Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study
Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study
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DOI：
10.1136/bmj.c3111
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发表时间：
2010-06-16
影响因子：
105.7
通讯作者：
Potts, Henry W. W.
中科院分区：
文献类型：
--
作者：
Greenhalgh, Trisha;Stramer, Katja;Potts, Henry W. W.
目的评估制定和实施集中存储的患者病历电子摘要的国家计划。设计混合方法、多层次案例研究。设置英国国家卫生服务 2007-10。简要护理记录 (SCR) 是作为国家信息技术计划的一部分引入的。对 SCR 的评估在国家政策及其在三个地区的一线实施和使用的背景下进行了考虑。 参与者和方法 对定量数据（全国创建的累积记录加上参与初级保健非工作时间和预约中心的 416 325 次接触的数据集）进行了统计分析。对定性数据（140 次访谈，包括政策制定者、管理者、临床医生和软件供应商；2000 页人种学实地记录，包括对 214 次临床咨询的观察；以及 3000 页文件）进行了主题和解释性分析。 结果 创建个人 SCR 并支持其采用和使用是一个复杂、技术上具有挑战性的、劳动密集型的过程，其发生速度比计划要慢。到 2010 年初，已创建了 150 万条此类记录。在参与的非工作时间初级保健中心和非预约中心中，4% 的就诊中获得了 SCR，而在有 SCR 的就诊中，有 21% 的就诊获得了 SCR；这些数字在一些但并非所有地点都在上升。 SCR 访问的主要决定因素是临床医生的身份：个别临床医生在 0 到 84% 的时间内访问可用的 SCR。当使用时，SCR 似乎支持更高质量的护理并增加临床医生在某些情况下的信心。没有直接证据表明安全性有所提高，但研究结果与对预防用药错误的罕见但重要的积极影响一致。 SCR 有时包含不完整或不准确的数据，但临床医生会明智地利用这些数据以及其他来源。 SCR 的使用与缩短咨询时间或减少转诊次数无关。 SCR 的成功引入取决于来自不同领域（临床、政治、技术、商业）、具有不同价值观、优先事项和工作方式的多个利益相关者之间的互动。该计划的命运似乎取决于变革推动者的能力，以弥合这些不同的制度世界，调整其相互冲突的逻辑，并动员实施工作。 结论 集中存储的电子摘要记录的好处似乎比许多利益相关者预期的更加微妙和偶然，临床医生可能无法访问它们。当它们在全国范围内实施时，复杂的相互依赖性、固有的紧张关系和高实施工作量是可以预见的。
Objective To evaluate a national programme to develop and implement centrally stored electronic summaries of patients' medical records.Design Mixed-method, multilevel case study.Setting English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts.Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively.Results Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme's fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort.Conclusions Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.