Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process

Highlights

• Longitudinal study of implementation and integration of ambulatory and hospital records.

• User focus evolves from technology acceptance to structural adaptation to coordination.

• Views on standardization evolve from concern to importance recognition to active acceptance.

• Organization must impose work process changes prior to individual adaptation and aligned change.

• Computer integration is insufficient; users must value and incorporate information within workflow.

Abstract

Objective

The increase in electronic health record implementation in all treatment venues has led to greater demands for integration within and across practice settings with different work cultures. We study the evolution of coordination processes when integrating ambulatory-specific electronic health records with hospital systems.

Materials and methods

Longitudinal qualitative study using semi-structured interviews and archival documentation throughout a 5-year implementation and integration of obstetrical ambulatory and hospital records with a goal of achieving a perinatal continuum of care.

Results

As users implement and integrate electronic health records, there is an evolution in their focus from technology acceptance to structural adaptation to coordination. The users’ perspective on standardization evolves from initial concern about the unintended consequences of standardization to recognition of its importance and then finally to more active acceptance. The system itself cannot drive all reengineering; the organization must impose specific work process changes and as the user's perspective evolves, more individually adapted and aligned change will occur. Computer integration alone does not result in coordination; users must value integrated information and incorporate this information within their workflows.

Discussion

Users initially view electronic health records as a documentation tool, but over time they come to recognize the benefits of the system for clinical information retrieval, and finally, for care coordination after the integrated information provided through electronic health records becomes more complete, accessible and adapted to meet user needs. As this occurs, coordination mechanisms move beyond pooled standardization through sequential plans coordinated by the organization to reciprocal mutual adjustments for clinical decision making by individuals. Trust in the information source, not software interoperability, is critical for information sharing.

Conclusions

Organizations implementing commercial electronic health records cannot simply assume that reciprocal coordination will immediately occur. It takes time for users to adjust, and enculturate coordination goals, during which time there are adaptive structurations that require organizational response, and changes in mechanisms for achieving coordination.

Introduction

Adoption of electronic health records (EHRs) in the U.S. is increasing as a result of the incentives created by the HITECH Act [14], [15], [29]. As these basic systems are adopted, true meaningful use will require integration of information with other systems across ambulatory practices, hospitals, and other facilities, both within a health care network and across networks. Furthermore, as healthcare organizations assume financial/clinical risk for populations, the need for integration of clinical data across the continuum is critical to achieve financial success and improve clinical quality.

While EHR implementation challenges have been documented [18], [25], there have been few studies of integration challenges [5]. Custom developed systems that support existing work processes were the basis for most early reported successful implementations [6], but developing these systems is simply not cost effective for most health care organizations. As a result, commercial vendor-supplied applications are the mainstream of health information technology (HIT) adoption [1]. Integration of these non-customized applications with other existing applications and work processes across multiple care settings that often have different organizational cultures can be challenging.

Patient care coordination through integrated systems requires not only user acceptance, but user technology appropriation and work process adaptation aligned with organizational integration goals. EHR workarounds within a single facility have been found to have unexpected consequences [20], [24], [60] and users can adapt technology in ways that challenge organizational goals [12], [42], [43], [21]. There are many sociotechnical changes accompanying EHR use [24], [37], [38], [35], [44], [20] and factors impeding implementation and use [19]. A systematic review of research on EHR implementations between 2001 and 2011 reported a lack of socio-technical connections between the clinicians, the patients and the technology when developing and implementing EHRs [41]. Drivers of workarounds and sociotechnical changes are operational, cultural, organizational, and technical, and include the need to maintain productivity when acclimating to new systems, discomfort with new work processes, and the potential for information overload [39], [50], [8]. However, there are few reports of integrated EHR programs [18], and in particular the process changes required to achieve coordinated care benefits [1].

Our study addresses the research questions: how do users achieve coordinated care goals via information sharing with integrated health records? How do their views evolve and how do they adapt their usage of EHRs to achieve their integration goals? We use a grounded theory approach, using longitudinal case studies to build theory.