Use of Electronic Medical Records and the road towards paperless hospitals in Norway. A socio-technical perspective

Abstract

Electronic medical records (EMRs) have for a long time been a topic of interest for researchers and practitioners both nationally and internationally. The main reasons seem to be the expectation that EMR-systems can contribute to higher quality and more efficient health services.

In Norway almost all general practitioners and all except one hospital have introduced and started to use EMR systems. Still, studies have revealed limited utilization of the available functionality, especially among nurses and physicians. One of the reasons for the limited use is argued to be the dual existence of both electronic and paper based medical records. Several Norwegian hospitals have therefore started a process of removing their paper based medical records from clinical workflow. The first study of a Norwegian hospital deprived of the paper based record was published in 2003, and the results showed a higher degree of EMR-system use compared to the control group. The high use was however mostly in tasks where the users had no other choice but to use the EMR-system since the paper-based records no longer existed. To further explore the use of EMR systems in Norwegian hospitals and to investigate the promises of scanning, three broad research questions were established as point of departure for this thesis:

• Why is the functionality offered by the EMR systems not used?

• What are the effects of removing the paper based medical records?

• What can be done to increase usage and fulfill the promises of EMR systems?

In relation to these main research questions, three studies were conducted providing data for four articles.

Article 1 explored change in use and satisfaction with an EMR system over a three year period at a hospital deprived of the paper based medical record. The results showed a significant increase in use of optional functionality among physicians and nurses largely independent of technological factors, highlighting the importance of seeing technology and organization as interrelated issues.

Article 2 presented results from a questionnaire study about use and satisfaction with EMR systems from 6 hospitals working without the paper based medical record. The results showed large variances between professions and between departments/hospitals, suggesting that for instance the amount of time since removal of the paper based alternatives and the initial situation are important conditions for successful projects to take place.

Article 3 presented an in depth qualitative study of the two departments in article 2 where respondents distinguished themselves with both high reported use and high reported satisfaction with their EMR system. Two main areas were of particular interest at the start of the study; what had they done organizationally during the introduction processes, and how did the clinicians experience working without the paper based records. From the interviews, involvement and close clinical-administrative collaboration during the implementation processes emerged as important prerequisites for the apparent success. Still, even though almost all clinicians preferred EMR-only to maintaining dual systems, the shortcomings of organizing the EMR according to the paper based ancestor was getting apparent and it was clear that the EMR systems only to a modest degree met the clinical needs of experienced physicians.

An EMR-system should not be a goal itself, but rather be an enabling technology in order to provide more efficient and better quality health services. Article 4 investigated the potential for interdisciplinary teamwork in hospitals. The results were promising showing little or no deep cultural differences between various professions. Still, established routines and an EMR reinforcing established professional boundaries might limit the potential.

Even though the range of available functionality is increasing, the articles point to lack of routine changes as a barrier for successful EMR implementation. By having an EMR similar to the paper based records and a workflow following the traditional way, no large benefits except availability is gained for the individual clinicians, even though some benefits can be gained by the hospital as a whole. Further, for those used to the old tools, a change of tool without a change of routine might result in decreased performance. A change of perspective from the individual’s benefits to a hospital-wide focus can be valuable, but it is argued that the large benefits thought to be achieved by EMR-systems can first be reached when seen in relation to organizational change. In the same way scanning and removing the paper based record from clinical workflow has limited potential in isolation. More precisely, work routines and technology should be addressed in parallel. To reach the promises of the electronic medical record, the bonds to the paper-based medical records have to be broken. This implies both a change of EMR structure and a change of routine to fully exploit the potential of new technology. Digitalizing the paper is simply not good enough.