obtain understanding for this, the model was a necessary foundation.
Three ways of communication were identified, including read, verbal and written.
Read refers to the mean by which healthcare professionals acquire information through existing documents. In this case, communication is defined as a passive process and the direction of information transfer is from fixed information to professionals. Verbal refers to the mean by which healthcare professionals
exchange information face to face. The direction of information transfer regarding this type of communication is thus presented as mutual. Written refers to taking notes and checking off to-do lists or similar. Additionally, five tools that usually were used for these types of communication were confirmed: Board, EHRs, Notes, Phone calls and Reporting.
Figure 4.1: Model for framework of communication at the inpatient ward
At the inpatient ward, there was found to be many interactions and information transfers between the healthcare professionals. The information that is being transferred is mainly information regarding a patient or a task that has been performed or that is to be performed. During the interviews, the assistant nurse was asked question Q2: ”What is your own perception about communication at the inpatient ward?” and the answer was: ”Communication is a big part of our daily work at the inpatient ward.”
Following, the results are presented in the categories of the model which are the board, EHR, notes, phone calls and reporting. The results consists of field notes and interviews, where the field study was performed before the implementation of the MHS and the interviews six weeks after the implementation. At the time for the interviews had the nurse had been sick for two weeks and had therefore not been working at the inpatient ward and not used the MHS very much. The assistant nurse had at the time for the interviews not undergone any training on the MHS as well as been on vacation for one week and had therefore not used the MHS much.
4.1.1 Board
The board has a central position in the department, both geographically and in terms of importance. It is used by all involved professions as well as by other de- partments. The information on the board serves as a unit overview for the inpatient ward and is reported live to the Emergency Department via a video camera, to easily communicate the condition of the ward and if there is an opportunity to take in a new patient. Information available on the board about a patient include their age, gender, medical need, position and when the patient is expected to be discharged.
Primarily, the board is used in all forms of reporting, where all staff gather in front of the board to get an overview of patients and to access information about a patient outside their own area of responsibility. Most commonly, professionals use the board to quickly get information about a patient, for example, if a relative has called or to get information about how many patients that are being discharged.
Excerpt about the board from field notes:
07.25 Check-in reporting at the board. One nurse stands by the board and informs other healthcare professionals about a patient, what is expected to happen during the day, the condition of a patient and regarding medication.
07.35 Another nurse takes over and talks about another patient which has been clas- sified to have a risk of falling and therefore has a magnet with this marked on the board. Information regarding patients getting discharged during the day is getting added on the board and other information is getting erased.
4.1.2 Electronic Health Records
EHRs are widely used at the inpatient ward as decision-making support, especially during the reporting. During the day, it is most commonly used to quickly obtain important information about a patient regarding other professionals’ clinical assess- ments, notes written in medical records or decisions regarding medication and test results. When medication is being distributed, the nurses usually look in the EHR for each patient before distributing them. In addition, EHRs are widely used for the discharging a patient. Other functions used on the computers at the inpatient ward include geriatrics, reading e-mail, getting answers about referrals or booking times at other departments when functions such as surgery or ultrasound are needed. The distribution of the activities used on the EHR are found in Figure 4.2.
Excerpt about EHRs from field notes:
09.32 The nurse is logged into the EHR and looks for test results for a patient, in- cluding the test results from the tests the assistant nurse took earlier this morning.
Some of the test results are missing, which the nurse thinks is weird.
09.27 Two doctors are reading about a patient in the EHR. They talk about what medications to give the patient. The nurse notifies the doctors regarding distributed medications.
Figure 4.2: Types of activities that occurred with the EHR and the distribution of these before the implementation of the MHS (n=101)
4.1.3 Notes
There are many different types of notes used at the inpatient ward and notes are generally used extensively for information transfer. Notes are being used to read, write or verbally communication and are being used by every profession at the in- patient ward. There is no established process for the use of notes and everyone uses notes in different ways. Some have their own system for how to make notes, such as using different colors. The most commonly used note is called the Patient Reporting-note, which is a note that occurs at each reporting and medical round.
The Patient Reporting-note is a paper sheet in size A4 where squares are to be filled in with information about a patient such as their age, gender, medical need, position and more. Further, Post-it Notes are commonly used at the inpatient ward.
These Post-it Notes are usually written by the receptionist when a phone call has been received about information intended for another healthcare professional. In addition, there are many notes that are used in the department in the work, which are, among other things, notes for daily review, notes that are sent with a patient for surgery, information sheets, list of medications and papers for documentation when discharging a patient. A summary of the type of notes being used at the inpatient ward is found in Table 4.1.
It was calculated for if either reading or writing on notes was most common at the inpatient ward and found for the activities to be carried out to almost the same extent. Writing on notes was a bit more common (n=36) than reading (n=21).
Reading is mainly done for informational purposes, either to get reminded about information or to inform others. This activity is usually performed during reporting.
The action of writing on paper usually occur during reporting but can also occur during the day when new information appears. This has been found to be done either by making to-do lists, checking off an activity which has been performed or by taking notes.
Excerpt about notes from field notes:
07.32 The nurse is sitting at reporting with a white paper where she has written the numbers 1, 2, 11(1), 11(2), 11(3) and 11(4) which represents each patient. I guess that she is going to take notes on this paper later on. The nurse received a report on a Post-it Note from another nurse.
14.02 The nurse reads from her Patient Reporting-note to inform the evening shift nurse about the patients.
Table 4.1: Type of notes at the inpatient ward.
Type of notes Patient Reporting-note
To-do list Post-it Note
Preparations at the inpatient ward before surgery Documents for discharging a patient
Note with information from the Emergency Ward Daily check for assistant nurse
Calorie list
Note for registration of fluid for patient with catheter Information for patient about operation
Blood sampling note Medication list
4.1.4 Phone Calls
Phone calls are commonly occurring at the inpatient ward and were of types: phone calls from relatives, conversations regarding test results, conversations with the geri- atrics and with other departments such as the orthopedic reception, surgery or with the ultrasound department. All professions received phone calls during their shift and in total 28 calls were observed. A nurse could receive at most 9 calls during a shift and a minimum of 3 calls. Type of phone calls and quantity are shown in Table 4.2.
Table 4.2: Type of phone call and quantity.
Type of phone call Quantity
Ward at same hospital 10
Ward at other hospital 7
Patient’s relative 5
Other 6
Excerpt about phone calls from field notes:
13.45 A doctor walks to the nurse and informs that they called from the geriatrics about a blood sample for a patient which has not been taken, since the sample has not been ordered. The doctors calls the clinic for geriatrics.
4.1.5 Reporting
Reporting is as part of this master thesis project defined as a form of meeting with the aim of exchanging and transferring information between the healthcare profes- sionals at the inpatient ward. Reporting varies in length, with the shortest reporting lasting five minutes and the longest for 26 minutes. In total, reporting was usually done between 4-6 times during a work shift for both assistant nurses and nurses. An activity flow of how reporting might take place during a shift is presented in Figure 4.3. Reporting could take place at different settings depending on occupation, pro- fession and time for reporting. One example of this was that the reporting in the morning between shifts took place in the expedition, while reporting in the morning between assistant nurse and nurse took place in the staff room. On average, the reporting went on for 12 minutes. During the reporting, many different activities take place as well as a lot of communication, such as verbal, written and reading on notes and computers, since most of the reporting is done in front of computers and the EHR.
Figure 4.3: Activity flow of reporting at the inpatient ward
Questions are frequently asked during reporting, such as the clinical need of the patient or clinical assessments regarding the patient. These kinds of questions were asked in between nurses and assistant nurses. Further, there were questions asked regarding coordination such as where a patient should be placed. Questions related to the doctors were usually asked during the reporting before the medical round and during the medical round. These questions were usually asked by the doctor, to the nurse who responded either with the use of notes she had or from her own memory. These types of questions could be about test results. During reporting, the nurses also asked the doctors several questions before the medical rounds, which were usually regarding tasks that were to be performed. These questions were usually ending up in a discussion based on the patient’s EHR and clinical assessments were reached together. In Table 4.3, type of question and quantity are summed up.
Table 4.3: Type of question and quantity.
Type of question Quantity
Coordination 8
Help and support 5
Patient’s clinical needs and assessments 21
Excerpt about reporting from field notes:
09.39 Report meeting in the doctors expedition in front of the EHR. Discussions with the doctors. The nurse writes down activities that are to be performed on her to-do list, as the doctors discuss and tell the nurse what is to be performed. The nurse tells the doctors how things were at the inpatient ward yesterday and discusses patients with the doctor. The nurse tells the doctors how one patient is doing and the doctor tell the nurse what medication the patient should be receiving.
The doctor notifies the nurse about a test result that the doctor received verbally.
The nurse tells the doctor that the nurse has been waiting for the test results and that the nurse has spent time looking for this test result on the EHR without finding it. The doctor has however received the test result verbally earlier and notifies the nurse about the result of the test.
4.2 Usage of the Mobile Healthcare Solution
This section aims at answering research question RQ1: ”What are some reasons for members of the staff to use, or not use, the MHS?”. Following are results from the interviews. It was found after the implementation of the MHS that not all of the professions working at the inpatient ward was using the MHS. This, due to some professions being new to the inpatient ward and had therefore not undergone any training on the MHS. Another reason for some not using the MHS was because some people were about to retire and it was therefore considered to be unnecessary for training.
When the assistant nurse was asked why the communication has not changed since the implementation of the MHS the answer was: ”We are still spending time looking for each other, that happens just as often today as before the MHS. I believe that this is because we are still very early in the implementation phase. I also think that it is because some of the professions don’t always check their MHS to look at tasks or information, it really depends. Like, I have to go back and forth to look for nurses to verbally document that I have washed a patient or given medication. This is also because it is faster to report verbally than to do it in the MHS. Regardless of what I write in the MHS, professions will still come and ask and talk to me about tasks and information, and I will tell them about what I have written in the MHS. I think this is mainly due to habits, because we are used with working in this way, but also because we want to give attention to the information and to remind each other. I think it is important to talk to each other when you are working in a team.”
When the interviewees were asked question Q7: ”We observed that sometimes, information got lost. Is that something you would agree on? Are there any activities that could be missed now with the use of MHS, such that information would get lost?” the answer from the nurse was: ”Yes, information sometimes gets lost and yes, this is problematic. I believe that this has already gotten better with the MHS, since activities are connected to patients and it is easier to get an
overview of tasks that are to be performed. If more people in the staff would use the MHS, the potential for the MHS as a support to help information not getting lost is huge.” When they were further asked why the members of the staff don’t use the MHS, the answer from the assistant nurse was: ”I believe that it depends on different generations working at the inpatient ward and whether one is used to technology or not. My colleagues who are older think it is difficult, so there is a difference for young and old generations.” and the answer from the nurse was:
”We need time to get used to it and learn it better, such as all the different settings. Generally, it takes time to get used to new routines.”
On the question Q11: ”Would you say that the MHS has the same content as the Patient Reporting-note had?” the answers were: ”Yes, it has the same content. The MHS can’t replace our own notes about a patient, to solve this we stick Post-it Notes onto the tablet”. The assistant nurse said: ”You are not allowed to write everything about a patient in the MHS, therefore you need to write your own notes on a piece of paper sometimes.” The nurse is still using the Patient Reporting-note: ”I am still using the Patient-Reporting note as a support, mainly because of old habits that are hard to break but also as a security to know that the information is available there.
But the idea is that the paper disappears. However, I think that people still are going to have small notepads to take notes to remember stuff.” The assistant nurse is not using the Patient Reporting-note after the implementation of the MHS: ”I like the idea of not having to take own notes, everything is on the tablet. I don’t need to erase old information, it gets updated on its own.”. Further, the assistant nurse carries a notepad to take own notes that are not possible to write in the MHS.
On the question Q17: ”How do you use the setting for medication today, on the MHS or the EHR?” the nurse answered: ”Mostly on the EHR since I have the trolley with the computer still and since I am not used to only using the MHS. It’s convenient with the trolley and even if I wouldn’t have the computer, I would still bring the trolley since I have the medication on it and other gadgets such as syringes, drips and spirits”. Further, when the nurse was asked question Q19: ”How do you experience the new board? How does it work?” the answer was: ”The new board can be pretty slow since it is only possible to do one thing at a time, which is more time consuming than doing it manually.”
4.3 Reasons for Double Documentation
This section aims at answering research question RQ2: ”Why do healthcare profes- sionals transfer information from digital to non-digital and vice versa?”
It was found that double documentation occurred, in such ways that staff wrote the same information from one paper note to another paper note, or transferred information from digital to non-digital forms. On the question Q14: ”We observed that it is common for some double documentation, such as writing off something from the EHR to a paper note, or from a paper note to the EHR. Why do you do this?” the nurse answered: ”I do it to make sure that the same information is avail- able for everyone” and the assistant nurse answered: ”Because you can’t log in all the time, logging into the computer takes such a long time. It is not always available, so maybe you write down important things. With the MHS, you do not need to log in, you are already logged in. Paper notes are therefore easier to carry around and more accessible”.
Excerpt about information transfer from field notes:
07:35 The nurse shows her papers with information regarding a patient, the assistant nurse is copying her paper by hand.
13:35 The nurse is in the expedition room and logs in to the computer and opens the EHR. There, the medical record is being opened and the nurse writes down information from the EHR to the Patient-Reporting note.
4.4 Communication after Implementation
This section aims at answering research question RQ3: ”Have the means for com- munication changed after the implementation of the MHS? If so, how?”. The results presented below are from the interviews.
The assistant nurse was asked the second part of question Q2: ”Has the communi- cation at the inpatient ward changed in any ways?” and answered: ”No, it has not changed. Even though we have the MHS, we have to communicate with our colleagues about important tasks so that everyone is informed and that nothing gets missed, we remind each other in this way. I still have to look for my colleagues to inform them.”
When the assistant nurse was asked question Q4: ”Would you say that previously, you often had to spend time looking for colleagues to tell them about activities per- formed? Is this perceived as disturbing? Do you experience that this has changed due to the implementation of the MHS?” the answer was: ”Yes, this is disturbing me in my daily work when I am doing other things. I believe that I get disturbed as often now with the MHS as before the implementation, since we talk just as much as before.”
4.4.1 Board
The new digitized board had the same information as the old, whiteboard, one. On question Q19: ”How do you experience the new board? How does it work?” the nurse answered: ”I would say that my experience of the board is that it has overall simplified the work at the inpatient ward and offers a great overview of the ward. It is great that the different teams are more visible now. We use the board a lot and it is nice to be ensured that the information is updated and valid.”
4.4.2 Electronic Health Records
On the question Q18: ”Regarding the usage of the EHR - Would you say that you use it more than before the implementation of the MHS, or less?” the assistant nurse answered ”I use it less since I use the MHS instead” and the nurse answered:
”Unchanged”. In Figure 4.4, activities of the EHR after implementation of the MHS is presented. The data presented is collected from a database with data about how members of the staff at the inpatient ward are using the EHR.
Figure 4.4: Types of activities that occurred with the EHR and the distribution of these after the implementation of the MHS (n=250)
4.4.3 Notes
According to both interviewees, notes are still being used after the implementation of the MHS. Further, Post-it Notes are still used when getting information via phone call. The nurse: ”We are still using Post-it Notes for that and I think this is problematic since a Post-it Note easily gets lost and is temporary.”
4.4.4 Phone Calls
When the interviewees were asked question Q3: ”Would you say, that you receive the same amount of phone calls today as before the implementation?” the nurse answered: ”Sadly, yes, I would say that the amount of phone calls is the same”
4.4.5 Reporting
Both interviewees were shown the activity flow of reporting presented in Figure 4.2 and were asked question Q15: ”Would you say that this activity flow matches the reality? Would you say that you are having reporting as often now as before the MHS?”. Both confirmed Figure 4.2 and the time, 12 minutes, for each reporting.
On the question Q15: ”Would you say that you have reporting as often now as be- fore the MHS?”, the nurse answered: ”Yes” and the assistant nurse: ”Not as many, there are less reporting today”.
A difference from reporting before and after the implementation of the MHS is how the information was presented, where it was on paper notes before the imple- mentation and on a tablet after the implementation. The assistant nurse pointed out that reporting can vary a lot, depending on which meeting it is and between what professions: ”In the morning, reporting usually takes longer than the scheduled 15 minutes, since we need to get information about each patient and know what has happened during the night, what medication the patient received and so on. Hence, the scheduled 15 minutes are not enough and I arrive late to the first patient.”
