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Bottom up & Middle Out Approaches to Electronic Patient Information Systems: A Focus on Healthcare Pathways

Published in ‘Journal Of Innovation in Health Informatics’

Background
A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities.

Objective
These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care.

Results
The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that enabled effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver.

Conclusions
The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a ‘middle-out’ level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.

BCS Journal Link

2012 EASON K. D., DENT M., WATERSON P., TUTT D., AND THORNETT A. Bottom up and middle out approaches to electronic patient information systems: A focus on healthcare pathways Informatics in Primary Care 20:1 51-56

The Implications of e-health System Delivery Strategies for Integrated Healthcare: Lessons from the UK & Elsewhere

Abstract:

Purpose
This paper explores the implications that different technical strategies for sharing patient information have for healthcare workers and, as a consequence, for the extent to which these systems provide support for integrated care.

Methods
Four technical strategies were identified and the forms of coupling they made with healthcare agencies were classified. A study was conducted in England to examine the human and organizational implications of systems implemented by these four strategies. Results were used from evaluation reports of two systems delivered as part of the NPfIT (National Programme for Information Technology) and from user responses to systems delivered in two local health communities in England. In the latter study 40 clinical respondents reported the use of systems to support integrated care in six healthcare pathways.

Results
The implementation of a detailed care record system (DCRS) in the NPfIT was problematic because it could not meet the diverse needs of all healthcare agencies and it required considerable local customization. The programme evolved to allow different systems to be delivered for each local health community. A national Summary Care Record (SCR) was implemented but many concerns were raised about wide access to confidential patient information. The two technical strategies that required looser forms of coupling and were under local control led to wide user adoption. The systems that enabled data to be transferred between local systems were successfully used to support integrated care in specific healthcare pathways. The portal approach gave many users an opportunity to view patient data held on a number of databases and this system evolved over a number of years as a result of requests from the user community.

Conclusions
The UK national strategy to deliver single shared database systems requires tight coupling between many users and has led to poor adoption because of the diverse needs of healthcare agencies. Sharing patient information has been more successful when local systems have been developed to serve particular healthcare pathways or when separate databases are viewable through a portal. On the basis of this evidence technical strategies that permit the local design of tight coupling are necessary if information systems are to support integrated care in healthcare pathways.

Highlights

  • Links between electronic patient databases and healthcare agencies are defined in terms of tightness of coupling, range and scale.
  • The English Detailed Care Record System was unable to serve the diverse needs of healthcare agencies and was not successfully deployed.
  • Tight coupling was successfully deployed at a local level between agencies engaged in integrated care in healthcare pathways.
  • Widespread uptake was also found when portal systems were deployed that permitted viewing of a range of patient databases.
  • Adoption of patient databases was greater when there was middle-out design and technical strategies delivered looser forms of coupling.

Link to PDF

Science Direct Link

Eason K.D. and Waterson P.E. (2013) The Implications of e-health system delivery strategies for integrated healthcare: lessons from the UK and elsewhere. International Journal of Medical Informatics. 85(5) 96-106 Doi:10.1016/j.ijmedinf.2012.11.004