The implications of e-health system delivery strategies for integrated healthcare: Lessons from England

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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.

Section snippets

Introduction: e-health systems and integrated care

Coordinating healthcare in complex cases can involve many different healthcare agencies and a major goal in many countries is to use e-health systems for health information exchange in order to share information about patients across agencies in order to promote ‘seamless’ care. One of the debates about achieving this goal is the organizational level at which it has to be undertaken: it cannot, for example, be achieved completely ‘bottom up’ with every healthcare agency developing its own

Alternative technical strategies for the delivery of e-health systems

In Fig. 1 different technical strategies for healthcare information management are identified that were found in practice in the EPICOg project and that are in use in different parts of the world. We have used the concept of coupling [4], [5] to differentiate between these strategies. Coupling is a systems concept that defines the relationship between sub-components of a system. A tightly coupled system is one in which a change in one sub-system has a direct and significant impact on another

Methods

In England the dominant strategy for sharing electronic patient information in the last decade has been the NPfIT (the National Programme for Information Technology), the largest part of which was a national strategy to deliver detailed care record systems (DCRS) to every healthcare agency in the country. However, although this has been the dominant technical strategy, the other strategies listed in Fig. 1 have also been adopted in England. The strategies are used to deliver electronic patient

National shared databases

The decision in 2002 of the Department of Health in England to launch detailed care record systems (DCRS) applications across England as part of the NPfIT represents a major national attempt to get healthcare agencies to share the same patient database. Initially the country was divided into five regions and all healthcare agencies in a region were to adopt a single DCRS. The aim was to replace any existing electronic patient information systems that were in use with a standard ‘best of breed’

Discussion

In the cases presented above each technical strategy has led to a different response from the user population. These cases are all from one country and some of these responses may be influenced by local culture, the particular organization of healthcare agencies in the country etc. However, there is evidence of a strong causal link between the nature of the strategy and the responses of the user population and this may mean these responses are replicated when these strategies are adopted in

Conclusions

There is an obvious logical argument that, if you want to provide integrated care in a health service, all healthcare agencies should share a common patient database. It should ensure they all ‘sing from the same hymn sheet’. As a result one of the major technical ambitions in delivering electronic patient records has been to get everyone using the same record. If such a strategy is to be attempted it needs high level adoption, perhaps at a national level, in order to deliver the system to all

Authors contributions

Both authors were investigators in the EPICOg project and were involved in the secondary analysis of the data for this paper. The paper has been jointly prepared and edited.

Competing interests

None.

Acknowledgements

We gratefully acknowledge the contributions to the EPICOg project of our co-workers Professor Mike Dent, Dr. Dylan Tutt, Dr. Andrew Thornett and Mr. Phil Hurd. The funding for the EPICOg project was provided by the NIHR Service Delivery and Organisation programme under grant number 08/1803/226. The secondary analysis of data undertaken for this paper is the responsibility of the authors and received no funding. The views and opinions expressed herein are those of the authors and do not

References (26)

  • T. Greenhalgh et al.

    Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

    BMJ

    (2012)
  • E-health Insider, Welsh Clinical Portal given go-ahead, 2010...
  • Z. Morrison et al.

    Understanding contrasting approaches to nationwide implementations of electronic record systems: England, the USA and Australia

    J. Healthc. Eng.

    (2011)
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