Electronic health records implementation: An evaluation of information system impact and contingency factors

Health information technology: fallacies and sober realities

PURPOSE:The purpose of this article is to discuss the current state of implementation of Lean production in health care. The study focuses on the definition of Lean in health care and implementation process, barriers, challenges, enablers, and outcomes of implementing Lean production methods in health care.DESIGN/METHODOLOGY/APPROACH:A comprehensive search of the literature concerning the implementation of Lean production in health care was used to generate a synthesis of the literature around the chosen research questions.FINDINGS:Lean production in health care is mostly used as a process improvement approach and focuses on 3 main areas: (1) defining value from the patient point of view, (2) mapping value streams, and (3) eliminating waste in an attempt to create continuous flow. Value stream mapping is the most frequently applied Lean tool in health care. The usual implementation steps include conducting Lean training, initiating pilot projects, and implementing improvements using interdisciplinary teams. One of the barriers is lack of educators and consultants who have their roots in the health care sector and can provide support by sharing experience and giving examples from real-life applications of Lean in health care. The enablers of Lean in health care seem not to be different from the enablers of any other change initiative. The outcomes can be divided into 2 broad areas: the performance of the health care system and the development of employees and work environment.

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The current state of Lean implementation in health care: literature review.

Objectives: Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved. Methods: Literature search based on “Electronic Health Record”, “Medical Record”, and “Medical Chart” using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review. Results: By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today’s rapidly changing healthcare environment. Conclusion: The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

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Electronic Health Records: Then, Now, and in the Future

Workarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses’ use of workarounds in acute care settings. A literature assessment was undertaken in 2011–2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses’ workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses’ conceptualisation and rationalisation of workarounds. The majority of studies examining nurses’ workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses’ workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, ‘being competent’, and collegiality influence the implementation of workarounds. Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses’ individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses’ use of workarounds.

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Nurses’ workarounds in acute healthcare settings: a scoping review

Exploring the persistence of paper with the electronic health record

The widespread gap between evidence and practice for clinical and preventive services argues for a deeper understanding of effective quality improvement (QI) and system change. Using implementation and system redesign sciences, we have developed and used an effective strategy to enable robust implementation of QI initiatives, including clinical practice bundles, within a health care setting. Our program, which applies Lean and systems engineering methodologies, is specifically designed to exploit the five characteristics of effective innovations, as outlined by Berwick. This strategy has been applied in over 21 hospitals (six hospital systems) throughout the State of Indiana and is currently being used as part of the Radically Reducing methicillinresistant Staphylococcus aureus (MRSA) initiative funded by the Agency for Healthcare Research and Quality (AHRQ). The benefits of the process redesign activities are detailed at the business level through a business case analysis. Additionally, benefits at the personal level are quantified through workflow analysis (prior to and following the interventions). The intervention strategy is integrated into the current quality framework for each organization to ensure compatibility with existing organizational programs. Our staff engagement, training, and educational programs make systems engineering methodologies and principles readily accessible to frontline staff. Additionally, each project session requires immediate application of tools and techniques. This article will discuss our implementation strategy, provide examples of Lean and systems engineering tool applications, and provide an assessment of spread adoption and sustainability as a function of this implementation strategy.

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Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption

Lean and Six Sigma quality concepts and terminology have been applied in the manufacturing arena since the late 1980’s and early 1990’s. It has only been in recent years that healthcare administrators have identified these methods as being adaptable to their organizations so that they may realize organizational improvements for continuing success and delighting customers. Unfortunately, this is not an application that is widely taught in typical Industrial Engineering curriculum and therefore there are few educated professionals coming right out of college that are able to apply these principles to healthcare. There are however, many experienced professionals knowledgeable in the basic Lean and Six Sigma principles as applied to manufacturing. This paper presents research conducted by the IUPUI School of Engineering and Technology in partnership with Sister of St. Francis Health Services (SSFHS) which was focused on the development and implementation of a Lean Six Sigma Training Program specifically for healthcare. Through the development of this training program, Purdue faculty have adapted traditional manufacturing Lean methodologies for healthcare specific applications. This paper will present multiple examples of successfully adapted Lean manufacturing training for Healthcare organizations. The authors will then present their findings and recommendations concerning Lean training specifically for Healthcare professionals. They will also present in-depth explanations of hands-on exercises used to demonstrate application of lean tools such as value stream mapping, 5S and visual controls that can be used to effectively train employees in most any healthcare organization.

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Adaptation of lean methodologies for healthcare applications

Increased focus is being placed on the quality of care provided by Hospital Healthcare Systems around the country. Caught in the middle between tightening government standards, stricter compliance guidelines for insurance companies, and the basic mission to serve those in need with quality and compassion; hospitals are looking for ways to improve their processes (services) for the benefit of all. CT (Computed Tomography – CAT Scan) and MRI (Magnetic Resonance Imaging) services in the hospital radiology departments are revenue-generating areas. The reimbursement rates for these services are very high, the scan times (especially in CT) are relatively low, and so the potential for additional revenue to the hospital comes with increasing patient capacity for these services. However, it is also a very competitive time for hospital radiology departments as many outpatient diagnostic centers are being built, drawing patients and physicians to their fast, efficient, no hassles approach to imaging. This brings additional hurdles to the already struggling hospitals. The Sisters of St. Francis Health Services (SSFHS) group enlisted the aid of faculty at IUPUI to address issues within their organization. The objectives: improve the key performance indicators directly tied to patient and physician satisfaction, improve and streamline CT/MR processes, increase the capacity to perform CT/MR services, and regain a portion of the referral base lost to outpatient diagnostic centers. To address these issues, Lean/Six Sigma methodologies were implemented. Considerable success has been documented in the manufacturing industry using these models, but little has been done in the service-based industry of healthcare so an uncharted area was being entered. Specially organized teams were created for the project within the hospital organization. Faculty experts provide education and training to these individuals in Lean/Six Sigma methodologies modified to fit healthcare services. The radiology project has been initiated and current results positively support the successful transferability of these manufacturing-originated methodologies into service-based applications. Modeling, simulations, and Cost/ROI of implementation projections for these projects are also being developed. These activities insure transportability of the models between hospitals so the benefit can be felt system-wide.

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Implementing Lean Six Sigma Methodologies in the Radiology Department of a Hospital Healthcare System

Healthcare organizations are increasingly implementing electronic medical records (EMRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, there are still instances where employees rely on paper to complete their work. The use of paper suggests that parts of the EMR may not be sufficiently designed to support clinicians and their work processes. To understand the use of paper-based alternatives, we conducted 14 key-informant interviews in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EMR. We found nine distinct categories of paper-based workarounds to the use of the EMR. In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EMR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EMR design and implementation.

Heather Hagg

Papers

Exploring the persistence of paper with the electronic health record

Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption

Adaptation of lean methodologies for healthcare applications

Implementing Lean Six Sigma Methodologies in the Radiology Department of a Hospital Healthcare System

Paper Use with the Electronic Medical Record: An Important Supplement or Negative Circumvention?