Development and implementation of an EPR: how to encourage the user
Introduction
Information technology (IT) is believed to create many opportunities in health care. One is the computerised support of the primary process. In 1990, a study of the Institute of Medicine (IOM) identified the strengths and weaknesses of paper based records [1]. Poor availability, illegibility, poor organisation and incompleteness are such weaknesses. These shortcomings are often used to justify the call for widespread use of electronic record keeping [2]. Access to clinical information can be improved by well-organised, legible data, but also with availability of information at several places simultaneously. Nowadays, the process of care is still mainly supported by paper-based medical and nursing records. These records play an important role in accumulating information and coordinating medical work [3]. Patient records are not simple stores and sources of information that are filled and referred to whenever necessary, but they also influence medical work. Berg explained that paper records and health care workers interact with each other and mutually affect each other [3]. Hence, the information present in the records is not simply the basis of decision-making, it has an influence on the decisions made as well. In the process of computerisation of paper records this is an important aspect to consider, because it means that records are not just tools in the hands of a doctor or a nurse. It also explains why electronic records need to be tailored to the work practices in order not to obstruct the process of care. Tange analysed the satisfaction of physicians with paper based medical records in the Maastricht University Hospital [2]. They appeared to be rather satisfied with their paper records, although data retrieval could be improved. Opportunities of IT, then, lie in those features that reduce administrative tasks of health care workers, performing computations or generating reminders in case of specific events for example [3]. To increase the usability of systems the involvement of health care workers in design and development processes of electronic record systems is important [4]. Moreover, considering the attitude of future users in the process of development and implementation is important to increase final acceptance [5].
The Department of Medical Informatics, Maastricht University, co-operates with the Department of Neurology, Academic Hospital Maastricht, to develop and implement an electronic patient record (EPR) for stroke patients [6], [7]. In this project we involved the future users in an early stage, which served three purposes: (1) to determine the required functionality of the EPR; (2) to create and increase social support; and (3) to measure social support for the EPR. The purpose of this paper is to describe in more detail the participation of our future users, realised as follows:
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Two nurses and two residents were actively involved as key users in the development process to determine and test functionality and to create social support. They were expected to act as change agents.
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We measured the attitude, knowledge and expectations about the use of computers in health care of all potential users by means of a questionnaire. These results served to determine the training the users required, to measure the social support for our project and to trigger the interest and curiosity of potential users.
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We conducted in-depth interviews to clarify and supplement the questionnaire results. Additionally, we wanted to assess and increase social support with these interviews.
Section snippets
Methods
Data were collected with two different questionnaires and two sets of in-depth interviews. The aim of the interviews was to explain and supplement the results of the questionnaires. Fig. 1 explains how questionnaires and interviews relate to each other in time and content.
Background of the users
In March 1998 the users received the questionnaire to measure their attitude towards computerising the paper clinical patient records. Forty-one of the 63 questionnaires were returned completely filled in (65%). Nurses had the lowest response rate, 52% of them returned the questionnaire. The response rate of residents and specialists was 92% and 82%, respectively. Twenty-eight respondents were younger than 40 and on average the respondents had 12.6 years of working experience (range 0–35).
Discussion
The participation of health care workers in the development and implementation process of a system is said to be crucial for its success [16], [17], [18], [19]. In addition, to prevent one single viewpoint on a system's requirements it is important to involve all user groups in the development phase [20]. Furthermore, the organisational aspects of health care work should be considered [17]. The choices we made during the development and implementation process were aimed at enhancing
First impressions of the EPR in daily practice
Currently, the implementation of the EPR is ongoing and so far no major problems have been reported. Users are reporting both in the EPR and in their paper records, but the number of nurses and physicians actually using the EPR is still limited. So far, the users have encountered several difficulties. The first is the number of stroke patients. We started off with the main population of the department being the stroke patients. For unknown reasons, the number of stroke patients admitted to the
Conclusions
Involving the users is said to be important in the development process of an EPR. Initially, we considered the way we consulted the users, besides the project team, as sufficient. The users received two questionnaires about subjects that related to electronic record keeping and the subsequent changes in their daily work. We expected them to start thinking about the consequences of an EPR and maybe to become interested. However, after the development phase their opinions had not significantly
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