Editorial
Special issue on human factors and the implementation of health information technology (HIT): Comparing approaches across nations

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Introduction

The worldwide implementation of large-scale health information technologies (HIT) continues at a rapid pace and this trend is unlikely to change in the future [1], [2]. The next few years are likely to be especially important given the demand for health system modernisation and the recognition that HIT has a key role to play in achieving this [3]. The USA, Australia and the United Kingdom have all invested large amounts of government funding to support the implementation of systems such as Electronic Health Records (EHR), Computerised Provider Order Entry (CPOE) systems, telehealth applications, and consumer HIT applications. These types of HIT are also being used to support an expanding range of healthcare contexts (e.g., medication administration, electronic prescribing, health information exchange and communication between patients and clinicians) [4]. HIT is often argued to lead to benefits such as improvements in healthcare quality (e.g., better communication), increased efficiency (e.g., accelerated transfer of patient information) and safety (e.g., reducing the likelihood of human error) [5], [6]. These claims, however, are often hard to justify in the light of often poor levels of uptake and adoption of these technologies by front-line clinical staff [7], [8], [9]. Within the UK for example, the National Programme for Information Technology (NPfIT) has cost over the last decade something in the order of £12 Billion [10]. A large part of this effort has been given over to implementing EHR systems across the whole of England. Despite huge efforts on the part of government and National Health Service (NHS) managers to realise the vision of ‘joined-up, seamless’ care supported by HIT, the NPfIT programme has been plagued by project delays, budgetary problems and in some cases, severely negative outcomes in terms of the effectiveness and quality of care delivery [11].

Examples such as these raise the need for better evidence regarding the factors which influence and shape the character of successful large-scale HIT implementation initiatives. We believe this special issue comes at a time when it is vital to learn some of the lessons of HIT implementation initiatives in various countries and assess their potential to be transferred to other contexts and health systems. The benefits which can accrue from HIT have been demonstrated in a number of healthcare contexts [12], however the evidence base as it applies to key success factors is often seen as weak [3], [11]. A key aim of the special issue is to outline some of the different approaches and strategies which have been used to implement large-scale HIT systems. Accordingly, the eight papers in special issue describe HIT implementation across a range of nations (e.g., USA, Canada, UK, Switzerland, New Zealand, Australia, Denmark, the Netherlands), as well as drawing comparisons between them. A specific focus is the human factors issues associated with the introduction of HIT. We define human factors broadly to mean the role played by humans in the design, development and deployment of HIT, as well as the impact of HIT upon the working practices of healthcare workers and patient outcomes. The goal of a human factors systems approach to HIT is to ensure benefits for both patients and clinicians [13]. A central tenet of applying a human factors systems approach to HIT is the principle of equifinality, namely that the same goal (e.g., improved patient safety) can be arrived at through different routes (i.e., different implementation strategies) [14]. Therefore, it is important to examine the diversity of HIT implementations across countries and understand how various approaches can produce benefits for both clinicians and patients.

Section snippets

Models, frameworks and approaches for understanding HIT implementation

A number of models, frameworks and approaches exist to characterise the conduct of large-scale HIT implementations and to distinguish between contrasting approaches towards nationwide implementations [15], [16], [17]. One of the most well-known of these is Coiera's [18] typology of top-down, bottom-up and ‘middle out’ implementation approaches. A ‘top down’ approach is seen as primarily government-led or sponsored, with central procurement of standardised healthcare IT systems. England's

Human factors and HIT

A good deal of human factors research has focused on the consequences of introducing various types of HIT. Some of this work has focused on the changes which have been brought about to the way in which patient care is administered and delivered in hospitals, ambulatory surgery centres, community clinics and other healthcare settings [9], [21], [22], [23]. In many cases these changes have brought about a number of negative consequences (e.g., persistent paperwork, clinical workarounds [8], [24],

Comparing across nations

A number of the papers in the special issue attempt to draw lessons regarding HIT implementation using comparisons between nations. Greenhalgh et al. (Introducing a national shared electronic patient record: case study comparisons of Scotland, England, Wales and Northern Ireland) describe the findings from a set of studies carried out across the UK. Efforts to introduce a nationwide EHR as part of NPfIT resulted in very different outcomes for the four countries within the UK. The findings from

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