Contents. Angela Randall 101. Exploring the interface between organisations and clinical information systems Johanna Westbrook 102

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1 Contents Health Information Management Vol. 34 (4) 2005 Health informatics and health professionals Editor: Kerin Robinson Managing Editor: Dr Lindsay Paul Associate Editor: Guest Editor: Dr Joanne Callen Associate Professor Johanna Westbrook President s report Health informatics and health professionals Angela Randall 101 Guest editorial Exploring the interface between organisations and clinical information systems Johanna Westbrook 102 Reviewed articles The work practice of medical secretaries and the implementation of electronic health records in Denmark Pernille Bertelsen and Christian Nøhr 104 Does the EPR support the discharge process? A study on physicians use of clinical information systems during discharge of patients with coronary heart disease Inger Dybdahl Sørby and Øystein Nytrø 112 Factors influencing diffusion of electronic medical records: a case study in three healthcare institutions in Japan Otieno George Ochieng and Ryozo Hosoi 120 Multiple perspectives on the impact of electronic ordering on hospital organisational and communication processes Andrew Georgiou, Johanna Westbrook, Jeffrey Braithwaite and Rick Iedema 130 A contemporary case study illustrating the integration of health information technologies into the organisation and clinical practice of radiation oncology Andrew Miller and Aaron Phillips 136 Reports Health Data Standards Committee meeting report Heather Grain 146 IT14/2 Semantic Interoperability meeting report Heather Grain 147 Conference report Information Management for Healthcare Julie Ritchie 149 Health Information Management 2005 ISSN Vol 34 No 4

2 President s report Health informatics and health professionals Angela Randall The roles of health professionals are overlapping and becoming increasingly interrelated. The implementation of the electronic health environment is rapidly encroaching on our professional playing fields, and we are forced to acknowledge our relationships with peers from other professions. How are we approaching the development of the electronic environment in our healthcare settings, and how are we approaching the need to update and enhance our knowledge of the new technologies? As I read through the following articles, a number of themes or concepts became apparent: technology or systems; human resources or people; evaluation or appraisal; and finally risk management. What stood out in the reports of research into all these categories was that the systems being integrated into our healthcare environments were selectively chosen to enhance the delivery of a service by a clinician or practitioner for the benefit of the patient, and to prevent human error, and that this required constant evaluation and analysis. Perhaps this is an obvious conclusion to the articles, but what we must consider are the various facets of the process and how we as health professionals must continuously strive to stay abreast of technologies, processes and practices through professional development, training in health informatics and developing an understanding of the relationship between the technology, our profession and our peers. I am often asked for a definition of the term metadata and often I have to stop and think of an appropriate answer. McFadden states that metadata are properties or characteristics of other data, but do not include the data. Other terms such as relational database, data warehousing and attributes all require some amount of knowledge of health informatics. In the articles in this issue of the Journal, we see how the authors have used their skills and knowledge of the technologies they have employed as well as other essential skills (such as project management, risk assessment and evaluation methodology), to utilise systems being implemented, and to assess the engagement and acceptance by colleagues and staff exposed to the new technology. Human interaction with technology can in fact be the key factor in the success or failure of a project and in essence comes down to the success or failure of the education and training the participant has received. Georgiou et al. look at the personnel interacting with the new electronic ordering system in a hospital environment and the impact on their daily work practices. Miller and Phillips note the various software suites used in radiation oncology, and the natural extension to the relational database of various treatment regimens. Another approach, taken by Bertelsen and Nøhr, and also by Ochieng and Hosoi, looks at the human element of information technology and the impact of technology on the workforce. Increasingly, we are faced with the implementation of new systems, software and databases which we are expected not simply to be able to operate, but to operate efficiently, accurately and proficiently. This in turn means for the health professional the need for continual professional development and an understanding of the very basics of health informatics. Angela Randall President, HIMAA Phone: himaa@himaa.org.au Health Information Management 2005 ISSN Vol 34 No 4 Page 101

3 Guest editorial Exploring the interface between organisations and clinical information systems Johanna Westbrook This issue of the Journal focuses on the organisational aspects associated with the design, implementation and evaluation of clinical information systems. The technical features of clinical information systems often attract great attention, yet increasingly research is demonstrating that it is the complex interaction between the technical features of a system and the human, social and organisational dimensions which will determine whether a system will be used by healthcare providers, and whether it will be effective and safe (Massaro 1989; Ash 1997; Gosling, Westbrook & Coiera 2003). IT failures in healthcare are well known to all. At conferences I regularly ask the audience whether they have worked in a healthcare organisation where an IT system has failed and invariably all hands in the room go up. Asked if technical problems were the main reason for failure, most arms go down. Many readers will know from direct experience that systems which are perfectly good technically can be disastrous when placed in real-world clinical settings. A frequent reason for this is that the system does not represent how clinical work is done, so it cannot easily be integrated into everyday clinical practice. Individuals will often use systems in quite unexpected ways, and the social and professional cultures of an organisation will also greatly influence if and how systems are used. Our own research has provided some local examples of this issue. In 2001, we undertook an evaluation of the Clinical Information Access Program (CIAP [ in NSW. This is an online evidence retrieval system aimed at providing all healthcare providers in public hospitals with access to high quality evidence at the ward level to support their decision making. Many states have similar systems, such as the Clinicians Health Channel in Victoria. From experimental studies we have demonstrated that when clinicians have access to these evidence systems they make more accurate decisions (Westbrook, Coiera & Gosling 2005). Yet, when examining how CIAP was used in the field, we found that there was enormous variation in rates of use (Westbrook, Gosling & Westbrook 2005). In some hospitals, clinicians used the system at very high levels and in other very similar hospitals, there were low rates of use. Following indepth case studies at high and low use hospitals and a survey of over clinicians across the state, it was clear that it was not the technical factors, such as IT infrastructure, that were driving this great variation in use; it was social, professional and organisational cultures (Gosling, Westbrook & Coiera 2003; Gosling & Westbrook 2004; Gosling, Westbrook & Spencer 2004; Westbrook, Gosling & Westbrook 2005). For example, high use hospitals demonstrated organisational cultures which valued an evidence-based approach to care. CIAP was used in real-time decision making and not confined to the retrospective review of cases, and nurses were encouraged to view evidence searching as a legitimate part of their clinical role. Active CIAP use was more likely to occur when clinicians believed they had the support of their supervisors and where they saw their colleagues using the system. Most recently, there has been a flurry of research papers which present warnings of the potential dangers of poorly designed, implemented or evaluated clinical information systems (Ash, Berg & Coiera 2004). This has included a study at a paediatric hospital in the United States which found an increase in mortality following system implementation (Han et al. 2005). The reasons for this serious and unexpected outcome are complex, including factors such as the method and speed of implementation, along with a poor assessment of work processes prior to system introduction and how the new order entry system might impact upon these. Such studies highlight the vital importance of setting up evaluation processes prior to clinical system implementation. The articles in this issue of the Journal draw attention to the important issue of the interconnection between the technical features of a system and the social and organisational environments in which they are deployed. This is an area of international interest as papers by Bertelsen and Nøhr (2005), Sørby and Nytrø (2005) and Ochieng & Hosoi (2005) illustrate. While we are often exposed to the experiences of our colleagues in the United States it is of particular interest to read of the Scandinavian experience with the implementation of electronic medical records. Australia and the Nordic countries have healthcare systems which have many similarities. Bertelsen and Nøhr (2005) present a fascinating study of medical secretaries, who perform similar functions to ward clerks in Australian hospitals. Their paper highlights how important work roles within healthcare organisations can be hidden and sometimes forgotten when considering the implications of clinical information systems implementation. Sørby and Nytrø (2005) report an observational study of doctors preparing discharge summaries in Norway. The findings are of relevance to many Australian hospitals which are in the process of implementing electronic discharge summary systems. Georgiou and colleagues (2005) present an Australian study which evaluates the impact of a computerised pathology order entry system on the work and relationships of staff within a major teaching hospital. This study builds upon their earlier research which showed that the introduction of these systems Health Information Management 2005 ISSN Vol 34 No 4 Page 102

4 Guest editorial can significantly improve laboratory turnaround times (Westbrook, Georgiou et al. 2006). Together, these studies illustrate the importance of taking multiple measures of systems impact in order to ensure that new clinical systems are used and deliver benefits to health professionals and patients. References Ash, J. (1997). Organizational factors that influence information technology diffusion in academic health sciences centers. Journal of the American Medical Informatics Association 4: Ash, J., Berg, M. and Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information systems related errors. Journal of American Medical Informatics Association 8(4): Bertelsen, P. and Nøhr, C. (2005). The work practice of medical secretaries and the implementation of electronic health records in Denmark. Health Information Management Journal 34(4): Georgiou, A., Westbrook, J., Braithwaite, J. and Iedema, R. (2005). Multiple perspectives on the impact of electronic ordering on hospital organisational and communication processes. Health Information Management Journal 34(4): Gosling, A., Westbrook, J. and Coiera, E. (2003). Variation in the use of online clinical evidence: a qualitative analysis. International Journal of Medical Informatics 69: Gosling, A. S. and Westbrook, J. (2004). Allied health professionals' use of online evidence: a survey of 790 staff working in the Australian public hospital system. International Journal of Medical Informatics 73: Gosling, A. S., Westbrook, J. and Spencer, R. (2004). Nurses' use of online evidence. Journal of Advanced Nursing 47: Han, Y., Carcillo, J., Venkataraman, S., Clark, R., Watson, R. S., Nguyen, T., Hülya Bayir, H. and Orr, R. (2005). Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116: Massaro, T. (1989). Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behaviour. Academic Medicine 64(1): Ochieng, O. and Hosoi, R. (2005). Factors influencing diffusion of electronic medical records: a case study in three healthcare institutions in Japan. Health Information Management Journal 34(4): Sørby, I. and Nytrø, O. (2005). Does the EPR support the discharge process? A study on physicians' use of clinical information systems during discharge of patients with coronary heart diseases. Health Information Management Journal 34(4): Westbrook, J., Coiera, E. and Gosling, A. S. (2005). Do online information retrieval systems help experienced clinicians answer clinical questions? Journal of American Medical Informatics Association 12: Westbrook, J., Georgiou, A. et al. (2006). Computerised pathology test order entry reduced laboratory turnaround times and influences tests ordered by hospital clinicians: a controlled before and after study. Journal of Clinical Pathology In press. Westbrook, J., Gosling, A. and Westbrook, M. (2005). Use of point-of-care online clinical evidence retrieval systems by junior and senior doctors in NSW public hospitals. Internal Medical Journal 35(7): Westbrook, J., Gosling, A. S. and Coiera, E. (2004). Do clinicians use online evidence to support patient care? A study of 55,000 clinicians. Journal of American Medical Informatics Association 11(2): Johanna Westbrook PhD, MHA, GradDipAppEpid, BAppSc(MRA) Deputy Director, Centre for Health Informatics University of NSW Kensington, NSW 2052 Australia Phone: Fax: j.westbrook@unsw.edu.au Health Information Management 2005 ISSN Vol 34 No 4 Page 103

5 The work practice of medical secretaries and the implementation of electronic health records in Denmark Pernille Bertelsen and Christian Nøhr Abstract The introduction of electronic health records will entail substantial organisational changes to the clinical and administrative staff in hospitals. Hospital owners in Denmark have predicted that these changes will render up to half of medical secretaries redundant. The present study however shows that medical secretaries have a great variety of duties, and often act as the organisational glue or connecting thread between other professional groups at the hospital. The aim of this study is to obtain a detailed understanding of the pluralism of work tasks the medical secretaries perform. It is concluded that clinicians as well as nurses depend on medical secretaries, and therefore to reduce the number of secretaries because electronic health record systems are implemented needs very careful thinking, planning and discussion with the other professions involved. Keywords: Computerised medical records; medical records; professional practice; medical secretaries; practice management; quality of healthcare As the implementation of electronic health record (EHR) systems seizes the attention of politicians, hospital management and system consultants, it is becoming evident that in Scandinavia as well as other countries this innovation offers tremendous opportunities for organisational change in public hospitals, which in some cases make up more than 99% of hospital services. Among health informatics system developers in Denmark there seems to be a consensus that EHRs in Danish hospitals have to be more than paper based medical records with added IT-power. Full integration between data from different feeder systems, and later also from primary and secondary sectors, together with seamless care, are the new goals. Currently however, discussions in hospitals at ward and departmental levels are concerned with how implementation of EHR, or parts of EHR, changes the socio-technical use of medical records, how it affects the quality of the work, and further, how to avoid negative effects for the patients. In Denmark the national strategy outlines a structure for a basic EHR, with interdisciplinary documentation of patient data. As a consequence nurses, clinicians and other health professionals within the hospitals will now document their work in a single record for each patient. Within this context, the future of medical secretaries 1 has been a subject for debate. Some counties have announced a 50% reduction in the number of medical secretaries, arguing that there is no longer a need for them to type up the clinicians dictation. These statements seem to be based on a stereotyped perception of the work medical secretaries currently perform, and an understanding of the clinicians future EHR work tasks which is still to be seen in practice. The debate about who will do what kind of work when and how, and the fact that the nature and con- tent of medical secretarial work in Danish hospitals never has been formally described, has made this study topical. The present research investigates the work practice of medical secretaries in order to create a more balanced basis for discussing the changes in work which the new technology brings. Background From an administrative point of view, healthcare in Denmark is highly decentralised. Responsibility for healthcare rests, as much as possible, at the lowest administrative level; that is, the level closest to the patient. Denmark is divided into 273 Local Authorities, which are responsible for primary healthcare and most social services. Fourteen counties 2 (at the regional level) and the Copenhagen Hospital Cooperation are responsible for hospitals. The counties organise healthcare services according to their own needs and priorities, without referring directly to the state organisation. The main task of the state is the formulation of a national health policy which initiates, coordinates and advises the healthcare sector. The Danish healthcare service is characterised by funding through taxes (85%) and is run directly by the public authorities. Denmark has given priority to free access to most healthcare services for all, regardless of economic situation. To summarise, according to Bernstein et al. (2005) and Lippert & Kverneland (2003): The National Health Service covers all 5.3 million citizens. There are 3500 general practitioners (GPs). More than 98% of GPs use some kind of EHR. GPs are predominantly publicly funded. 1 Medical secretaries perform a similar role to those of ward clerks in Australian hospitals. 2 By January 2007 they will be reorganised into five major regions. Health Information Management 2005 ISSN Vol 34 No 4 Page 104

6 There are 65 hospitals, owned by 14 counties and the Copenhagen Hospital Corporation, referred to as hospital owners (there are no major private hospitals). There are 5.3 million outpatient visits per year. There are in total hospital beds. The average length of hospital stay in 2004 was 4.6 days; in 2002, 6 days). Total admissions in 2004 were 1.3 million. Twenty-two percent of hospital beds were served by EHR by mid-2004, compared with 13% by mid : Structure of shared data (a) Data are totally unstructured and not reusable. (b) Digital access to pooled information, not well structured. (c) Final state: all the data are shared and highly structured. EHR in Denmark EHR development in Denmark is the responsibility of the hospital owners and is under the supervision of the National Board of Health. The Ministry of the Interior and Health has developed an IT strategy to support and coordinate national implementation (Danish Ministry of the Interior and Health 2003). A few years ago, the different health providers communicated by sending messages to each other every time a patient was referred or a treatment or test had been completed. Even when the messages were communicated electronically via electronic data interchange there was still a lot of redundant information flowing, and it was impossible to aggregate information for other purposes (Box 1a). Currently electronic communication in the Danish healthcare service is based on standardised messages, but the content of the message cannot be read at machine level (Box 1b). With the prospect of more IT systems being introduced there is a genuine risk that information islands will arise, where information has to be copied manually, or is organised in such a disparate manner that it cannot be regrouped for analysis. It will be difficult for staff to find their way around in large amounts of data presented in ways not known in advance. It is, however, possible to navigate comprehensively through the wealth of health related information by using a common and well-documented method of structuring the information input to the system (Box 1c). To the extent that the information is also based on some sort of classification, it can be reused by different IT systems. SNOMED CT is currently being translated into the Danish language to form the basis of terminology and infrastructure. To ensure input of a certain granularity and structure, a common national structure for EHR has been defined by the National Board of Health: the Basic Structure for Electronic Health Record (BEHR), schematically represented in Box 2. This is a clinical solving process model demanding structured information based on an episode of care, problem orientation and cross-professional documentation. It consists of four actions (diagnostic analysis, planning, execution, assessment) and four information elements (diagnosis, plan, goal, result). The content of From Danish Ministry of the Interior and Health (2003). each information element is structured according to set rules. The diagnosis is a professional labelling of the patient s problem, using any relevant classification. The planning activity results in a set of planned interventions. When executed they produce a result which can be assessed in relation to a goal (Bernstein et al. 2005; Lippert & Kverneland 2003). The aim is to follow the interventions carried out and to assess the results achieved for a specific patient problem, regardless of which healthcare institution provided the service. The national strategy does not provide funding for the development of concrete systems because power lies within the counties. This leads to different progress for EHR implementation in each county. A few Health Information Management 2005 ISSN Vol 34 No 4 Page 105

7 2: Basic electronic health record (BEHR) model concept level (Bernstein et al. 2005; Lippert and Kverneland 2003) The future situation of medical secretaries in hospitals is currently being debated and hence there does not at present exist a full picture of what work will be assigned to them following implementation of EHR. The term medical secretary evokes in most people s mind an indelible stereotypical picture of a white coated woman equipped with a headset, typing to the clinicians dictation on a computer, who then prints and files it as a printed medical record. Aim of the study The purpose of this study was to investigate which work tasks the medical secretaries actually perform, and in addition, to evaluate the significance of these work tasks to the organisation of clinical work and shared care. It was not our purpose to appraise which work tasks will potentially disappear when the paper record eventually becomes interdisciplinary and electronic. counties have implemented EHR systems for more than 80% of their beds, but others have just started a call for tender process. Another consequence of county freedom is the difference in choice of EHR implementation strategy; 60 different projects have been documented (Nøhr et al. 2005). The strategy at national level is to ensure compliance with the common standard and framework. This allows inter-communicability between different implementation and different proprietary systems. Inter-communicability permits a free market; as providers are forced up to a certain degree to communicate in a predefined form, different providers can implement different parts of the project. Medical secretaries and EHR The first medical secretaries in Denmark were employed at the end of the 1930s. Their purpose was to assist clinicians in their documentation work. Since then they have been called the doctor s secretary (directly translated from Danish). The notion that this labelling of a profession (which by 2005 had grown in number to more than ) has influenced the debate about their future in the hospital following implementation of EHR cannot be avoided. It has also added to a stereotypical perception of the kind of work medical secretaries perform in the hospitals. In Danish hospitals medical secretaries are employed at the department and ward levels. Over time, they build up a specialised domain of knowledge within the medical specialty of the ward in which they are employed (for example, cardiology, ophthalmology, urology), and they apply this knowledge when talking to patients or their next of kin over the telephone to identify primary contacts and to assess the urgency of the patient s situation. They also apply their knowledge when correcting errors in the clinicians dictation. Method Our concept of the importance of developing a method to identify formal and informal work routines centred around the work of medical secretaries in hospitals is in line with the principles in Soft System Methodology and a fundamental proposition that in order to conceptualize, and so create, a system which serves, it is first necessary to conceptualize that which is served, since the way the latter is thought of will dictate what would be necessary to serve or support it. (Checkland & Holwell 1998: p. 10). The present research places itself in the action research tradition. The specific research questions were developed in collaboration with the Danish Medical Secretary Association. The action research method is highly clinical in nature and places the researcher in a helping role within the (hospital) organisation that is being studied (Baskerville & Wood-Harper 1998). Action research merges research with practice and by doing so produces highly relevant research findings. The social and organisational realities in hospital and other healthcare organisations are realities that are continuously being constructed and re-constructed during dialogue with the staff and in the context of the action which they take (Checkland & Holwell 1998). Design The actual study design chosen was inductive and interpretive. It did not consider the researcher as neutral, but as someone who influences the result. We perceived the organisation of work in a hospital as a social construction by human actors. Each department or ward and its medical secretaries have their own reality that we wanted to explore, not deduct. An explorative method is thus valuable when the objective is to break new ground and yield insights into a new topic (Babbie 1998). Our study target was the work functions of the medical secretaries. Our aim was to disclose the variety of tasks in which Health Information Management 2005 ISSN Vol 34 No 4 Page 106

8 secretaries are involved, rather than the time spent on each task. Neither were we concerned with which secretary was focused on which tasks. This was a qualitative and not a quantitative approach. Generalisation of findings from the sample cannot be justified; rather they serve as an eye-opener to the activities of medical secretaries. Unit of analysis The sample was selected by using what may be called a convenience or haphazard sampling method where the aim was to investigate different departments and work areas rather than compare them (Bernard 2002). The informants comprised 10 medical secretaries in four hospitals. They were each interviewed for approximately two hours, and six of the 10 were observed at work for four to five hours by two researchers using video recordings. In order to test the method prior to carrying out the study, a pilot study with one medical secretary was carried out before data collection started. Data collection After selecting the informants, they were sent a disposable camera together with a covering letter asking them to photograph their workplace and colleagues, then return the camera in a self-addressed envelope. In particular, they were requested to photograph their physical workplace, the technical aids they used at work, the different tasks in which they are involved, planning and distribution of tasks, their area of responsibility, colleagues, superior staff, co-workers and whatever came to mind. A convenient day for conducting the interview was also agreed upon. Interview Each medical secretary was interviewed using a semistructured interview guide and visual aids such as flip chart paper, post-it notes, and marker pens. The interview method was participatory in that as the participants explained their activities, they also analysed the technology they used as exemplifying the knowledge, technique, organisation and the product/outcome of their work (Bertelsen, Madsen & Hostrup 2005; Müller 2003). The flip chart paper was placed on top of the table and divided into four squares, each representing one of the four elements of the technology we wanted the medical secretaries to describe. All interviews were recorded and later transcribed. The flip charts were used to note the issues related to the four elements in the technology concept and later to encourage the medical secretaries to organise the product of their work under different headings. We understand the current change from paper based medical record to electronic patient record as a change from the use of one technological system to another. The introduction of electronic devices is merely the introduction of a new technique which will never be successful without a simultaneous adjustment in two of the other three elements of the technology, namely the organisation and the knowledge elements. Changes in these three elements will finally affect the end result, the product, which in the case of the work of the medical secretary, we defined as the products/outcomes that can either be stored or are immediately consumed (Müller 2003). Verification For verification of our interview and video recording results we read available reports and studies on the work of medical secretaries and extracted from these the work tasks mentioned and matched them up against our own results. 3 Furthermore, two workshops with a total of 32 medical secretaries from all over the country were arranged. The first edition of the video recordings was presented and discussed so as to ensure that the final edited version would represent a common understanding of the work of the medical secretaries. Prior to conducting the workshops, the results of the interviews were arranged in a mind map illustration and were distributed to the participants who were then asked to mark the work task they performed at their present job. Results Analysis of the data by the use of a Mind Manager tool ( identified seven major categories of work that accommodated the identified work tasks. The many work tasks were then written into seven mind maps where we operated with a maximum of four levels. Here only the two top levels will be described. The seven categories at the very top level were: data input to the medical record data output from the medical record other operations involving the medical records support of clinical care plans administration of the professional clinical staff miscellaneous clerical tasks research and development activities. The work tasks were sorted with the purpose of identifying the total number of work tasks done by the 10 secretaries. Category 1: Data input to the medical record Work tasks that have to do with data input to the medical record include the more classical medical secretarial tasks, to: type up the clinicians notes or dictation onto the medical records set up new medical records print information for the records edit information already in the records 3 The reports are in the Danish language. A full account can be seen in Bertelsen (2005). Health Information Management 2005 ISSN Vol 34 No 4 Page 107

9 enter test results into the records order data from other departments or hospitals code information already in the records. Category 2: Data output from the medical record The following subcategories all have to do with handling data output from the medical record: registration of record data elsewhere procedures for coding of data for different types of clinical databases coding of data (mainly ICD-10 and local standards) settlement arrangements a number of lists, for example, waiting lists, regional lists, incident reporting quality assurance data. Category 3: Other operations involving the medical record The third major category of residual tasks is other operations involving the medical records, which includes: getting the medical record to and from the archive maculating confidential sheets of information from the medical record sorting and prioritising medical records into those required urgently and those that can wait photocopying of records to the patient, the insurance companies or other authorities. Category 4: Support of clinical care plans The medical secretary assists in different ways to make the patient s contact with the hospital as smooth and seamless as possible. In the support of clinical care plans, three different subgroups of activities support this effort. The first category identified as planning of clinical interventions contained myriad tasks dealing with: booking of appointments or admission re-booking coordinating planned clinical interventions coordinating acute clinical interventions arranging for transport of patient to and from the interventions. Tests and test results are sent to and received by medical secretaries between the various departments and wards both within and external to the hospital. An important task is to assume an overall logistic responsibility for those tasks that are conducted by other professions in the hospital. That involves: checking up on the physician to make sure he or she remembers to call back the patients waiting for test results detecting both spoken and written mistakes in the documentation. External communication regarding patient care is a task which encompasses communication through mail correspondence or by telephone. More specifically, it entails writing s and other types of correspondence to the staff in home care and in other institutions, answering telephone enquiries from patients, their next-of-kin, and primary sector staff. A quite frequent task is to request interpreters to assist non- Danish/English speaking patients, which is also a task involving external communication. Inhouse communication concerns welcoming new patients to the hospital, answering telephone calls from inhouse staff from other departments and correspondence to other departments. The medical secretary handles referrals to and from other departments and general practitioners. A considerable amount of communication in referring patients is handled on standard forms and paper charts, often in multiple copies in different colours. In most cases it is the medical secretaries task to fill in the forms, sort them, and make sure the form of a particular colour goes to the right place. In addition, many of the forms are also designed by the medical secretary. Category 5: Administration of professional clinical staff The administration of professional clinical staff incorporates two major subcategories, formal and informal staff administration. Formal staff administration is a matter for decentralised management and includes keeping a record of notification of illness among staff, making on-duty schedules, and reporting of working hours for salary payment purposes, as well as monitoring staff vacation days. The purposs of these concerns is to ensure the smooth running of the logistics surrounding other professions, and to facilitate the running of a large and complex organisation by hospital management. Supplementing the formal work tasks is informal staff administration. This could include introduction and coordination of trainees and medical, nurse, and midwifery students. In general, secretaries play an important role in introducing new staff to the rules, routines and regulations in the department, and the new staff ask questions of the secretaries as they are more accessible than other staff categories. Category 6: Miscellaneous clerical tasks In the category miscellaneous clerical tasks the concern is to make the daily work of colleagues and patients more comfortable, and by doing so strengthen the social capital. To go to the bakery for fresh bread, make coffee, feed the fish, and tidy the meeting room after meetings are tasks that the secretaries take on. Health Information Management 2005 ISSN Vol 34 No 4 Page 108

10 We did, however, also find they are involved in tasks such as participating in meetings, committees and projects of different kinds, where they coordinate meeting dates, make photocopies, take minutes and maintain the project accounts. Office materials and medical equipment used by hospital staff are ordered by medical secretaries. Materials and equipment are also lent out and registered by secretaries, and they carry out such tasks as tidying up the depot to make it easy for the staff to locate the materials they need. When equipment breaks down the secretaries call technicians to repair it, and they order the necessary number of beds for patients that are admitted to the ward. Clinicians or researchers with non-danish training, and having not yet mastered the Danish language, need more support than their Danish colleagues. Medical secretaries often help these colleagues to document their clinical work in the Danish language and to find their way around the hospital. Category 7: Research and development activities The last top level category is termed research and development activities. Five different subcategories related to research and development activities have been identified. The first category concerns setting up a research project. It contains the different support activities needed to write research proposals, such as setting up research protocols, and correspondence with funding agencies and different authorities, for example to seek approval of tests by ethics committees. The second category is operation and management of research projects. It deals with all the activities that occur when research funds are in place. Here we find work tasks related to controlling and accounting for the funds, arranging meetings and conferences, as well as different tasks related to the researcher s travel. The third category consists of reporting to research councils and administration, searching for literature, and establishing contact with different research groups. Minutes from meetings are written and contacts with councils, companies and insurance companies are maintained. The fourth category comes into play when the research projects are completed and the results are to be communicated in writing, necessitating translation into English, proofreading and writing and/or editing annual reports. Writing articles from dictation as well as designing PowerPoint presentations for researchers are also part of the work tasks. A special task in relation to research projects is to bring clinical guidelines up to date. Especially in relation to development programs within the hospital, the secretaries often participate in committees and working parties, not only in a clerical capacity, but also as qualified members of the professional staff. Discussion Our concern was not to identify how many of the informants carried out the different work tasks. With a unit of analysis of 10 informants generalisation of this kind is not possible. The objective of the data processing has been to obtain a detailed understanding of the pluralism of work tasks the medical secretaries perform, but not to identify the work tasks that are performed by a majority of the informants. Such an exercise has yet to be done in Denmark. During the sorting out of the work tasks we often encountered tasks that could be placed in more than one of the seven categories; for example, data from medical records used for treatment as well as research purposes, and which is also being reported to the clinical database. It is important for us to acknowledge that we are aware that as researchers, from time to time, we have influenced the category into which the work tasks have been placed. However, we have been guided by a wish to generate major categories that would allow us to make sense of the myriad different work tasks we came across. It is not our intention to document all the secretaries tasks at all times and in all hospital departments in Denmark that would fit into the same category. Thus, it is our perception that there will at all times be a socio-technical difference between hospitals and departments in respect of how secretaries work tasks are performed. For this reason it will never be possible to find one blueprint that will apply to all situations. Using the methodology outlined by the study has constructed a very detailed and sophisticated understanding of the work of Danish medical secretaries (Checkland & Holwell 1998). In relation to EHR systems, it has provided a foundation for discussion of the development and implementation of an EHR system that will best serve a particular hospital organisation or institution. The study disclosed a multiplicity of formal as well as informal work tasks that, by their sheer number, challenged the researchers to comprehend them. Even by using mind maps, to handle up to four levels of categories which are not entirely exclusive nor exhaustive is a complex undertaking. Though the different departments employing medical secretaries have almost identical names at different hospitals, their organisation as well as priority of work tasks to be performed by medical secretaries varies considerably. A number of secretaries may perform the similar task of writing notes for the medical records, but the rest of their working hours may involve work on very different tasks. This makes it virtually impossible to compare and classify their tasks into fixed job profiles. That exercise will have to be done at the local departmental level. We can only use our findings to indicate the diversity in work tasks, particularly informal work tasks, among medical secretaries. One relevant example of this diversity is the crosscutting role where the medical secretary serves as a Health Information Management 2005 ISSN Vol 34 No 4 Page 109

11 broker, the organisational glue or the connecting thread between other professional groups at the hospital. The medical secretary connects the other professionals by making sure the patient and care providers are in the same place at the same time with the required information to perform whatever task is required of them. In addition, they are the ones who manage follow-up on actions, making sure information or data are available when needed. However, in the debate about the future need for medical secretaries in hospitals when EHR is introduced, these important work tasks are rarely appreciated or discussed. Such lack of recognition may be due to the fact that this type of work is consumed immediately and cannot be stored like other work tasks (e.g., typing up dictation). Further, there seems to be a correlation between what can be labelled the informal work tasks and the work that cannot be stored, and between the formal work tasks and the work that can be stored. The interview method presented in this paper has made it possible to go beyond the tell me about your work approach. An investigation of work practices can target three levels of knowledge: what they think they do what they say they do what they actually do. The interview method in this case targets the first two levels of understanding. By asking questions about the knowledge, technique, and organisation behind the work tasks, a much more detailed picture of the work of medical secretaries was achieved. Compared with interviews where only the end result of the work is investigated, this method has, by its holistic approach, investigated the related artefacts, colleagues, formal and informal knowledge, and the organisational issues relevant to the secretaries roles. This has resulted in a sophisticated knowledge of the work tasks performed in very complex settings. At a later stage of each interview the participants were asked questions relating to the photographs they had previously taken. This enabled the interviewer to point at different people, files and artefacts on the photographs, triggering the memory of the informant to recall additional work tasks that could be added to the list. This method became very important when interviews took place in a setting different from the workplace. If photographs were taken over some time they could illustrate work that was not done every day and which may be difficult to identify through participant observation in one- or two-day visits to the worksite. The video observation of six informants revealed information about the third level, what they actually do. Thus the methodological requirement that empirical data be verified was satisfied. Random selection of participants from all hospitals across the entire country was not possible, and workshops were conducted to compensate for any regional bias that may have occurred. In these workshops, 32 medical secretaries, representing hospitals across the country, debated the accuracy of the interview results as a true representation of their professional tasks. The present participatory technology analysis approach, combined with the workshop verification of the content, is a useful amendment to the representative democratic approach where one medical secretary represents the profession in a working group with representatives of other professions and the management. A hospital or regional IT authority can deploy the knowledge of the medical secretaries to better understand the important need for an organisational change to go hand in hand with implementing a new EHR system. Furthermore, the results have been verified through study of all the available reports, articles and papers on medical secretaries work in Denmark. The results have been matched to the work tasks mentioned in those reports to further strengthen the validity of the data. Conclusion Successful change from paper to electronic documentation technology in hospitals signifies changes in the organisation of formal as well as informal work. This analysis of the work of hospital medical secretaries in Denmark gives an insight into a very complex work organisation. Both clinicians and nurses depend on medical secretaries in a number of ways, and therefore to reduce the number of secretaries because EHR systems are to be implemented needs very careful thinking, planning and discussion with other professions. Major reorganisation of existing work practices needs to be accomplished simultaneously with the introduction of EHR systems. Acknowledgement This empirical study was partly financed by the Danish Medical Secretaries Association, (see <www-dl-hk.dk>) and we are grateful for their cooperation and support throughout the study design and data collection. References Babbie, E. (1998). The practice of social research (eighth edition). Belmont CA, Wadsworth Publishing Company. Baskerville, R. & Wood-Harper, A. T. (1998). Diversity in information systems action research methods. European Journal of Information Systems 7(2): Bernard, H. R. (2002). Research methods in anthropology: qualitative and quantitative approaches (third edition). Walnut Creek CA, AltaMira Press. Bernstein, K., Bruun-Rasmussen, M., Vingtoft, S., Andersen, S. K. and Nohr, C. (2005). Modeling and implementing electronic health records in Denmark. International Journal of Medical Information Informatics 74(2-4): Bertelsen, P. (2005). Hvad laver lægesekretærerne når de ikke er sekretærer for lægen? Aalborg Universitet. ISBN: Available at: < LANDSFOR/DDLLAWWW.NSF/d179200c64bc35a6c c0043d5d4/91f524782f576077c12570eb004657a8/$file/ Rapporten_Ny%20Samlet.pdf> (accessed 18 January 2006). Health Information Management 2005 ISSN Vol 34 No 4 Page 110

12 Bertelsen, P., Madsen, I. and Hostrup, P. (2005). Participatory work flow analysis prior to implementation of EPR: a method to discover needs for change. Studies in Health Technology and Informatics 116(89-94): Checkland, P. and Holwell, S. (1998). Information, systems and information systems. Making sense of the field. London, John Wiley & Sons. Danish Ministry of the Interior and Health (2003). National IT Strategy for the Danish healthcare service. Available at: < National_IT_Strategy.pdf > (accessed 18 January 2006). Lippert, S. and Kverneland, A. (2003). The Danish National Health Informatics Strategy. Studies in Health Technology and Informatics 95(845-50): Müller, J. (2003). A conceptual framework for technology analysis. In: J. Kuada (Ed.). Culture and technological transformation in the south: transfer or local innovation? (first edition). Copenhagen, Samfundslitteraturen: Nøhr, C., Andersen, S. K., Vingtoft, S., Bernstein, K. and Bruun-Rasmussen, M. (2005). Development, implementation and diffusion of EHR systems in Denmark. International Journal of Medical Informatics 74(2-4): Pernille Bertelsen CandTechnSoc, PhD Department of Development and Planning Aalborg University Fibigerstraede Aalborg OE Denmark pernille@plan.aau.dk Christian Nøhr Department of Development and Planning Aalborg University Fibigerstraede Aalborg OE Denmark cn@v-chi.dk Health Information Management 2005 ISSN Vol 34 No 4 Page 111

13 Does the electronic patient record support the discharge process? A study on physicians use of clinical information systems during discharge of patients with coronary heart disease Inger Dybdahl Sørby and Øystein Nytrø Abstract This study has been performed in order to categorise and measure usage of different information sources and types in a well defined stage of clinical work. The underlying motivation is to improve computersupported presentation and retrieval of relevant information and to be able to evaluate the functionality of a future improved interface to the electronic patient record (EPR). By observing 52 discharge processes and categorising information types and sources, we have observed that the paper chart is used as a primary source of information about recent events and procedures, while the EPR is mostly used for retrieving background information and verification. Direct communication with other clinicians and the patient is also important during the discharge process. Results from an additional survey show that the physicians report greater use of the EPR than the result from the observational study. The study clearly indicates that there is a large potential for improved EPR systems that support the physicians in their work regarding discharge of patients, especially in the future planning part of the discharge. Keywords: Computerised medical record systems; patient discharge; discharge planning; observation This paper describes a study that was conducted in order to investigate to what extent clinical information systems in particular, the electronic patient record (EPR) system support clinicians in critical and information intensive tasks such as patient discharge. The study was performed at a Norwegian university hospital in The underlying motivation behind the study was to improve computer-supported presentation and retrieval of relevant information and to be able to evaluate the functionality of a future improved interface to the EPR. By studying how and where relevant information is represented in current clinical information systems, and the cost of retrieving that information, an impression can be gained of how the EPR system supports or does not support the physicians in a specific situation. This study is a step towards a more complete survey of information usage in several clinical situations, which is necessary when developing future situation-aware and user-friendly interfaces to clinical information systems. EPR systems and other electronic information systems are extensively used in Norwegian hospitals, although as yet only a few hospitals are paperless and paper based information systems are essential in most patient-centred work (Lærum, Ellingsen & Faxvaag 2001). The most obvious reasons for the limited use of EPR systems are that today s systems do not support the healthcare workers real needs because the systems are not always available, they are not integrated with other clinical systems, they do not support the clinical procedures performed by the different healthcare workers, and they are not context sensitive or adaptable to individual needs (Dahl, Sørby & Nytrø 2004; Sørby, Melby & Nytrø 2002). In order to be able to develop better EPR interfaces that really support physicians in their patient-centred work, it is necessary to investigate how current information systems are used. This is complicated and time-consuming, as every physician has his or her own working style or pattern, and each patient has an individual investigation and treatment plan based on their condition, previous illnesses and other important factors. However, at least two stages of a hospital stay are to a certain degree well defined and predictable; hospital admission and discharge. In this study, we focused on the discharge of patients in one particular hospital ward. The discharge process includes preparations and writing a preliminary discharge summary, the physician then conducts a discharge conversation with the patient, and finally writes or dictates a concluding discharge summary. The discharge summary serves as a basis for further treatment and follow-up of the patient when transferred from hospital specialist to primary care. The quality and content of discharge summaries have been discussed in several studies (Archbold et al. 1998; Solomon, Maxwell & Hopkins 1995; van Walraven & Rokosh, 1999; Wilson et al. 2001). However, few systematic evaluations to investigate to what extent EPR systems and other clinical information systems are used in the discharge process have been performed. The underlying research questions of the study were: 1. To what extent does the EPR system support the physicians in the discharge process? 2. Is the physicians work, in relation to the discharge of patients, characterised by regularity? 3. What areas of the discharge process can be improved by appropriate computer support? Our main hypothesis was that the EPR system does not satisfy the physicians information needs during the discharge process, and thus is not preferable to other information sources. We also presumed that the discharge process to a certain extent is characterised Health Information Management 2005 ISSN Vol 34 No 4 Page 112

14 by regularity. Our third hypothesis was that certain areas of the discharge process can be improved by appropriate computer support. Method The study was carried out in the Department of Cardiology at a large Norwegian university hospital (922 beds) during the period March to September The first part was an observational study of physicians work regarding discharge of patients, including preparations and writing a preliminary discharge summary, conducting discharge conversations with the patients, and dictating final discharge summaries. Every physician working in one particular ward (15 beds) during the study period participated in the observational study. This ward takes care of patients suffering from coronary heart disease. Most of them are undergoing extensive heart examinations such as percutaneous coronary intervention during their hospital stay. The patients who were followed in this study were mainly suffering from angina pectoris or heart failure, and the investigation of their heart disease typically led to hospital stays of three to five days. Several information systems, both paper based and electronic, are used in this ward. The most important paper based systems are the patient chart and the patient record. The patient chart is a binder that contains the most essential information regarding the current hospital stay of one or several patients in the ward, such as printouts of the most recent laboratory and test results, medication charts, and plans for further treatment (Ellingsen & Monteiro, 2003; Sørby, Melby & Nytrø 2002). The patient record contains old information about previous hospital stays. Other paper based systems are reference books such as Physician s Desk Reference (PDR) and ICD-10 codes overview, personal notes, and patient lists. The main electronic information systems include the EPR system, the Patient Administrative System (PAS), an integrated interface to a Picture Archiving and Communications System (PACS), Laboratory Information Systems (LIS), and various specialist systems. The observations were conducted by two medical students who performed non-participatory observations of physicians during the discharge process. The medical students were interested in medical informatics, but they had little or no prior research experience. The observational study was followed up by a survey distributed to every physician at the Department of Cardiology, totalling physicians. The survey was carried out in order to validate the results of the observational study. The survey is further explained below. Observational study The observational study (also described in Sørby et al. 2005) took place during the period of March to June The participants included two chief physicians with many years of experience in the ward, three medium experienced senior residents, three newly hired assistant residents, and one young house physician. Both male and female physicians were among the participants. A total of 52 discharge processes were studied, and the observers spent 100 hours in total in the hospital ward. The medical students followed one physician at a time, observing the physician s work concerning the discharge of patients. During the first week of the study, the two medical students observed 10 discharge processes together in order to coordinate their observation notes and to agree on a standard for the remaining observations. The observers used a notetaking form partly based on a form described in a textbook on task analysis for interface design (Hackos & Redish 1998: pp ). The form was changed twice during the study, based on the students experiences and feedback. The changes of the form only led to easier note-taking for the students, and had no effect on the content or the quality of the resulting observation forms. The first main part of the form included nine columns; one for each known/expected information source. The sources were paper based and electronic patient records, the patient chart, ICD-10 code overview, X-ray reports or pictures (including other picture results such as CT and MR), PAS (not integrated with the EPR), PDR, colleagues, and patient. Personal notes were an important additional information source for some physicians. During the observations, the appropriate table cells were marked X with an exception for the ICD-10 codes and the PDR which existed both on paper ( P ) and electronically ( E ). In addition, the columns marked Supplementary information could be used if several sources were used to find, control, verify, or check consistency of some information. In order to focus on patient-specific information, and eliminate regular use of static reference tools, we have omitted PDR and ICD-10 usage from the further analysis. The second main part of the form was used to describe the information that was retrieved from the selected information source. The last main part included a field for the observers personal comments or questions, as it is important to separate their own thoughts and interpretations from the objective observations noted in the Information column (Hackos & Redish 1998). The forms were filled in chronologically, from top to bottom. In addition to the notes taken by the observers, a few of the discharge processes were videotaped for further analysis. The contents of the 52 observation forms were coded into matrices (one matrix per observation) containing information sources versus information categories. In order to ensure consistency, one of the students performed the coding of all the observation forms. The information categories were adapted from a discharge summary template suggested by the Nor- Health Information Management 2005 ISSN Vol 34 No 4 Page 113

15 1: Distribution of total number of information elements retrieved from human, paper based, and electronic information sources Information sources Information categories Patient administrative information: biographical data, family/social history Past clinical information: allergies, previous illnesses, reason for referral Present clinical information: diagnosis and procedure, progress and treatment, findings and examination results Future clinical information: assessment, followup, medications, info to next of kin, medical certificate Human (Doctors, nurses, patient) Paper based (Record, chart, notes) Electronic (EPR, X-ray, PAS) Sum Other: unanswered tests, function level wegian Centre for Informatics in Health and Social Care (Ree 2002). During analysis of the results, most of the information categories were divided into four disjunctive groups of different temporal significance: Future clinical information: Information that pertains to plans and future patient care. This group contains the categories Assessment, Follow-up, Medications, Info to next of kin, and Medical certificate. Present clinical information: Information about current state and hospital treatment. This group contains the categories Diagnosis and procedure, Progress and treatment, Findings and Examination results. Past clinical information: Historic/permanent patient information. This group contains the categories Allergies, Previous illnesses, and Reason for referral. Patient administrative information: Information not related to the patient s current hospital stay: biographical data and family/social history. Survey In order to validate the findings from the observational study and to gain insight into potential differences between perceived and actual use of different information sources during the discharge process, a survey was distributed among the physicians at the Department of Cardiology shortly after the observations were finished. The survey consisted of a few questions on one page and a form similar to the form used in the coding of the observations. The questions were: 1. Position (Head Physician, Resident or Other). 2. Working experience (Number of years/months at department of cardiology, Number of years/months at any hospital). 3. Did you participate in the observational study? (No, Yes, 1-3 times or Yes, more than 3 times). 4. Do you have any general comments regarding the EPR system or other clinical information systems that are used at your workplace? 5. Do you use a determined procedure or sequence in your work regarding discharge of patients, and do you experience that the available information systems are supporting these tasks? 6. What sources do you use when you gather various types of information in relation to discharge of patients (including preparations, discharge conversations, and discharge summaries)? (Values: 0 [never] 1 [sometimes], 2 [often]. The values were plotted into tables consisting of information types versus information sources). Appendix A shows an example of a survey response (translated from Norwegian). The survey was distributed by to every physician at the department. The physicians could fill in and deliver the survey electronically or on paper. The survey was also presented and distributed at a morning meeting where the chief physician urged the other physicians to respond to the survey. The time usage for filling in the survey was estimated to be approximately minutes. After the first distribution of the survey, seven physicians responded. The survey was once again mentioned at the department s morning meeting and re-distributed by in September, which led to another nine answers. In total, the survey was distributed to between 30 and 40 physicians (the exact number of recipients is not known due to the rotation scheme of the residents and the house physicians, and hence corresponding variations in the lists at the time of the initial distribution and the redistribution and reminders). Results The results from the observational study are presented below according to information categories and sources, followed by the survey results. Health Information Management 2005 ISSN Vol 34 No 4 Page 114

16 4: 2: Survey Percentage results: distribution mean values of information of physicians elements use of retrieved patient from record, human, patient paper chart based and EPR and electronic for retrieving information future sources clinical information 3: Mean rank of first use per information source category The human information sources were mainly used as third choice (average rank: 2.36), often in order to verify data collected from other information sources. Observational study: information categories During the 52 discharge processes, a total of 735 information elements were identified, 688 of these were patient specific and belonged to one of the four information categories mentioned in above. Appendix B shows the total numbers of information types versus information sources. Box 1 shows the distribution of the information elements categorised in the three groups of information systems: human, paper based, and electronic. Box 2 shows the relative distribution of the information elements retrieved from the different information sources. Observational study: information sources The EPR was used as an information source in 27 of the 52 observed discharge situations, while the patient chart was used in 51 of 52 situations. The number of sources used in the discharge processes varied from one to nine (average: 3.77 sources), while the number of information elements varied from only two to 25. By analysing the sequences of first time usage of each information source type (i.e., paper based, electronic or human) for every observation, we were able to calculate mean values for each of the information source types. The resulting numbers are shown in Box 3. The results of this analysis show that paper based information systems were most often used as primary sources (average rank: 1.37), while the electronic sources were often used as secondary sources (average rank: 1.82), for example, when the physicians could not find the expected information in the available papers. To what extent the electronic information sources were used varied a lot, depending on the individual physicians. The younger physicians showed a tendency to use the EPR as a primary information source more often than the more experienced and older physicians. Survey results A total of 16 physicians responded to the survey; among them where eight head physicians and eight residents. Seven head physicians and eight residents completed the survey. One additional head physician responded but reported that he had not been involved in the discharge of patients lately and hence did not complete the survey. Eleven of the respondents had not participated in the observational study, one head physician had been observed between one and three times, and three of the residents had been observed more than three times. The residents had been working in the department between three months and two years, while their clinical experience varied from one year to 10 years. The head physicians experience in the specific department varied from five to 20 years. The answers to questions four and five of the survey varied to some extent. To summarise, the physicians were mainly satisfied with the EPR system when it works as intended. However, most of them found it cumbersome and time-consuming that different systems like PACS systems and the EPR are not integrated and hence they need to switch between several systems to get access to all relevant information about one patient. A few of the respondents reported that they did not use the system much because they already knew most of the important information and/or the nurses printed out the necessary information from the various information sources prior to the discharge process. Most of the physicians reported that to a certain degree they use a fixed procedure when discharging the patients, but only two of the respondents answered whether the available information systems support the discharge process. The answer to this question was respectively sometimes and yes. The results of question six were summarised in one table. Some of the findings from this question are shown in Boxes 4 and 5. Box 4 shows the mean values of the physicians responses regarding future clinical Health Information Management 2005 ISSN Vol 34 No 4 Page 115

17 4: Survey results: mean values of physicians use of patient record, patient chart and EPR for retrieving future clinical information 5: Survey results: mean values of physicians use of patient record, patient chart and EPR for retrieving patient administrative information information types while Box 5 shows the corresponding patient administrative information types. Many of the physicians completing the survey reported that they used the EPR system often (value 2) to find most of the relevant information types. Some also reported surprisingly little use of the patient chart. Discussion The study presented in this paper was performed in order to investigate how physicians, exemplified by cardiologists, use various information sources in the patient discharge process. All the patients in the study had been treated for similar heart diseases, such as angina pectoris or heart failure, but there were large variations in their previous medical histories and thus the volume of the patient records and, for instance, the extent of medication of each patient. Consequently, these factors had implications for the complexity of the physicians work regarding the discharge process. This is clearly shown in the individual observational notes, as they vary from only two information elements to 25. The results of the observational study show that Patient administrative information is almost constant, and has surprisingly low reliance upon electronic sources (12%); the main sources for this information type are the paper record and chart. The high percentage of human sources can be interpreted as need for validation of information (and patient identity). Historic patient information (Past clinical information) is mainly taken from paper sources, which is costly and difficult to find in old, and often large, records. The paper chart is obviously the most convenient source of Present clinical information, in addition to actually remembering the patient and the course of actions. Human sources are surprisingly little used, even if they are easily available. There is considerable variation in work style; we have seen an effect of physicians writing personal notes, later used in addition to chart and other tools. Much of the Future clinical information is about plans regarding future treatment and medication (involving colleagues and the patient), and the necessary assessment and decisions are often made during the discharge process. We have also seen that development of medication plans and prescriptions involve searches in many separate sources that frequently are inconsistent and incomplete (Rognstad & Straand, 2004). Due to the limited time during which the students performed the observations, not every observation included the entire discharge process. Most of the observations, however, included the physician s preparation for the discharge conversation, including writing a preliminary discharge summary. Most observations also included the discharge conversations, but due to time pressure of the physicians, the final discharge summaries were not always written immediately after the discharge conversations, and hence some observations do not include the writing and dictating of these summaries. However, this also means that some discharge summaries were written separately, some time after the patient left the hospital and possibly by a different physician from the one who performed the actual discharge of the patient. A few of these situations were also observed and are included in the analysis. The nine physicians that participated in the study varied in age, gender and experience, both as clinicians and in the specific ward. Every physician had his or her own established working pattern, and this varied a lot from individual to individual. In similar studies, prospective participants have been excluded if they had less than, for instance, one month of experience in the ward being studied (Brown, Borowitz & Novicoff 2004). In our study, however, no such exclusion criteria were used, as we regard physicians with little experience of particular interest since they are even more dependent on appropriate information systems than the more experienced physicians. Even though the number of physicians participating in the study is limited, the sample is fairly representative as it included every physician working in the specific ward during the observational study period. The quality of observational studies depends to a large extent on the observers; their knowledge of the Health Information Management 2005 ISSN Vol 34 No 4 Page 116

18 domain, and their ability to transform the observations into data and written information that can be analysed. The subjects being observed might also be affected by the presence of the observers. However, by using medical students as observers, the intention was to minimise this problem, as the physicians are used to being followed by students and house physicians. The note-taking form that was developed prior to and iterated during the study helped the students in structuring their observations, and at the same time it allowed for comments and questions that could be discussed later. The physicians completing the survey reported that they used the EPR often to find most information types. Some also reported little use of the patient chart. This corresponds poorly with the more than 50 observed discharge processes where the patient chart is used in approximately 50 percent of the enquiries and the EPR in only about 10 percent. The main reasons for this discrepancy might be related to the design of the survey and the physicians personal interpretations of the questions. This is also one of the reasons why using surveys as a means of evaluating the use of information systems is difficult. One example of this is when the value 2 ( often ) is used for the information source EPR; does this mean that the physician often used the EPR system to find information, or that a nurse had done it and printed the information, or that the physician thought that he or she has used a lot of time to find information in the EPR system? Another aspect that needs to be taken into consideration when comparing the results of the survey and the observational study is that only four of the survey respondents had participated in the observational study, and so it is only possible to use the survey as an additional source of information regarding the physicians use of the various clinical information systems. Despite the weaknesses in the methods used in the study and the dissimilarities between the observational study and the survey mentioned above, the analysis of more than 50 different discharge processes gives a good impression of how the various information sources are used in the discharge process at the Department of Cardiology. Even though this is a very limited study performed in only one hospital ward, this department is one of the most complex departments in the hospital, characterised by high activity and large variations in the patients illness patterns; it is thus expected to be fairly representative of Norwegian hospital departments. At the time of study, all main regional hospitals in Norway used the same EPR system product. The analysis of the results has so far not been used for more qualitative descriptions of the discharge process. However, the analysis clearly shows that the EPR and other clinical information systems are not integrated into the clinical practice, as they are still not preferred to paper based systems even if they are available and contain the needed information. This means that there is an obvious need for improved user interfaces to these systems that would make it easier for the physicians to retrieve and produce relevant information when preparing and performing the discharge of patients. Conclusion Our research hypotheses were to a large extent confirmed. The analysis of the observations shows that today s EPR system is not preferable to paper based information systems, as the current EPR system was not designed to support the discharge process in particular. The analysis also shows that the discharge process is predictable to a certain degree, but with large individual variations due to different working patterns of the various physicians, and also due to large variations in the patients illness histories. This was also confirmed by the survey results. We have seen examples of discharge processes where the physician has known the patient well and most information has been retrieved from the physician s memory, while other situations have required the physician to search for information in up to nine different information sources. A new and improved EPR system would be preferred by every physician in every discharge situation in order to provide the most recent and correct information; hence it has to be simple and easy to use but also flexible and adaptable in order to support the different working styles of individual users. Acknowledgments We would like to thank the staff at the Department of Cardiology at the University Hospital of Trondheim for their cooperation during the study. This research was financed by the strategic research area Medical Technology (< at NTNU and the NTNU Innovation Fund for Business and Industry (< idefondet/>). References Archbold, R., Laji, K., Suliman, A., Ranjadayalan, K., Hemingway, H. and Timmis, A. (1998). Evaluation of a computer-generated discharge summary for patients with acute coronary syndromes. British Journal of General Practice 48: Brown, P. J., Borowitz, S. M. and Novicoff, W. (2004). Information exchange in the NICU: what sources of patient data do physicians prefer to use? International Journal of Medical Informatics 764(1). In Press. Dahl, Y., Sørby, I. D. and Nytrø, Ø. (2004). Context in care - requirements for mobile context-aware patient charts. Proceedings of the MedInfo Ellingsen, G. & Monteiro, E. (2003). A patchwork planet: integration and cooperation in hospitals. Computer Supported Cooperative Work (CSCW) 12: Hackos, J. and Redish, J. C. (1998). User and task analysis for interface design. New York, John Wiley & Sons. Lærum, H., Ellingsen, G. and Faxvaag, A. (2001). Doctors' use of electronic medical records systems in hospitals: cross sectional survey. British Medical Journal 323 (7325): Health Information Management 2005 ISSN Vol 34 No 4 Page 117

19 Appendix A: Example of survey answer (translated from Norwegian) Health Information Management 2005 ISSN Vol 34 No 4 Page 118

20 Appendix B: Total distribution of information types versus information sources Information sources Information types Patient record EPR Patient chart ICD-10 (p) ICD-10 (e) X-ray PAS Biographical data Diagnosis and procedure Allergies Previous illnesses Family/social history Reason for referral Progress and treatment Unanswered tests Functional level Findings and ex. results Assessment Follow-up Medications Medical certificate Info. to next of kin Sum PDR (p) PDR (e) Colleagues Nurses Patient Notes ICD-10 (personal list) % Sum % Ree, A.O. (2002). Medical contents of discharge summaries - 'The good discharge summary' (in Norwegian). Trondheim, Norwegian Centre for Informatics in Health and Social Care. Rognstad, S. and Straand, J. (2004). Do general practitioners know what medication community nurses give their shared patients? (In Norwegian). Tidsskrift for den Norske Lægeforening 124(6): Solomon, J., Maxwell, R. and Hopkins, A. (1995). Content of a discharge summary for a medical ward: views of general practitioners and hospital doctors. The Journal of the Royal College of Physicians of London 29(4): Sørby, I. D., Melby, L. and Nytrø, Ø. (2002). Characterising cooperation in the ward: a framework for producing requirements to mobile electronic healthcare records. Proceedings of the Second International Conference on the Management of Healthcare and Medical Technology: The Hospital of The Future. Sørby, I. D., Nytrø, Ø., Tveit, A. and Vedvik, E. (2005). Physicians' use of clinical information systems in the discharge process: an observational study. Proceedings of the MIE Connecting Medical Informatics and Bio-Informatics. van Walraven, C. and Rokosh, E. (1999). What is necessary for high-quality discharge summaries? American Journal of Medical Quality. 14 (4): Wilson, S., Ruscoe, W., Chapman, M. and Miller, R. (2001). General practitioner-hospital communications: a review of discharge summaries. Journal of Quality in Clinical Practice. 21(4), Inger Dybdahl Sørby MSc Department of Computer and Information Science Norwegian University of Science and Technology NO-7491 Trondheim Norway inger.sorby@idi.ntnu.no Øystein Nytrø MSc, PhD Department of Computer and Information Science Norwegian University of Science and Technology NO-7491 Trondheim Norway Health Information Management 2005 ISSN Vol 34 No 4 Page 119

21 Factors influencing diffusion of electronic medical records: a case study in three healthcare institutions in Japan Otieno George Ochieng and Ryozo Hosoi Abstract This study examines the effect of three factors: information technology (IT) skills of healthcare workers, present status of computerisation in their organisations, and workers attitudes on the diffusion of electronic medical records (EMRs) in the healthcare environment. Data were obtained from a self-questionnaire distributed to 390 healthcare workers. The study finds that respondents need an expanded EMR capability to include decision support systems and reminder systems, and that diffusion of EMR is heavily influenced by attitudes of healthcare workers. However, targeted training of healthcare workers is needed to foster positive attitudes about EMR, and build confidence in the benefits of these systems. Keywords: Staff attitude; health personnel medical records; computerised medical record systems; medical informatics The potential benefits of using electronic medical records (EMR 1 ) over paper records in improving the quality of healthcare delivery have been extensively studied (Mekhjian et al. 2002; Pizzi et al. 2005; Fung et al. 2004). The EMR promises rapid access to health information, which leads to improved healthcare outcomes and more efficient use of resources; for example, the US Institute of Medicine has presented information technology (IT) based operations such as EMR as essential technology for healthcare in the 21st century (US Institute of Medicine 2001). The Institute of Medicine report emphasises the critical role played by IT in achieving patient safety, effectiveness, patient centredness, timeliness, efficiency and equity of healthcare. Although EMR has many advantages over paper records, its adoption in healthcare has been slow. A survey conducted by the Japan Hospital Association (JHA) (Japan Hospital Association 2001) reports that only 30% of hospitals in Japan have adopted EMR and cites the high cost of computerisation as the major barrier to EMR adoption. Other authors have also cited the high cost of healthcare computerisation as being the greatest impediment to EMR adoption (Leung et al. 2001; Johnston et al. 2001; Loomis et al. 2002; Lee 2000). There is, however, emerging evidence that even large healthcare institutions that possess the capacity to adopt EMR choose not to (Middleton et al. 2005; Japan Hospital Association 2001). In recognition of this, the Japanese Government recently issued a policy paper requiring larger healthcare institutions with 400 beds or more to implement EMR. While the government did not offer direct incentives to encourage adoption of EMR, the benefits are expected to arise out of faster filing of insurance claims and efficiency of patient care leading to retention of clients (patients). 1 Also referred to as Computerised Patient Records (CPR) or Electronic Health Records (EHR), the EMR is a comprehensive paperless patient chart. The following questions concerning the introduction of EMRs into the Japanese healthcare system have been addressed in this study: Could the observed reluctance by hospitals in adopting EMR be a result of other factors besides financial cost? What is the effect of human factors, particularly behavioural factors, on the adoption of EMR? To what extent do IT skills and the present level of computerisation affect the desire to adopt EMR? We hypothesised that the present status of computerisation and IT skills will enable healthcare workers to form unique beliefs towards use of computers in healthcare. The beliefs then influence the healthcare workers attitudes resulting in their decision to desire to use or not to use a computerised system. An understanding of these relationships can provide insights for effective EMR implementation and adoption into clinical practice. The specific aim of this study was to examine the effect of three factors, namely: present status of healthcare computerisation, healthcare workers IT skills, and attitudes towards computerisation on the diffusion of EMR. Methodology Research design A cross-sectional survey design was used to meet the objectives of this study. Data were collected between November 2003 and January Study environment and subjects The sample was derived from three Japanese healthcare institutions that are currently in different stages of implementing EMR. Two of the institutions were carefully selected to represent different sizes of hospitals (i.e., 400 bed category and <400 bed category). Health Information Management 2005 ISSN Vol 34 No 4 Page 120

22 1: Characteristics of participating institutions Institution Type Beds System type System Age Location Hospital 1 General hospital 556 EMR 1 10 years Tochigi Prefecture Hospital 2 Teaching hospital 206 CPOE 2 2 years Tochigi Prefecture Hospital 3 Health centre Nil CPOE & PHIS 3 10 years Kanagawa Prefecture 1: A more comprehensive electronic patient records including both an ordering system and clinical information. 2: A computerised physician order entry system for test ordering and result querying not integrated with clinical information systems. 3: A public health information system mainly for general public health use and follow-up of cases. The third institution was implementing a government sponsored e-health project (E-Japan) at the time of this study and therefore presented an excellent opportunity to examine factors that influence transition to EMR. Box 1 shows some characteristics of the institutions that participated in the survey. Hospital 1 ( Hosp 1 ) is a semi-governmental general hospital with a total of 592 healthcare workers. The hospital has an average daily bed occupancy of 85.5% and sees an average of 900 patients daily at the outpatient department (OPD). The institution is currently upgrading its EMR to a filmless state (all radiological images are captured and stored digitally using Picture Archival Communication Systems (PACS). Already, some neighbouring healthcare institutions are connected to the EMR through a network capable of transmitting digital images. Hospital 2 ( Hosp 2 ) is a private teaching hospital with about 400 healthcare workers. It has average daily bed occupancy of 78.6% and 749 patients visit the OPD daily. It is currently in the process of upgrading the ordering system to EMR. Hospital 3 ( Hosp 3 ) is a primary healthcare facility managed by local government. It employs a total of about 103 healthcare workers. The hospital screens healthy members of the community for chronic diseases such as diabetes, hypertension, high cholesterol levels, and obesity. In the year 2003, people were screened for various chronic diseases. Nine hundred and ninety-seven people were found to be at high risk of developing chronic diseases and were enrolled into a community health service program to monitor and improve their health status. All data relating to the program, dubbed New Health Promotion Fujisawa 21st Century (NHP21), are stored and maintained in a computerised system (Ogata, Onoda & Kobori 2004). The initial sampling plan targeted doctors, nurses and healthcare administrators only. However, we received reports from the staff overseeing the survey in respective hospitals that other healthcare workers, including physical therapists (PT), occupational therapists (OT), medical lab technologists (MLT), medical imaging technologists (MIT) and pharmacists (Pharm) were also interested in the survey. Questionnaires were distributed to a cross-sectional sample of 390 healthcare workers in total. Only healthcare workers who were full-time employees and had worked for a period of six months in the respective hospitals were included in the survey. The questionnaires were completed anonymously. Theoretical framework The Theory of Reasoned Action (TRA) described by Ajzen & Fishbein (1980) was used to inform this study. This theory describes how people develop beliefs, which ultimately determine their behaviour. A person develops beliefs based on observations, reflection and experiences (Davis, Bagozzi & Warshaw 1989; Hebert & Benbasat 1994). Behavioural intentions, such as desire to have computerised systems (in the case of this study), are the immediate antecedents to behaviour; the stronger a person s intention to perform a particular behaviour, the more successful they are expected to be (Ajzen & Fishbein, 1980). TRA has been used successfully to examine behaviours in technology adoption in information management sciences (Liker & Sindi, 1997). Rogers (1983) defined diffusion of innovation (such as EMR) as the process by which an innovation is communicated through certain channels over time among the members of a social system (e.g., an hospital), having two dimensions extent of diffusion and extent of infusion (Ash 1997a). As discussed by Ash, extent of diffusion is the spread in breadth of innovation. On the other hand, infusion is the spread in depth of innovation. In this study, we looked at the infusion dimension of EMR diffusion and we define EMR diffusion as the extent to which the full potential of EMR should be embedded within patient care processes. Four constructs were measured in this study. Desired status of computerisation, the dependent variable, was measured using dichotomous adoption (should it be computerised?). Three independent variables were also included: Present status of computerisation was also measured using dichotomous adoption (has it been computerised?). IT skills of healthcare workers were measured using self-reported knowledge of computer application in healthcare and frequency of use of common application programs, including , Internet browsers and word processors. Attitudes of healthcare workers were measured using their attitude towards the use of computers in patient care. Health Information Management 2005 ISSN Vol 34 No 4 Page 121

23 Instruments The survey questionnaire was designed following Leung et al. (2001) and Johnston et al. (2001). The survey consisted of five sections: Two items on IT skills with response options ranging from none/never to a great deal/always. A list of 16 functions in patient care where respondents were asked to check whether each had been computerised (present status) or whether they should be computerised (desired status) were included. A 10-item attitude scale assessing the healthcare workers attitude towards the use of computers in patient care, where response options were: strongly disagree, disagree, neutral, agree and strongly agree. An open-ended section that welcomed comments from respondents. One item asking the respondents to indicate their professions. A draft of the questionnaire was translated into Japanese, and pre-tested for clarity and relevance on a group of doctors and nurses familiar with EMR. The result of the pre-test was used to adjust the length and improve wording and layout of the questionnaire. Data collection In order to obtain permission from the institutions, a letter was sent to the president of each institution explaining the purpose of the study. The researchers visited the institution once permission was obtained. During the visits, the details of the study were discussed with the president and assigned staff from each hospital. An adequate number of questionnaires (as determined through consultation with each individual facility) was then provided to the staff overseeing the survey. All questionnaires were returned within six weeks. Analysis The responses from the completed questionnaires were entered into a computer using a double entry method to ensure accuracy. Data were cleaned and then analysed using SPSS v10. IT skills were measured on a four-point scale ranging from none/never (1) to a great deal/always (4). Level of computerisation was on a 3-point scale ranging from no (1), not sure (2) to yes (3) for computerised functions (present status) and desire for computerisation (desired status). Attitudes were measured on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). A copy of the questionnaire is available from the authors on request. The data were explored in three stages: description of the sample, comparison between professional groups, and comparison between healthcare institutions. Between-group differences were analysed using Kruskal-Wallis tests. We also used exploratory factor analysis to generate factor scores representing values of IT skills, present status, attitudes and desired 2: Distribution of all healthcare workers in the three hospitals according profession* Professional groups status for use in the multivariate analysis. Aggregate scores of the variables were computed by summing the product of the first principal component coefficient of the factor analysis with each corresponding respondents answer of each variable separately for each institution. The scores were standardised, then entered for analysis. Test of significance for multivariate analysis was decided based on the conventional alpha (P value) of 0.05 at 95% level of confidence. Results Percent of sample Percent of healthcare workers Doctor Nurse Administrator Others (PT, OT, MLT, Pharm, MIT) Total *Source: Data supplied by individual hospitals. The sample Hosp 1 had a response rate of 67.7% (129/190), Hosp 2 a response rate of 67% (67/100) and Hosp 3 99% (99/100) giving an overall response rate of 75.6% (295/390). Doctors produced a response rate of 29.4% (25/85), nurses a response rate of 91.2% (145/159), administrators a response rate of 76.3% (58/76) and the others (PT, OT, MLT, Pharm, MIT) category had a response rate of 97.1% (67/69). The respondents therefore comprised 25 (8.5%) doctors, 145 (49.2%) nurses, 58 (19.7%) administrators and 67 (22.7%) others. Since the survey was completed anonymously, we could not adequately compare the respondents and the non-respondents. As shown in Box 2, representation of staff based on professional groupings was somewhat similar. IT skills of healthcare workers (whole sample) Of the respondents, 138 (46.8%) reported that they sometimes use common computer application programs such as s, word processing and Internet browsers. A further 136 (46.1%) reported that they usually or always use these common application programs. When asked to assess their level of knowledge about computer application in clinical medicine, 174 (59.0%) reported their knowledge to be a little and 93 (31.5%) of the respondents reported their knowledge to be a moderate amount or a great deal. Attitudes of healthcare workers (whole sample) In response to the attitude statements, it was found that at least 50% of respondents agreed with the following statements: Health Information Management 2005 ISSN Vol 34 No 4 Page 122

24 3: Differences between the professional groups on five attitude statements Profession Doctors Nurses Administrators Others 1. Using computers means Disagree 9 (36.0%) 30 (20.7%) 21(36.2%) 30 (44.8%) longer consultation Neutral 9 (36.0%) 76 (52.4%) 31(53.4%) 26(38.8%) Agree 7 (28.0) 39 (26.9%) 6 (10.3%) 11(16.4%) 2. Computers interfere unduly Disagree 13 (52.0%) 44 (30.3%) 20 (34.5%) 35 (52.2%) with doctor-patient con- Neutral 8 (32.0%) 76 (52.4%) 27(46.6%) 28 (41.8%) sultation Agree 4 (16.0%) 25 (17.2%) 11(19.0%) 4 (6.0%) 3. Cost of computerisation is Disagree 2 (8.0%) 6 (4.1%) 6 (10.3%) 3 (4.5%) prohibitive Neutral 12 (48.0%) 89 (61.4%) 23 (39.7%) 21(31.3%) Agree 11(44.0%) 50 (34.5%) 29 (50.0%) 43 (64.2%) 4. Training of staff is of too Disagree 4 (16.0%) 9 (6.2%) 15 (25.9%) 12 (17.9%) much effort Neutral 6 (24.0%) 52 (35.9%) 24 (41.4%) 20 (29.9%) Agree 15 (60.0%) 84 (57.9%) 19 (32.8%) 35 (52.2%) 5. Electronic clinical records Disagree 0 (0.0%) 10 (6.9%) 7 (12.1%) 0 (0.0%) are of more value than paper Neutral 12 (48.0%) 77 (53.1% 23 (39.7%) 24 (35.8%) files Agree 13 (52.0%) 58 (40.0%) 28 (48.3%) 43 (64.2%) EMR is a necessity in clinical practice (83.1%). EMR can significantly improve the quality of patient care (61.1%). Computers are more beneficial for administrative than clinical functions (53.9%). Training staff is too much effort (51.9%). It was further noted that more staff remained neutral on the following statements than those who agreed or disagreed: Computers create a good impression with patients (55.6%). 2 Using EMR means longer consultation (48.1%). Computers interfere unduly with doctor-patient consultation (47.1%). Cost of computerisation is prohibitive (49.2%). Privacy issues have been dealt with adequately in EMR (55.9%). Comparisons between professional groups Differences between different professional groups were observed for five attitude statements. In most instances, where nurses tended to agree or remain neutral, the category of others tended to disagree or remain neutral, with doctors and administrators being in between. Box 3 shows items where differences were observed between professional groups. Overall, Others tended to be extremely positive compared with the rest of the professionals. As a whole, nurses tended to remain neutral to the attitude statements. Comparisons between the hospitals IT skills of healthcare workers Box 4 shows how the respondents rated their IT skills. Hospitals were similar in terms of their use of common computer application programs such as 2 Percentages refer to the respondents who remained neutral to the statements. 4: Respondents IT skills self-rating , Internet browsers and word processing. However, in response to the question What is your level of knowledge of computer applications in clinical practice? the hospitals differed. Hosp 1 had better knowledge of computer application in clinical practice. Less than one half (45.0%) of respondents in Hosp 1 reported their knowledge as moderate or great. The percentage of respondents that felt they had moderate to great knowledge of computer application in medicine was even lower in Hosp 2 (13.4%) and in Hosp 3 (26.3%). Present status of computerisation Box 5 presents results of analysis of the status of computerisation of clinical and administrative functions in each institution. The functions considered by the highest number of respondents to be computerised were scheduling of appointments in Hosp 1 (94.6%), writing prescriptions in Hosp 2 (70.1%) and registration of patients in Hosp 3 (87.9%). Health Information Management 2005 ISSN Vol 34 No 4 Page 123

25 5: Present status in the three hospitals 6: Desired status in the three hospitals Legend: Are the following functions computerised? Clinical functions 1. Writing patients summaries 2. Storage of patient information 3. Storage of patients' image files 4. Preparation of referral letters 5. Writing Prescriptions 6. Recording consultations 7. Accessing educational materials 8. Recall system (that reminds patients that they are due for routine tests) 9. Decision support system (to assist doctors to solve diagnostic or treatment problems) Administrative functions 10. Registration of patients 11. Billing and payments 12. Scheduling of appointments 13. Staff payroll 14. Stock and stores control 15. Finance management 16. Making insurance claims Legend: Should the following functions be computerised? Clinical functions 1. Writing patients summaries 2. Storage of patient information 3. Storage of patients' image files 4. Preparation of referral letters 5. Writing Prescriptions 6. Recording consultations 7. Accessing educational materials 8. Recall system (that reminds patients that they are due for routine tests) 9. Decision support system (to assist doctors to solve diagnostic or treatment problems) Administrative functions 10. Registration of patients 11. Billing and payments 12. Scheduling of appointments 13. Staff payroll 14. Stock and stores control 15. Finance management 16. Making insurance claims Using decision support was reported by the least number of respondents as being computerised in all the three hospitals. Overall, the present status score (defined as the average number of respondents indicating the functions have been computerised expressed as a percentage of the functions) was higher in Hosp 1 (76.6%) followed by Hosp 3 (71.6%). Hosp 2 had a present status score of 53.1%. Desired status of computerisation Box 6 summarises the proportion of the respondents who indicated that the functions in the survey should be computerised (desired status). The functions most respondents would want computerised were appointments scheduling in Hosp 1 (93.8%), patient information in Hosp 2 (89.6%) and registration of patients and billing and payments in Hosp 3 (94.9%). In all the three healthcare institutions, the function the least number of respondents would want computerised was using decision support with only 53.5% (Hosp 1), 53.7% (Hosp 2) and 65.7% (Hosp 3) of the respondents interviewed feeling that using decision support should be computerised. Even though there were individual item variations in terms of the desired level of computerisation (Box 6), there were remarkable similarities in the overall desired status score, obtained using similar calculations as for present status scores. Hosp 3 had desired status of computerisation of 99.1%, while Hosp 1 had 98.6% and Hosp 2 had 98.5%. Attitude Box 7 summarises the attitudes and perceptions of respondents in each institution about EMR. Generally, respondents tended to agree with positive statements on computerisation (items 1, 2, 3 and 9) and disagree with negative statements (items 4 and 5). However, a large majority of respondents across the institutions considered computers to be more beneficial for administrative functions than clinical functions (62.8% in Hosp 1; 59.7% in Hosp 2 and 38.4% in Hosp 3). Most respondents also agreed with the statement that cost of computerisation is too high. However, very few respondents agreed with the statement that privacy issues have been dealt with adequately (20.2% in Hosp 1; 14.9% in Hosp 2 and 33.3% in Hosp 3). As shown in Box 7, items 2, 5, 6, 7, 8, and 10 had differences between the hospitals. Respondents from Health Information Management 2005 ISSN Vol 34 No 4 Page 124

26 Hosp 3 tended to be more positive towards these items than respondents from the other two hospitals. 7: Attitudes of health professionals in the three hospitals Multivariate analysis Correlation analysis The results of correlation analysis for the institutions are summarised in Box 8. Pearson s correlation coefficients indicated low and sometimes nearly nonexistent correlations between the variables for each institution, except between present status and desired status in Hosp 1. However, attitude was the only variable that was significantly correlated with desired status in all three institutions. Research question Box 9a indicates the results of the regression analyses completed to answer the research question based on the TRA model. The variables entered were present status and IT skills against attitude and then attitude against desired status separately for each hospital. The results were then plotted to reflect a path model based on TRA (Box 9b). F tests were significant in all of the models except between present status and IT skills against attitudes in Hosp 2. As shown by Box 9, attitudes had a significant positive effect on desired status of computerisation in all three institutions. Discussion 1. EMR is a necessity in clinical practice 2. Computers creates good impression with patients 3. EMR can significantly improve quality of patient care 4. Using EMR means longer consultation 5. Computers interferes unduly with doctor-patient consultation 6. Computers are beneficial for administrative than clinical functions 7. Cost of computerisation is prohibitive 8. Training of staff is of too much effort. 9. Electronic clinical records are of more value than paper files. 10. Privacy issues have been dealt with adequately in EMR 8: Correlation results of the major variables Present status Major variables Desired status Attitude IT skills Hosp 1 Present status * 0.314* Desired status * Attitude * IT skills 1 Hosp 2 Present status Desired status * Attitude IT skills 1 Hosp 3 Present status Desired status * 0.220** Attitude * IT skills 1 * Correlation is significant at the 0.01 level (2-tailed) ** Correlation is significant at the 0.05 level (2-tailed) The purpose of this study was to examine the influence of three factors on the diffusion of EMR in the healthcare environment, namely: IT skills of healthcare workers, present status of computerisation, and attitudes of healthcare workers to computerisation. The analysis provided evidence from a sample of healthcare workers drawn from three healthcare institutions in Japan that are at various stages of computerisation. The results show that IT skills of healthcare workers are moderate. Given the IT infrastructure in Japan (International Telecommunication Union 2003), we doubt whether the results reflect the actual level of IT skills of the respondents. Formal examination and direct observation would have given a better picture of the level of IT skills of healthcare workers. Nevertheless, our findings are a good pointer to the fact that most healthcare workers already have computer skills. We discovered that most of the functions already computerised are administrative in nature. In particular, these functions are either clinical or general administrative (Simpson & Gordon 1998). Our findings confirm the trend that adoption of computer technology in healthcare is driven largely by a desire to streamline administrative functions (Japan Hospital Association 2001; Leung et al. 2001). Functions that purely support management of patient care such as reminder systems, decision support systems and accessing educational materials for patients have not been computerised to the same extent as the administrative ones. It was encouraging to note, however, that all the institutions have already computerised some of these functions. Health Information Management 2005 ISSN Vol 34 No 4 Page 125

27 9: Results of regressions completed to answer the research question There is, however, a gap between what respondents desire to be computerised and what actually is computerised. For instance, the functions reported by less than 30% of respondents as being currently computerised, are desired by over 50% of the respondents. In other words, there is a demand for expanded EMR capabilities. The results show that healthcare workers desire to have functions that support clinical management, such as recall (reminder) and decision support systems, computerised. Computerised recording of consultations and writing of patients summaries at the point of care make patient information immediately available for use by other healthcare workers. Electronic patient information should be integrated with computerised reminder and decision support systems as indicated by healthcare workers in this study, to enhance healthcare delivery. Evidence continues to support the effectiveness of a computerised reminder system and decision support in improving patient care. A recent meta-analysis of published articles between 1966 to 2003 revealed that automatic provision of decision support as part of clinical workflow, provision of reminder systems, and recommendations at the time and location of decision making are strong predictors of improved clinical practice (Kawamoto et al. 2005). Therefore, if these functions are computerised, healthcare workers are more likely to deliver safe and efficient healthcare. Those healthcare workers interviewed in the study have positive attitudes towards computerisation in healthcare. Contrary to other previous studies (Leung et al. 2003), the healthcare workers did not believe that use of computers interferes with the doctorpatient relationship, neither does it lengthen the consultation period. However, they agreed that the cost of computerisation, and the associated efforts needed to train healthcare staff, are prohibitive. The high cost of computerisation continues to be a major impediment to EMR adoption (Leung et al. 2003; Japan Hospital Association 2001). Nevertheless, these barriers will in all probability be overcome soon, as the costs of computer software and hardware are falling (Berndt, Dulberger & Rappaport 2000). At the same time, more healthcare workers are becoming computer literate through health informatics training. Health Information Management 2005 ISSN Vol 34 No 4 Page 126

28 This study also finds that privacy and confidentiality issues still remain major concerns of healthcare workers. Most respondents did not agree that privacy issues have been dealt with adequately. Although technologies that can be used to protect privacy and security of patient records already exist (Oslon, Peters & Stewart 1998; Kibbe & Bard 1997), respondents are not persuaded that these technologies can protect privacy and confidentiality of patient records. Consequently, privacy issues remain a major barrier to adoption of EMR. Even though privacy and security of patient data are no longer technological limitations (Leung et al. 2003), ensuring appropriate access is still a problem faced by many hospitals (Lederman 2005). Despite the high demand for EMR, respondents tended to be neutral to statements that portrayed computers negatively. Kirshbaum, in a survey of healthcare workers in two acute hospitals in the United Kingdom, also reported large numbers of respondents, particularly among nurses, who recorded uncertain options for attitude statements (Kirshbaum 2004). This trend may indicate that healthcare workers do not have faith in the effectiveness and efficiency of computers in supporting patient care, particularly the view that privacy and confidentiality have not been dealt with adequately in the computerised environment, and the belief that computers are more beneficial for administrative functions than clinical functions. These beliefs are likely to discourage use of computer systems in daily patient care. Results show that the level and extent of computerisation varied across the institutions. This was expected: the hospitals are administered under different organisations, thus have different organisational leadership, goals and objectives; factors which directly influence the uptake of a computerised system (Ash 1997b). Hosp 1 and Hosp 3 are partly supported by the government, consequently they showed higher computerisation status than Hosp 2, which is a private institution. Among the attitude statements that registered significant differences between the institutions, Hosp 3 reflected a more positive attitude towards computerisation in healthcare. Hosp 1 and 2 demonstrated somewhat similar attitudes. Unlike Hosp 3, Hosp 1 and 2 are acute hospitals, suggesting that the critical turnaround time needed in acute care services could be making healthcare workers less enthusiastic about the use of computers in clinical practice. Pearson s correlation coefficients obtained in this study were acceptably low, indicating weaker but significant relationships among the variables. In past diffusion studies, 0.82 has been considered high and 0.47 low (Kimberly & Evanisko 1981). In the present study, only one alpha was above 0.50 with the rest being below The models, based on TRA, had very low R square values, consistent with the low coefficients obtained at the bivariate (correlation) tests, but the F tests were significant in all the models except between IT skills and present status, and attitudes in Hosp 2. Compared with the other two hospitals, our model could not be explained in Hosp 2. This could be due to a number of reasons. First, Hosp 2 had the lowest level of computerisation and knowledge of computers application in clinical medicine. Secondly, unlike the other two hospitals, respondents from this hospital had used the system for about two years at the time of this survey, suggesting that the respondents could still be at the learning phase of the system. Individual models showed that IT skills had higher beta values than present status in the three hospitals, suggesting that IT skills are an important factor in influencing the attitudes of healthcare workers. The models between attitude and desired status were significant in the three hospitals; fitting well to our hypothesis that attitude will significantly influence adoption of EMR in clinical practice. The best model was obtained in Hosp 1 where present status and IT skills had a significant positive effect on attitudes of healthcare workers, which in turn had significant effect on the desired status of computerisation. This study has provided fresh insights into factors that influence diffusion of EMR in healthcare. Despite the low R square values, the failure of our model to be fully explained in Hosp 2, and the low beta values, the results suggest that IT skills and present status of EMR will influence the attitudes of healthcare workers, which in turn influences the adoption of EMR. To enhance diffusion the EMR capabilities therefore need to be expanded, particularly those that add value to patient care, such as decision support and recall systems. EMR expansion should, however, be preceded by extensive training of healthcare workers to enable them to foster positive attitudes towards computer use in clinical practice. The study has several limitations. First, the findings of this study reflect the opinion of respondents in three healthcare institutions in Japan and cannot be taken to be the view of all healthcare workers in Japan. Second, respondents were not randomly selected and their individual interest and enthusiasm for EMR could have influenced their responses. Third, the study reports data that are based on respondents recall, which is subject to error and bias. However, the high response rate achieved in this survey makes it adequate to report these exploratory findings in the context of the environments where the study was conducted. Although the results of this study may lack external validity, the study does provide a framework for future research. In particular, a natural expansion of this study would be to examine whether and how the attitudes of healthcare workers can actually be translated into work practice in a computerised environment. Implications and conclusion The findings of this study have important implications for the implementation of EMR. First, if EMR is to be Health Information Management 2005 ISSN Vol 34 No 4 Page 127

29 used more widely, the functions that support clinical management of patients should be incorporated in the implementation program. These functions will enable healthcare workers to realise the potential benefits of EMR, hence encouraging the continued use of these systems. Second, the overwhelming feeling among health workers that privacy and security of patient records have not been well addressed calls for more education and training to alleviate these fears. Targeted training geared towards educating these different groups of healthcare workers is needed to increase confidence in the use of EMR for healthcare delivery, and access to EMR systems must be limited to authorised individuals. Third, overcoming the cost of computerisation will require a concerted effort that will bring together various healthcare stakeholders (system developers, insurers, healthcare providers and government) into a partnership to share the cost. The government can offer incentives at various levels to encourage adoption of EMR; for example, the government can increase reimbursements to hospitals that adopt EMR, or offer subsidies for its adoption. EMR is important in promoting safe, patientcentred, efficient and effective healthcare. However, for these outcomes to be realised, targeted training and education of healthcare workers in order to foster positive attitudes about technology, and build confidence in the benefits of these systems should precede implementation of EMR. Acknowledgements We are deeply indebted to the following for their support in data collection: Mr. Akihiro Fukuda, Ms. Tamae Ogata and Mr. Kouji Ogawa. We thank Dr. Daisuke Koide, Dr. Laura T. Pizzi and Dr. Robert Davison for their comments on an early draft of this manuscript. Many thanks to Professor Shigekoto Kaihara, Head of Graduate School, International University of Health and Welfare, for providing administrative support and Professor Sumiko Yamamoto for guidance in the analysis of the data. We are grateful to two anonymous referees for their full and stimulating comments. References Ajzen, I. and Fishbein, M. (1980). Understanding attitudes and predicting social behaviour. Englewood Cliff, NJ, Prentice Hall. Ash, J.S. (1997a). Organizational factors that influence Information Technology Diffusion in Academic Health Sciences Centers, Journal of the American Medical Informatics Association 4: Ash, J.S. (1997b). Factors affecting the diffusion of the Computer-based Patient Record. Proceedings of the Annual Symposium of American Medical Informatics Association: Berndt, E.R., Dulberger, E.R. and Rappaport, N.J. (2000). Price and quality of desktop and mobile personal computers: a quarter century of history. Available at: < (accessed 5 Jan 2006). Davis, F.D., Bagozzi, R.P. and Warshaw, P.R. (1989). User acceptance of computer technology: a comparison of two theoretical models. Management Science 35(81): Fung, C.H., Woods, J.N., Asch, S.M., Glassman, P. and Doebbeling, B.N. (2004). Variation in implementation and use of computerised clinical reminders in an integrated healthcare system. American Journal of Managed Care 10(2): Hebert, M. and Benbasat, I. (1994). Adopting information technology in hospitals: the relationship between attitude/expectations and behaviour. Hospital & Health Service Administration 39(3): International Telecommunication Union (ITU) (2003). Digital Access Index: world s first global ICT ranking. Available at: < 30.html>. Japan Hospital Association (2001). A survey on status of computerization. Available at: < (accessed 25 April 2005). Johnston, J.M., Leung, G.M., Wong, J..F.K., Ho, L.M. and Fielding, R. (2001). Physicians attitude towards the computerisation of clinical practice in Hong Kong: a population study. International Journal of Medical Informatics 62: Kawamoto, K., Houihan, C.A., Balas, E.A. and Lobach, D.F. (2005). Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. British Medical Journal 330(7494): Kibbe, D. and Bard, M.R. (1997). How safe are computerised patient records? Family Practice Management 4(5): 34-6; 41-4, 46 passim. Kimberly, J. and Evanisko, M.J. (1981). Organizational innovation: the influence of individuals, organizations and contextual factors on hospital adoption of technology and administrative innovations. Academy of Management Journal 24: Kirshbaum, M.N. (2004). Are we ready for the electronic patient record? Attitude and perceptions of staff from two NHS trust hospitals, Health Informatics Journal 10(4): Lederman, R. (2005). Managing hospital databases: can large hospitals really protect patient data? Health Informatics Journal 11(3): Lee, F.W. (2000). Adoption of Electronic Medical Records as a technology innovation for ambulatory care at the Medical University of South Carolina. Topics in Health Information Management 21: Leung, G.M., Johnston, J.M., Ho, L.M., Wong, F.K. and Cameo, S.C. (2001). Computerisation of clinical practice in Hong Kong. International Journal of Medical Informatics 62: Leung, G.M., Yu, P.L.H., Wong, I.O.L., Johnston, J.M. and Tin, K.Y. (2003). Incentives and barriers that influence clinical computerisation in Hong Kong: A population-based physicians survey. Journal of the American Medical Informatics Association 10: Liker, J.K. and Sindi, A.A. (1997). User acceptance of expert systems: a test of the theory of reasoned action, Journal of Engineering and Technology Management 14(2): Loomis, G.A., Ries, J.S., Saywell, R.M. and Nitish, R.T. (2002). If electronic medical records are so great, why aren t family physicians using them? Journal of Family Practice 51: Mekhijian, H.S., Kumar, R.R., Kuehn, L., Bentley, T.D., Teater, P., Thomas, A., Payne, B. and Ahmad, A. (2002). Immediate benefits realized following implementation of physician order entry at an academic centre. Journal of the American Medical Informatics Association 9(5): Middleton, B., Hammond. W., Brenna, P.F. and Cooper, G.F. (2005). Accelerating US HER adoption: how to get there from here. Recommendation based on the 2004 ACMI Retreat. Journal of the American Medical Informatics Association 12: Health Information Management 2005 ISSN Vol 34 No 4 Page 128

30 Ogata. T., Onoda, A. and Kobori, Y. (2004). From the viewpoint of community health service: exercise therapy at community; promoting physical therapy activities in community. The Japanese Journal of Clinical Nutrition 104(5): Oslon, L.A., Peters, S.G. and Stewart, J.B. (1998). Security and confidentiality in an electronic medical record. Healthcare Information Management 12(1): Pizzi, L.T., Suh, D.C., Barone, J and Nash, D.B. (2005). Factors related to physicians adoption of electronic prescribing: results from a national survey, American Journal of Medical Quality 20: Rogers, E.M. (1983). Diffusion of innovations (third edition). New York, Free Press. Simpson, K. and Gordon, M. (1998). The anatomy of a clinical information system. British Medical Journal 316: US Institute of Medicine (2001). Crossing the quality chasm: a new health system for the 21st Century. Washington DC, National Academy Press. Otieno George Ochieng Health and Welfare Information System Health Services Management, Graduate School International University of Health and Welfare Kitakanemaru Ohtawara, Tochigi Japan Phone: Fax: gotiochiengs@yahoo.co.uk Ryozo Hosoi Professor, Graduate School International University of Health and Welfare Kitakanemaru Ohtawara, Tochigi Japan Phone: Fax: hosoi@iuhw.ac.jp Health Information Management 2005 ISSN Vol 34 No 4 Page 129

31 Multiple perspectives on the impact of electronic ordering on hospital organisational and communication processes Andrew Georgiou, Johanna Westbrook, Jeffrey Braithwaite and Rick Iedema Abstract Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations. Keywords: Evaluation studies; communication; hospital information systems; hospital administration There is a high level of interest, both across Australia and internationally, in the application of Electronic Ordering Systems (EOS) (First Consulting Group 2003; Victorian Government Department of Human Resources 2003; Humber 2004; Oacis Programme 2005). These systems provide healthcare professionals with the ability to enter orders directly into a computer and receive results back electronically (Lee et al. 1996; Doolan & Bates 2002; Kuperman & Gibson 2003; Ash, Gorman et al. 2004). The potential benefits of EOS include increased compliance with guidelines, optimisation of clinical time and enhanced communication processes (Sittig & Stead 1994; Lee et al. 1996; Overhage et al. 1997; Weiner et al. 1999; Murff & Kannry 2001; Doolan & Bates 2002; Hwang, Park & Bakken 2002; Mekhjian et al. 2002; Geiger & Derman 2003; Berger & Kichak 2004). These systems are core components of electronic health records, which, when linked with other systems, allow clinicians greater accessibility to information sources along with the provision of decision-support that can improve healthcare (Ash & Bates 2005). Despite the numerous potential advantages of electronic ordering systems, they are costly and difficult to implement (Institute for Clinical Systems Improvement 2004), and can change the way organisations function with significant other unpredicted consequences (Kaplan 1997a). Indeed, it is these difficulties that have contributed to tempering some of the initial enthusiasm for EOS (Ash et al. 2000; Ash, Sittig et al. 2004; Hendy et al. 2005). Healthcare is complex and the problems encountered with IT systems like EOS are not just technical but are often related to the combined social and technical dimensions involved in implementation (Wears & Berg 2005). This is particularly the case with EOS where the changeover to clinicians placing electronic orders significantly alters the order management procedure and impacts on the work flow of physicians, nurses and others in the hospital (Stablein et al. 2003), affecting many work processes across departments and hospitals. Theoretical considerations There has been much research and commentary on the difficulties and sometimes failures associated with large scale IT implementations, but as Lorenzi & Riley (1995) point out, the organisational impacts are often ignored and not well understood by health informatics professionals. Many of the early studies into this field tended to regard technology as an objective, external force and failed to comprehend that technology in organisations both shapes and is shaped by human action (Orlikowski 1992; Jones, Orlikowski & Munir 2004). Evaluation studies often explore the impact of new systems on measures of employee acceptance and system efficiency, ignoring the organisational and inter-departmental implications of systems (Aydin & Rice 1992). More recently, there has been an expansion in the number of studies of organisational issues (Massaro 1993a, 1993b; Kaplan 1997a, 1997b; Davidson & Chismar 1999; Dykstra 2002; Cheng et al. 2003; Callen & Creswick 2004). A cross-site qualitative study of an EOS system in the US by Ash and colleagues used observations, focus groups and interviews with clinical, administrative, and information technology staff. Among the major themes identified were organisational issues such as collaboration, culture and power (Ash et al. 2003). Other studies have emphasised the dynamic and fluid character of organisational issues (Berg 1999) that are often not easily understood nor immediately quantifiable (Lorenzi & Riley 1995). Taken as a whole, these studies point to tension between the isolating capacity of computer systems (e.g., fewer interpersonal interactions) on the one hand, and the potential to integrate the organisation through shared access to information on the other hand (Aydin & Rice 1992). These approaches to the evaluation of IT systems have demonstrated the value of interpretive methods aimed at understanding the context and processes of IT system implementation as a socio-technical construction of organisational practice (Walsham 1993; Kouroubali 2002; Iedema et al. 2004; Braithwaite et al. 2005). Utilising such tech- Health Information Management 2005 ISSN Vol 34 No 4 Page 130

32 niques can contribute to methods such as clinical trials that are designed to determine causal relationships between IT interventions and specific changes in clinical relationships (Georgiou et al. 2005; Westbrook et al. 2005). This paper reports on the results of a qualitative case study which investigated the perspectives and experiences of healthcare professionals (doctors, nurses, pathology laboratory personnel and IT managers) of the impact of EOS on hospital organisational and communication processes. Methods Design Qualitative interviews and focus groups were used to increase our understanding of the processes and phenomena involved in the electronic system; and in the case of focus groups, to utilise group dynamics to stimulate discussion and provide insight into our research question (Bowling 1997; Krueger 2000). The comparison of different perspectives was aimed at broadening the description of the system s effects on areas of organisation as well as enhancing the validity of the findings (Denzin 1978; Murphy et al. 1998; Murphy 2001). The research and its design were approved by the University of New South Wales Human Research Ethics Committee and the relevant Area Health Service Human Ethics Committee. Setting The study was carried out at a major Sydney teaching hospital that has a large pathology test processing facility. The EOS system was rolled out in the hospital over the period of a year beginning in November 2003 to include diagnostic test orders (linked to the existing test reporting system) along with medical imaging, diet and orders for porter services. Participants Opportunistic sampling techniques, motivated by constraints of time and accessibility (Quine 1998), were used to obtain a sample comprising doctors, nurses and laboratory personnel for interviews and participation in focus groups. All interviews and focus groups were carried out in a semi-structured format that asked participants to describe their expectations and experiences of the new EOS. Data collection Sixteen interviews (11 involving doctors, two with pathology managers/scientists and three with nurse unit managers) were conducted separately by two researchers. Interviews generally lasted between 15 and 30 minutes. In addition, three focus groups were held with separate groups of nurse unit managers (four participants), information service personnel (four participants), and pathology laboratory managers and hospital scientists (six participants). One researcher facilitated the focus groups that lasted between 40 and 70 minutes. These sessions were carried out during the period August September 2004, nine months after the implementation of the EOS system. All sessions were taped. This resulted in nine hours of taped recordings each transcribed by a person experienced in the task, amounting to 118 pages of text. Analysis We adopted concurrent analysis techniques, including regular field notes and memos kept by our two field researchers to record reflections about the meaning of the data, to help identify emerging themes, categories and possible relationships or patterns (Gifford 1998). These reflections assisted in the content analysis of the recorded interviews and focus group sessions (Glaser & Strauss 1967; Bowling 1997). Themes were then reported and discussed during the course of four formal sessions with six other members of the research team. Qualitative data analysis software, NVivo 2.0, was used to assist our analysis (Bazeley & Richards 2000). Results Impact of the electronic ordering system on the ordering process Under the old system, doctors were required to fill in a hand written request form for a pathology laboratory test which accompanied a patient specimen delivered to the laboratory for analysis. The role of the laboratory staff was to receive the specimen, check that the information matched the specimen and contained the relevant patient and doctor identifiers (including doctor s signature). This information was then entered into a hospital laboratory information system which generated a laboratory identification number for the specimen. The specimen then proceeded through the laboratory analysis stage before a test result was reported back to the clinician. The EOS replaced several steps in the old hand written process. Clinicians were now able to place an electronic test order directly from a computer (on the ward or elsewhere) which generated its own laboratory identification number. After an order was generated, clinicians printed a paper copy of it which then accompanied the specimen to the laboratory. When specimens were received in the laboratory it was no longer necessary to enter information into the pathology information system as it was already present. Laboratory staff were now only required to match the specimen identification to the information available in their system before they proceeded with the analysis. From the doctor s perspective this new process proved to be more efficient, but with scope for greater improvement. As one doctor explained: Health Information Management 2005 ISSN Vol 34 No 4 Page 131

33 We didn t think [that it was more efficient] initially, but that was part of the initial learning curve I think. But that has settled down now, so that the ordering process is more efficient, although there are some areas where it is still quite difficult. There are quite a number of steps to go through, which hopefully will be improved in the future. But now everybody knows the process to place these electronic orders. Many doctors remarked that the actual physical component of typing in an order can be more time consuming and clunky because of the multiple screens that sometimes need to be accessed. Most doctors commented that the new system is more reliable because it required less human involvement, and hence decreased the potential for error: When we had hand written forms for the next day, you're hand writing the form and then you ve got a courier who has to pick up the form from everybody, then it has to be delivered to the department, then someone has to pick up the form and type in the right test off your handwriting. So there are a few things there, which have been cut out, where you just go online, you order what you want and if you're thorough with what you want to order, usually there is not a problem. Nurses also remarked on the efficiency benefits of the new system, noting that once a record of an intervention has been made, it becomes immediately accessible across the hospital. One nurse noted how the new system provided ancillary healthcare professionals, such as physiotherapists and social workers, with an instant case history with requisite patient identifiers and results. Impact on work processes Doctors reported that the new system made them more accountable for the test ordering process because there was now a clear audit trail which identified exactly when a test was ordered, collected, processed and test results issued. According to one doctor, it allowed them to clearly ascertain where the responsibility for follow-up lay at any particular time. A number of doctors and nurses reported that the new system had a positive impact on communication channels within the hospital. This is because more professionals are able to access the system electronically making exchange of information easier and faster. One nurse unit manager commented that: We re better informed to give information to other clinical people. With patients, if people are enquiring about people, you can find them if they re not on your ward. That s quite good in tracking their history. That s improved. A doctor described how the introduction has forced a change in work processes: An especially good thing was that we used that as an opportunity to change other things, like the blood collection policy. It had been a long standing policy in this unit that one member of the team, usually a junior doctor, collected all of the blood at night and that had multiple issues for us, which we wanted to fix, such as one staff going from patient to patient and touching devices with the infection risk that goes with that... So along with the implementation of the electronic ordering, we've successfully been able to shepherd through a change in the collection policy, so that by and large each patient s nurse collects blood from their patient at night, and the ordering now is electronic and online and done by the night doctor. Impact on organisational processes While many clinicians spoke highly of the benefits of the new system, pathology laboratory managers and scientists expressed concerns about the changes in responsibility. They reported that the implementation process was badly coordinated and paid insufficient attention to their needs and expectations. In the past, the pathology laboratory performed data quality checks on incoming hand written requests. They were required to identify and rectify any inconsistencies in the request particularly on occasions when the request form and the specimen did not match, or did not arrive together. Often this involved providing physicians with advice about the tests ordered. The new system may have streamlined the laboratory test reception process, but it had also reduced some aspects of their monitoring role and caused some initial confusion about how to follow up any potential discrepancies. As one senior pathology manager suggested: There s no interpretation from the staff, that s what it comes down to. So we re not interpreting what tests have been requested and what the clinical significance is. All the staff are doing now is bringing in orders into the laboratory. The issue of inter-departmental functioning also featured in discussions with clinicians. One doctor noted that a possible downside of the new system was that it has reduced inter-departmental communication: There's less need for different departments to talk to each other, which has never been an official sort of thing. If you know the person at the other end that you're dealing with, there's much less capacity for irritation. So I think it probably has reinforced people working in... I think silos is a pretty common buzz-word for it. Discussion The results of this study point to three distinct areas where the new EOS affected organisational processes and relationships: (i) information management; (ii) Health Information Management 2005 ISSN Vol 34 No 4 Page 132

34 Organisational impact of electronic ordering system communication and (iii) work relations (see Box 1). Within this framework information management refers to the actual performance and management of the ordering process; communication refers to areas such as interaction among staff and issues of responsibility and accountability involved in the actual fulfilment of the ordering process; and work relations includes issues of inter-department relationships, and the roles of healthcare professionals. The Box presents the themes as an interlinked diagram implying that the relationship between the three categories is strongly interconnected and reflexive rather than linear. Hence the implementation of new information management systems has the potential to both affect and be affected by existing communication processes and work relationships (Orlikowski 1992; Berg, Aarts & van der Lei 2003; Jones, Orlikowski & Munir 2004; Wears & Berg 2005). This point is exemplified by the descriptions offered by pathology scientists and managers. They felt that their previously existing work relationships and communication channels had not been taken into account by the information management processes introduced by the new system. Conversely, doctors and hospital information service staff explained that the new system had contributed to greater levels of accountability and reliability and provided them with the opportunity to re-engineer and improve some of their work processes. Our data also describe the potential of the new system to impose changes in the organisational relationships both within and between departments. Doctors and nurses described the change in their workflows and how this had affected communication with other departments. As one doctor noted it had the potential to lead to silos. This finding is consistent with other research in this area, which has pointed to the potential of electronic ordering to cause shifts in the power distributions between staff and departments (Ash et al. 2003) or even to foster an us versus them approach (Ash & Bates 2005), particularly among departments which lose ownership of data entry functions as a consequence of new order entry systems (Aydin 1994). The interviews and focus groups in this study were carried out nine months after the implementation of the new electronic ordering system began. Although this retrospective approach encouraged participants in the study to reflect on their experiences and views about the new system, its disadvantage is that it can mean that some factors seen as important in the formative period of the implementation are now overlooked or dismissed through hindsight. This study has incorporated multiple perspectives about the new system, and sought wherever possible to present differing views. The generalisability of its findings are restricted by the limited size of the sample and the circumstances peculiar to the hospital studied. Nevertheless, the findings do have a level of transferability to other settings and provide a useful overview of the potential organisational and communication issues that hospitals are likely to confront with electronic ordering. Conclusion The participants in this study pointed to a number of factors which had shaped the impact of the new system. These included: (i) the increased monitoring capacity and accountability created by the new system, allowing clinicians to monitor and better communicate with each other; (ii) flexibility of the system that made it easier for clinicians to enter and transfer information; and (iii) preparedness and collaboration between and within departments that played a key part in how staff perceived the system, with pathology laboratory staff reporting levels of disenfranchisement and clinical staff welcoming the chance to re-engineer some work processes. These findings can be used to help healthcare managers anticipate and deal with the complex variety of issues they are likely to confront. They also point to the importance of ensuring a robust interdepartmental collaboration in the planning and implementation process. This research shows that qualitative study designs can play a useful role in identifying factors that may trigger change in organisational and communication processes (Georgiou et al. 2005). They also have the potential to supplement and inform findings derived from other studies employing other methods (Westbrook et al. 2005) as part of multi-method approaches to ICT research (Mingers 2004). Acknowledgments This study is part of an Australian Research Council Linkage Grant funded project to evaluate the impact of information and communication technologies on organisational processes and outcomes using a multidisciplinary, multi-method approach. The partners in the study are the Centre for Health Informatics and Centre for Clinical Governance Research in Health from the University of New South Wales and the New South Wales Health Department. References Ash, J. S. and Bates, D. W. (2005). Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. 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36 Mekhjian, H. S., Kumar, R. R., Kuehn, L., Bentley, T. D., Teater, P., Thomas, A., Payne, B. and Ahmad, A. (2002). Immediate benefits realized following implementation of physician order entry at an academic medical center. Journal of the American Medical Informatics Association 9(5): Mingers, J. (2004). Re-establishing the real: critical realism and information systems. In: Social Theory and Philosophy for Information Systems. J. Mingers and L. Willcocks. (Eds). Chichester, John Wiley and Sons Ltd. Murff, H. J. and Kannry, J. (2001). Physician satisfaction with two order entry systems. Journal of the American Medical Informatics Association 8(5): Murphy, E. (2001). Micro-level qualitative research. In: Studying the organisation and delivery of health services; Research methods. N. Fulop, P. Allen, A. Clarke and N. Black (Eds). London, Routledge. Murphy, E., Dingwall, R., Greatbatch, D., Parker, S. and Watson, P. (1998). Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment 2(16): Oacis programme (2005). Available at: < sa.gov.au/oacisprogramme/desktopdefault.aspx> (accessed 25 November 2005). Orlikowski, W. (1992). The duality of technology: rethinking the concept of technology in organizations. Organization Science 3(3): Overhage, J. M., Tierney, W. M., Zhou, X.-H. and McDonald, C. J. (1997). A randomized trial of corollary orders to prevent errors of omission. Journal of the American Medical Informatics Association 4(5): Quine, S. (1998). Sampling in non-numerical research. In: Handbook of Public Health Methods. C. Kerr, R. Taylor and G. Heard. (Eds). Sydney, McGraw Hill Australia. Sittig, D. and Stead, W. (1994). Computer-based physician order entry: the state of the art. Journal of the American Medical Informatics Association 1(2): Stablein, D., Welebob, E., Johnson, E., Metzger, J., Burgess, R. and Classen, D. C. (2003). Understanding hospital readiness for computerized physician order entry. Joint Commission Journal on Quality and Safety 29(7): Victorian Government Department of Human Resources (2003). HealthSmart - strategy for the modernisation and replacement of information technology. Available at: <www. health.vic.gov.au/healthsmart/documents/healthsmartstrategy.pdf> (accessed May 2004). Walsham, G. (1993). Interpreting information systems in organizations. Chichester, John Wiley and Sons Ltd. Wears, R. L. and Berg, M. (2005). Computer technology and clinical work; still waiting for Godot. Journal of the American Medical Association 293(10): Weiner, M., Gress, T., Thiemann, D. R., Jenckes, M., Reel, S. L., Mandell, S. F. and Bass, E. B. (1999). Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system. Journal of the American Medical Informatics Association 6(3): Westbrook, J., Georgiou, A., Dimos, A. and Germanos, T. (2005). The effects of IT on the laboratory: a quantitative and qualitative study of the impact of a computerized pathology order entry system. Australasian Association of Clinical Biochemists 43rd Annual Scientific Conference. October 2005, Sydney. Invited presentation and published abstract, Sydney, AACB. Andrew Georgiou MSc, DipArts, BA, AFCHSE Senior Research Fellow Centre for Health Informatics University of New South Wales Sydney NSW 2052 Australia Phone: Fax: a.georgiou@unsw.edu.au Johanna Westbrook PhD, MHA, GradDipAppEpid, BAppSc(MRA) Deputy Director, Centre for Health Informatics University of New South Wales Sydney NSW 2052 Australia Phone: Fax: j.westbrook@unsw.edu.au Jeffrey Braithwaite PhD, MBA, MIR(Hons I), DipLR, BA Director, Centre for Clinical Governance Research in Health University of New South Wales Sydney NSW 2052 Australia Phone: Fax: j.braithwaite@unsw.edu.au Rick Iedema PhD, MA, BA Deputy Director Centre for Clinical Governance Research in Health University of New South Wales Sydney NSW 2052 Australia Phone: Fax: r.iedema@unsw.edu.au Health Information Management 2005 ISSN Vol 34 No 4 Page 135

37 A contemporary case study illustrating the integration of health information technologies into the organisation and clinical practice of radiation oncology Andrew A Miller and Aaron K Phillips Abstract The development of software in radiation oncology departments has seen the increase in capability from the Record and Verify software focused on patient safety to a fully-fledged Oncology Information System (OIS). This paper reports on the medical aspects of the implementation of a modern Oncology Information System (IMPAC MultiAccess, also known as the Siemens LANTIS ) in a New Zealand hospital oncology department. The department was successful in translating paper procedures into electronic procedures, and the report focuses on the changes in approach to organisation and data use that occurred. The difficulties that were faced, which included procedural re-design, management of change, removal of paper, implementation cost, integration with the HIS, quality assurance and datasets, are highlighted along with the local solutions developed to overcome these problems. Keywords: Radiation oncology; computerised medical record systems; database management systems; systems integration; professional practice; organisational efficiency Modern radiation oncology departments use one of a number of sophisticated software suites that can be described as Oncology Information Systems (OIS). The OIS was originally developed from the Record and Verify software of the 1980s. The Record and Verify software was developed to warn of human error in setting treatment fields on a radiation machine, and continues to do so. A relational database contains the intended settings for each field used on an individual patient, with hardware intercepts on the radiation machine delivering the actual settings for display and software comparison. Staff are notified of discrepancies which they can alter on the machine or override, before starting treatment. The parameters used when delivering the radiation were then written to the database and locked in. More recently, this functionality has been extended to use the intended parameter settings to set up the machine and step through treatment delivery much like the operation of a *.bat file. The inclusion of treatment scheduling was a natural extension of the relational database because of the unusual requirements of the radiation oncology department. At the time, no other medical scheduling software was able to book two to 30 consecutive days of treatment, which is a unique requirement within medical practice. In 1999, due to the Y2K issue, the radiation therapy department in a New Zealand hospital was required to upgrade to a Y2K-compatible Record and Verify system. An investigation of the functional abilities of the available software indicated that while all of the available OISs possessed the ability to manage demographics, documents, charges, resource management, disease parameter specification, chemotherapy drug delivery and scheduling, at the time the usability of the different offerings were substantially different. The major selection criteria for the medical staff included the ability of the system to function as a clinical disease database, and the ability of the system to replace current paper procedures. At the time there were no departments outside of the United States, and only one inside, that had implemented any of the software choices to achieve either of the criteria above. After consideration of the options and the functional specification of an acceptable system (see Appendix), we elected to purchase the IMPAC MultiAccess Oncology Information System, although this was marketed and sold by Siemens Medical Solutions as the LANTIS Oncology Management System under a licensing agreement. Radiation therapy aspects of this department's implementation have been described previously. This account examines the re-organisation from the clinician's viewpoint (Phillips et al. 2002). Installation and implementation of the program When purchasers of a new software system have little experience of the product and no access to mentor sites, the understanding of the potential of a system can sometimes be rudimentary, based more on sales talk than on fact. A number of events altered and matured the implementation direction undertaken by lead staff in this program. While the usual medical paradigm for data collection revolves around the data manager role, managers refused to undertake the additional expense of employing staff as data managers. As a result, a different medical paradigm was required, which was based on physician entry of data as part of routine clinical work. Paradoxically, this proved to be a major boon to the implementation strategy. Soon after installation of the OIS, lead medical and radiation ther- Health Information Management 2005 ISSN Vol 34 No 4 Page 136

38 apy staff were able to investigate the system more fully and to better judge its potential. It became clear within a few months that not only could the system be easily implemented as an electronic medical record, but that it had been designed as such. The lead staff, consisting of the Clinical Director (a radiation oncologist [AM]), the Chief Radiation Therapist and an interested and IT-capable Radiation Therapist (AP), therefore formed a project team to utilise the process design within the software to significantly alter routine departmental functioning. The project team formulated six major goals for the project. These are discussed in the following sections. Transition from a paper based clinical system to an electronic medical record On discovering the capabilities of the software, we decided to produce an electronic medical record which contained all the information which was currently contained in clinic notes, with the additions required to comply with national legislative requirements. We consciously resisted the urge to realise the full potential for infinite data collection during the initial implementation. Such capability is often met enthusiastically with a plethora of new items, resulting in greatly increased workloads and subsequent rapid diminution in enthusiasm for the entire process. The particular product purchased included an option for an infinitely expansible table for clinical and non-clinical assessments. The project team were very careful to reproduce only those items which were currently collected to replace current practice. Establishment of electronic data collection processes that exceed the accuracy of current manual processes Several features of our implementation made achieving this aim easier than expected. First, data required to undertake a clinical process (e.g., to decide whether radiation therapy is beneficial, an oncologist needs to know the patient's cancer diagnosis and stage) was assigned to the group that first met the data within a decision making process. This paradigm was called data ownership. Second, the data owner was required to enter the data as soon as it became available, and any consequent decisions made were recorded immediately. This action also reduced the unnecessary duplication of data as the data repository was always up to date. Third, progression of the patient through the system was dependent on the completion of this data. In accepting a patient for radiotherapy, bookings for planning or treatment could not be made until downstream staff could see the decision data which needed to be entered in the appropriate place. Incomplete data forced a block to a patient's progress, and a notification to the clinician of the incomplete entry. Fourth, the collected data was subject to routine quality assurance (QA), and the data owners were responsible for the QA. Routine reports interrogated the database to discover where mandatory data was blank or was inconsistent. This performance review was designed to be educational rather than punitive, so that routine performance could be improved. These reports were unable to ensure accuracy, only coverage and consistency with accepted rules (e.g., a T1 breast cancer will be 2.0 cm or smaller). Improve and extend access to the collected electronic clinical information from all sites where staff worked The department serviced a large peripheral community up to 420 km distant, making up more than 60% of patient workload. The project team identified the need to be able to carry all changes and improvements into the peripheral clinics as a major challenge. On reflection, this was easily achieved with a close dialogue with IT staff, but required substantial involvement and planning within that department. With the external access being achieved through VPN use, oncologists had access to the clinical information in other clinics, at home and even overseas. Reduction in workloads by reducing duplication in information collection and building in quality assurance Within the paper procedures, medical staff found themselves providing the same data to multiple staff, even without considering the requirement to identify each sheet of paper with the patient's demographic data. The project team initially utilised the notion that the consolidation of processes into a single repository would reduce duplication. We did not appreciate until later the additional improvements that resulted from a change in the ordering of processes so that staff could always work with all the necessary information already available. This step included the linking of Hospital Information System (HIS) with the OIS to provide demographic data from the New Zealand National Patient Database. A diagrammatic representation of this stepwise accumulation of data is shown in Box 1. The graphic clearly demonstrates that as data is accumulated it is available for use and analysis before the patient has completed treatment. Ease the achievement of certification by aligning our processes with the requirements of the hospital and New Zealand accreditation bodies The move from paper to electronic procedures permitted a redesign of systems to match the requirements of the modern era. To achieve this, the project team took the view at the start of the implementation that there were prerequisite and necessary processes that were already expressed in finite idiosyncratic paper procedures. Health Information Management 2005 ISSN Vol 34 No 4 Page 137

39 1: A graphical description of the planned cumulation of electronic data to demonstrate its clinical usefulness when accumulated at first revelation Health Information Management 2005 ISSN Vol 34 No 4 Page 138

40 Rather than translating procedures, we returned to the underlying processes and looking at the modern requirements, we rebuilt a new set of finite idiosyncratic electronic procedures. We felt no compulsion to make our electronic procedures mirror or resemble our past paper procedures, only to complete the same processes more safely and more easily. Once processes were defined, staff were then assigned responsibility and the procedure set also designed. Processes were designed with an input and an output. By design the output of the first process became the input for the second process, and served as the mechanism to hand-off responsibility downstream. All processes included a task list in the Quality Check List section (QCL), which included entries pertaining to the process, as well as items for the next process. In this way, the formal output of the process (e.g., the clerical person responsible for registration made an electronic appointment) accompanied a second and independent hand-off (e.g., a QCL item to ask for the oncologist to complete their data from the consultation process). An individual could have responsibility for a number of processes. Development of a database of sufficient quality to permit audit and reporting of both clinical and statistical information automatically For the medical member of the project team, the major concerns were to reduce workload in the short term through elimination of repetition, and in the long term to have a prospective, accurate, reportable database of clinical information from which treatment outcome and improvement could be demonstrated easily and repeatedly. Indeed the project team subsequently discovered that a plethora of statistical information was also easily available. The quality assurance for coverage and consistency meant that the data could be used to accurately determine answers for issues of resourcing, performance and quality. In order to undertake implementation of a new procedure, project teams should investigate their current procedures that define necessary processes, looking particularly for individual requirements. The most useful points to identify include those which require quality assurance, and those interfaces which involve hand off to other professionals or parts of the system. The process of defining processes and procedures should be undertaken in view of a detailed knowledge of OIS and knowledge of its inherent process engineering with defined and useful functions. The purpose of defining current processes is to ensure that the implementation into new electronic procedures is comprehensive, rather than to use the audit as a template to make the OIS fit the current paper based organisation. An illustration of our early process redesign is shown in Box 2. Changes in administrative processes The paper registration process involved pre-2000 is described below: Upon receipt of a referral letter, the patient's demographic data was manually transferred from the HIS into a stand-alone database. The disease type was entered in the stand-alone database. This field was a text field unrelated to any internationally accepted coding classification. As a result, a patient with lung cancer might appear in the database as non-small cell lung cancer, NSCLC, lung cancer, right lung cancer, cancer R lung, NSCLC R, right lung, Stage IIIA lung, 3A lung, and so on, through the entire permutation of terms. It was therefore impossible to identify reliably those with lung cancer. The database included no fields for staging, therapy, or outcomes. A cardboard file was printed from the database information. Names of consultants and general practitioners involved were written on a form. A front page which was designed as a summary sheet detailing the major diagnoses and treatments was inserted. This was not standardised, rarely filled out and never quality assured. The referral letter, imaging, biochemistry and histopathology reports were filed in appropriately marked sections. The patient's appointment along with contact details were entered into a large appointment book in pencil (to facilitate changes and alterations) and into the HIS appointments repository. The new file was filed in a large storage area. The day before clinic attendance, clerical staff collated the required files from storage. Dead patients had their date of death written on the cover and were culled from the storage area once a year. The project team redesigned this system to utilise the electronic functionality available. The redesign of the process of registration is shown in diagrammatic form in Box 3, and was fashioned using a black box concept where the inputs and outputs are visible and act as hand-offs to other professionals and processes. The 'hidden' interior of the box forms the component that needs to be undertaken and QA'ed by the group involved. This early design demonstrates that there are 'quick hits' that can be achieved to improve workload very quickly, while other improvements are dependent on other staff (coordination with nursing over workload division, IT staff linking the HIS and OIS) and other software options (entering typed and scanned notes into the document manager option of the OIS called 'Transcriber'). In examining the altered systems, the reader should consider whether the resultant procedures are likely to be more work, and more likely to miss vital information. Using the same categories as above, the final process after 2003 is defined as follows. 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41 2: An early phase of redesign of deparmental processes demonstrating where paper processes persist and where processes are connected electronically Health Information Management 2005 ISSN Vol 34 No 4 Page 140

42 Step 1 Upon receipt of a referral letter, clerical staff indicate in the HIS that the patient is now a patient of an oncologist. This triggers the download of the HIS demographic dataset to the OIS. Within the HIS a flag was set so that any change in the National Patient Dataset would occasion another demographic download. The National Patient Dataset also included a Date of Death when downloaded from the New Zealand Department of Births, Deaths and Marriages who routinely feed their death data to the National Patient Dataset. Hence Date of Death notification was automatic. As a corollary of this process, clerical staff are required to make changes to demographic data in the HIS, not the OIS. 3: Procedural specification of the process or registration, including the clerical process and responsibilities, relevant quality assurance and data issues within the OIS Step 2 The clerical staff open the patient record in the OIS and select the names of involved consultants and general practitioners from the drop-down lists of doctors within the software. Step 3 The process called for the referral letter, imaging, biochemistry and histopathology reports to be scanned and saved as images or document files, labelled appropriately (e.g., Histopathology report ). Numerical laboratory data, such as haemoglobin level or PSA level, can be manually entered or automatically downloaded via an HL7 gateway. Other third party products also permit the transfer of text reports (imaging and histopathology reports) directly into the notes section with the appropriate designation. Within the New Zealand setting, the majority of general practitioners were already operating electronic records and receiving HL7 feeds from laboratories. The project team realised quite early that our group were very poor users of the immense sea of electronic data already available. Step 4 When the patient is selected, an electronic appointment is made, and the patient is notified. The OIS permits clinics to be designated as New Patients and for the system to default the appointment to the next available new patient appointment. No individual timetables were printed. The clerical staff printed one master list each day in case of system failure. Step 5 The clerical staff could enter a disease category within the demographic data but this is not necessary at this point, as the oncologist enters the definitive disease diagnosis and stage according to ICD-0 coding immediately after consulting with the patient. The mandatory clerical entries in the demographic information are updated as part of the routine QA process for demographic data. Every Monday clerical staff compile an electronic report that highlights entries where mandatory data is missing or inadequate. The initial database had two independent fields for diagnosis, although upgraded versions saw these consolidated into a single field. Moving to a paperless record in an integrated department would require all staff, including medical oncologists, to make the same transition. Unfortunately, as the lead discipline, the radiotherapy department needed to maintain a paper file although that department did not use the file. The new file cover was printed from the OIS using the automatically downloaded HIS data. Once the medical oncologists migrate to the same system, the paper records will cease to be accumulated. Step 6 Once the clerical staff had completed their work, the file was not required for the consultation as all the information within the file was also contained within the OIS. Oncologists learnt to open a patient's file from the appointment schedule, particularly as clerical staff were no longer providing a paper record for radiation oncologists. The software contained the option to automatically display the photograph of any selected patient aiding identification. Changes to procedures were trialed by the lead oncologist and only introduced when subsequent changes had already been devised and tested. In this way the introduced changes were Health Information Management 2005 ISSN Vol 34 No 4 Page 141