‘That’s how The Bastille got stormed!’
Integration issues in an NHS electronic
patient records (EPR) project
David Martin and Mark Rouncefield, Computing
Department, Lancaster University, UK
Jacki O’Neill, XRCE Xerox, France
Mark Hartswood, Edinburgh University, UK
Dave Randall, Manchester Metropolitan University, UK
Integration and UK Healthcare
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‘Modernization’ through computerization
EPR systems, bought as customizable-off-the shelf (COTS) systems
delivered in partnership with the supplier:
• Robust, accessible and timely information
• Best practice and decision support
Formal integration of practices, processes and technologies
Previously informally integrated via talk, handovers etc.
Complex deployment situation:
The systems are envisaged to support multiple and varied medical,
administrative, reporting and regulatory processes.
The technologies incorporated in EPRs are more complex and sophisticated
– e.g. wireless, mobile, imaging and visualization technologies
NHS requirements are emerging, developing and changing as successive
programs are put into place and defined
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The Fieldsite: North England NHS Trust
• North England NHS Trust
– 3 Hospitals (one about to close)
• Phase 1 on 3 phase comprehensive EPR project
– Phase 1 – went live in February 2005 after being repeatedly delayed from
February 2004: core administrative system and connected reporting
system, A & E, theatres, order communications, pathology systems
– Phase 2: documenting care (medical records), GP access
– Phase 3: clinical pathways, electronic drug prescription
• Delivered as a PPP (public private partnership)
• 8.3 million pound 9 year contract with US company
• Core administrative/reporting system incorporates various clinical
applications and is integrated with legacy systems
• Paired US/UK implementation analysts
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Orientation, Study and Materials
Ethnomethodologically-informed ethnography of design
• Orientation to study and analysis
• Looking at ‘real world real time work’ in detail
• Explicating its how it is organized as a recognizable social accomplishment
without recourse to theory
Observation
• Shadowing the internal project team leader, observing internal implementation
analyst meetings, joint US/UK analyst meetings (catch ups), project leaders
meetings, IT communications strategy meetings, meetings with medical staff
in their departments and testing
Materials
• Field notes, tape recordings (some transcription), project literature and other
materials from meetings
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Analytic Themes and Aims
Analysis
• How is design work organized and coordinated – how do analysts (and users)
reason about the application domain, users, problems and the emerging
design?
• How do they grapple with the different integration requirements as part of this
process?
Aims
• Understanding issues around COTS system deployment (especially for the
UK NHS) – e.g. the limits of configurability
• Understanding design around integration issues ‘in the wild’
• Identifying important design activities that might be better supported, respecified or reorganized
• Identifying potential novel uses and roles for ethnography in design
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Forms of Integration – and Timing (i)
• Vic – “X has drawn my attention to upcoming changes in procedures –
it is important that these are done before go-live so they are not
associated with the system. If they are done before go–live, the
system will be seen to automate and speed this up. If not then you’ll
have a revolt and that’s how the Bastille got stormed.”
• At what time different types of organizational change and integration
work are undertaken, and how these activities are ordered, is of key
importance in design
• Work is ordered, problems and solutions are defined and
categorized, and requirements are prioritized as situated social
accomplishments in relation to certain ‘organizational’ priorities and
emergent contingencies
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Forms of Integration – and Timing (ii)
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Technical integration of disparate systems: the integration of the core
patient records system with modular systems for A & E, theatres, radiology,
etc. and with pathology legacy applications and with new imaging
applications. Issues such as data quality and matching come into play.
The integration of workplace procedures: in this case by implementing
generic process models in the system. This introduces a tension between
standardization and supporting local variants in practice.
Integrating the system with work practices: a good fit is achieved by
successfully sorting out which work practices need to be preserved and which
may be transformed
Integrating the system with wider organisational and NHS concerns and
requirements: these emergent requirements were given priority – they had to
be met – but they were not known in advance
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Achieving Artful Integration (i)?
• Uncovering the current organization of work is problematic
Barney – “For this area we need many different users to test as it is different for
different areas. I’m basing the build on call centre information. There’s a
problem that the build comes from either PAS or how you do it. Information
has not been provided in full or in a format to be used so I think I will just have
to go on how PAS does it.”
• Should practice be preserved or transformed?
Alice – “Enterprise wide scheduling would be full integration of a series of
procedures, bringing resources together in the ‘correct’ order to support
care…. the system would automatically work out what can be done,
when…[and] indicate what is required, as opposed to scheduling that is not
seamless across procedures.”
• A background of disputes over current and future practice
Helen – “There’s a problem of change management going on in the Trust right
now, particularly in the call centre, there are disputes over how things are
currently done and the requirements for modernization.”
• Buy in and validation of design – for now and for later
Alice – “But I must stress the importance of buy-in from the most tricky people
and areas during QA [Quality Assurance] testing.”
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Achieving Artful Integration (ii)?
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Integrating system ‘structure’ with the social ‘structure’ of work involves
‘matching’ exercises
Analysts envisage how the system will fit with current situated work practice
and the possible consequences
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Draw on own knowledge and user reports
3 interrelated forms of ‘matching’:
• Temporal and sequential structure: do system process models fit with
the ordering of activities as they unfold over time? Does the system
produce problematic sequential or timing constraints?
• Spatial structure: is the system (and the required information) accessible
where it is needed? What are the tensions in accessibility, public
availability and security?
• Social and conceptual structure: do the naming conventions and the
arrangements of services, functions and processes make sense to the
users? Do they relate favourably with the way work is currently
understood in practice?
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Achieving Artful Integration (iii)?
• Social and temporal structure, and security, in A & E
Bob – “Because if they’ve got to log out people will not log out of it they don’t
now ..”
Lenny – “But maybe they won’t have a chance because the log in time out will...”
Bob – “Well I understand that .. but if it doesn’t time out before someone gets
their hands on the keyboard, .hh that next action is taking place under
someone else’s signature”
Helen – “Mm hm it is a problem”
Bob – “And in A & E, in that chaotic, you know, environment, they will not log out”
Helen – “Well and again … this is one of the reasons why we’ve asked for the IT
trainers here as well so that this is ... yesterday I met with the IT trainers and
we started talking about some of the issues that we need to make sure that
everyone is aware of .. this is one of the key ones, making sure that people
log out and understanding the implications because in a fact it’s an electronic
signature, and that’s going to give a print, of where you’ve been on the
system and if you don’t log out you’re allowing someone else to use that
signature”
Bob – “But it’s not a training issue.. the fact is that the log out procedure will not
be looked upon as important as treating a patient”
• A training issue? Mobility of problem and solution definition
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Achieving Artful Integration (iii)?
• Which integration is prioritized, whose responsibility?
Lenny – “If the data entry process does not work in a smoother, slicker fashion
there will be bottlenecks which will slow the process and cause problems…
we already attract criticisms and problems with GP ordering which will be
manually input... It sounds like 5 steps when currently it is only one step – we
only take one code”.
Vic – “You need to have the ability for other areas of the system, what should be
easy is a problem because you risk the CDS integrity”.
Alan – “Integration is the number one job…it’s how systems will become part of
the family… it’s an issue for OurComp, fitting legacy lab applications to the
EPR”.
Helen – “Can someone take a stop-watch and time this?”
Alan – “It will take twice the time, more personnel and over 100,000 transactions
you can imagine… it takes Lenny longer and he knows what he’s doing”.
Helen – “We need the timing so we can take it up as an issue”.
Alan – “It’s the same thing for Bob and A & E, it has great importance for system
success, if inputters aren’t happy, the department’s not happy”.
• Different means for categorizing by ‘type’ and ‘seriousness’ and
escalating problems
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Integration, User Testing & Medical Users (i)
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‘Trust wide’, and ‘for NHS’, as ‘reasons’ for usability problems
Timing of user involvement
Problem definition
Training as the default solution
Jenny – “This is the first time I’ve seen a clinic, before they’ve never been working so I’ll
need to go back and practice it.”
Helen – “You need to fit in with the Trust that’s why it’s like this.”
Brian – “But it’s a problem that fitting in with the Trust involves more work.”
Helen – “Anything we can streamline we will… in the future with OurComp… and you
have to realise the importance of data gathering and sharing information across the
Trust.”
Jenny – “I’ve been trying registration for months and have a problem of getting lost and
not knowing where I am and I’m worried about how much training for our receptionists
will be required.”
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Integration, User Testing & Medical Users (ii)
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Supporting medical practice?
Where do the constraints come from – the technology, the NHS etc?
Jenny – “Speaking as an A & E nurse I need to know what the patient has come in with
to triage…. The presenting complaint… I need to know this… it should be a
mandatory field so I can look down the list and identify the patient out of 12 with chest
complaints… we do this now.”
[Brad suggests you can do this with the system and moves across to show them on the
computer… “you can get the information from the whiteboard.”]
Brian – “We don’t currently work from the whiteboard, it doesn’t fit with our workflow….
We have a separate triage list which we can view and re-order the patients on.”
Vic – “We can’t change this as the screen is hardwired.”
Brian – “But we currently prioritise using the triage list… it’s a fundamental facility….this
really worries me.”
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User Testing & Administrative Users (i)
• What are you testing, at which point in design?
• Are the problems due to integration or due to the configuration
possibilities of the system?
• Clinical or administrative suitability, and adapting the work to the
system?
• Christine - “There’s a problem of doing QA’ing when you’re QA’ing
something but you don’t actually know what you’ll be getting… ‘cos
they don’t have a PAS system in the States… it’s like fitting a square
peg in a round hole… in America they just go ‘have you got the
money – bang’.. at the end of the day it’s our managerial problem so
we need to start thinking of workarounds… we have to rely on the
Trust when they emphasise the clinical suitability of the system.”
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User Testing & Administrative Users (ii)
• Problems for local workflow due to generic services
• “I imagine it’s like the map of the tube (London Underground
Trains)… (she gestures as she speaks) you go along and sometimes
you get off here, go up there, and back, to get to there… it’s not a
completely linear process”
• Disputing ‘solutions’ and withholding sign-off as a bargaining
chip
• Christine – “We don’t want to sign this off before we go through
everything in the proper detail… we are not fully happy about
accepting that training will sort out all of these problems… some of
them seem like major problems.”
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Discussion: Timing in the Art of Integration (i)
Problem of using a to an extent unknown product as a forcing device for
un-thought through transformation
• COTS ‘black box’
• Achieving organisational change via technology
Timing and targeting ethnographic interventions
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Variant of ‘quick and dirty’ ethnography
1. During procurement can be used to look at the means by which integration
between and amongst people, processes and technologies is currently
informally achieved as this can serve as a useful resource for subsequent
formal modelling and assessment of candidate technologies
2. During Build and configuration can elucidate on ‘problems’ and ‘solutions’:
how serious, for who, how extensive, will a proposed technical solution
actually be disruptive? And may be used in specific focused projects. E.g.
explicating the current set of work practices in A & E.
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Discussion: Timing in the Art of Integration (ii)
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Integrating Users in Integration Work
Users involved most in (1) specifying their current practices and (2) testing
‘testable’ prototypes
Integration decisions are often taken without consultation even where several
possibilities for implementation exist
Include in discussions over practice preservation-transformation
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Provide hands-on access to the biography of the developing system
Timing Types of Integration Work
Configuration and simultaneous integration of all 4 types – of work processes,
of the system to the work practices, of the system to NHS requirements, and
of technical systems - overran by a year!
Separate forms of integration work and to undertake some integration work
prior to design
Undertaking integration work during procurement may help in selecting an
appropriate system
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Opening the black box
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Conclusions
(1) during the deployment multiple forms of integration work were going
on together
(2) different integration requirements competed with each other for how
they shaped the design
(3) the form of integration work most directly related to usability –
successful integration of the system with working practices – was
dealt with too late on in the project and was often treated as less
important than other integration requirements.
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Hybridizing ‘traditional’ RE with ethnographic and PD ‘patches’ in
specifically timed activities may help:
• Procurement – (1) focusing ethnography on current integration practices,
and (2) involve users in integration and standardisation decisions
• Build and configuration – targeting ethnography to study practices
where there are concerns or disputes that the new system may fit badly
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