small-scale implementation of structured documentation a...
TRANSCRIPT
Small-scale implementation of structured documentation
– A case study of user experience and implementation
approach
Author: Oskar Kuus
Master's Programme in Health Informatics
Spring Semester 2014
Degree thesis, 30 Credits
Author: Oskar Kuus
Main supervisor: PhD, Maria Hägglund, Department of Learning, Informatics,
Management and Ethics, Karolinska Institute
Co supervisor: ST Physician, Markus Takanen, Stockholm County Council
Examiner: Assoc. prof, Nabil Zary, Department of Learning, Informatics,
Management and Ethics, Karolinska Institute
Content
Abbreviations ...................................................................................................................................... 4
List of Figures ....................................................................................................................................... 5
list of tables ......................................................................................................................................... 5
Acknowledgment ................................................................................................................................. 6
Abstract ............................................................................................................................................... 7
Background ................................................................................................................... 8
Maria Ungdom..................................................................................................................................... 8
Organization .................................................................................................................................... 9
Electronic health record system at Maria Ungdom ...................................................................... 10
Structured Data in medical records................................................................................................... 11
Structured data at Maria Ungdom ................................................................................................ 13
Implementation in Health Care ......................................................................................................... 13
Problem Description .......................................................................................................................... 18
Aim .................................................................................................................................................... 19
Research Questions ........................................................................................................................... 19
Method ........................................................................................................................ 20
Design ................................................................................................................................................ 20
Other options ................................................................................................................................ 21
Why A case study .......................................................................................................................... 22
Setting ............................................................................................................................................... 22
Participants .................................................................................................................................... 23
Timeframe ..................................................................................................................................... 23
Data Collection .................................................................................................................................. 25
Questionnaires .............................................................................................................................. 25
Interviews ...................................................................................................................................... 27
Selection process ........................................................................................................................... 30
Ethical Consideration ......................................................................................................................... 31
Limitations ......................................................................................................................................... 32
Result .......................................................................................................................... 33
Implementation process at Maria Ungdom ...................................................................................... 33
Expectations Before the Implementation ......................................................................................... 36
Experiences during the implementation ........................................................................................... 37
Discussion ................................................................................................................... 42
Result Discussion ............................................................................................................................... 42
Method Discussion ............................................................................................................................ 45
Future Work ...................................................................................................................................... 46
Conclusion ......................................................................................................................................... 47
References ......................................................................................................................................... 48
Appendix 1 ......................................................................................................................................... 51
Appendix 2 ......................................................................................................................................... 54
Appendix 3 ......................................................................................................................................... 57
Appendix 4 ......................................................................................................................................... 58
Appendix 5 ......................................................................................................................................... 59
Appendix 6 ......................................................................................................................................... 60
4
ABBREVIATIONS
APT Regularly work place meetings
EHR Electronic Health Record
MD Medical Doctor
MM Mini Marior, subclinic to Maria Ungdom
MU Maria Ungdom Clinic in Stockholm
ST Residents Physician
TC Take Care, Electronic Record System
5
LIST OF FIGURES
Figure 1 Hierarchy Maria Ungdom (MU) ............................................................... 10
Figure 2 Adoption Curve (11) .............................................................................. 14
Figure 3 Timeframe for study and Implementation at Maria Ungdom ..................... 24
Figure 4 Questionnaire tool JotForm .................................................................... 26
Figure 5 Timeline of implementation process ........................................................ 33
LIST OF TABLES
Table 1 Pros and Cons of case study method ....................................................... 22
Table 2 Questionnaire participants working hours. ................................................ 30
Table 3 Questionnaire participants role at Maria Ungdom ...................................... 31
Table 4 Participants in interviews ........................................................................ 31
Table 5 Translation of questionnaire statements ................................................... 36
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ACKNOWLEDGMENT
Thanks to my supervisors Maria Hägglund and Markus Takanen supporting this study
and being an asset in the process of writing and analysing the material.
Also thanks to Maria Ungdom that let me into their organisation and follow the
implementation of structured documentation.
Big thanks to all in the personnel for a professional and nice treatment. Thanks for
your participants in the study as without it would not had been possible to do.
Thanks to friends that have supported by reading and helping to cope with the work
during the time of creating this study.
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ABSTRACT
BACKGROUND – Research has shown that there is a big interest both nationally
and internationally to increase the overall quality of clinical documentation. Poor
documentation quality lowers the readability and safety for the patients and it makes
documentation an increasingly important subject for improvements. Success rate of
changes relies on the resistance to change and how well the implementation is done.
Documentation at Maria Ungdom is in the process of changing from being
unstructured to a structured template.
OBJECTIVE – The main aim of this study is to explore the challenges of doing
continuous, day to day health IT implementations, by investigating the
implementation of a structured documentation template at one clinic. Focus lies on
the personnel’s experiences of the changes; what concerns and expectations they
may have. The study also aims to identify what potential problems and hinders can
occur when doing smaller implementations at clinics, and propose
solutions/strategies for how such issues could be avoided in similar implementation
processes.
METHOD – The study is a qualitative case study with instrumental design. All data
were collected using interviews and questionnaires that were analysed using content
analysis and descriptive statistic.
RESULT – The implementation process lacked a clear project plan with written goals
or risk analysis. The personnel had positive expectations and an interest in seeing
changes to their documentation but the implementation process caused some
unexpected challenges along the way that affected their daily work routines.
CONCLUSION – The result highlight the lack of well-established plan on how the
implementation should be conducted. The personnel did have a positive attitude and
high expectations for this implementation. They understood the problem that needed
to be solved and wanted it to be solved. Instead some disappointment was found
when the implementation did not fulfil their expectations and demands on solving the
issue at hand. Could this be helped by more support from higher up management
and get more support and information before launching a project.
KEYWORDS - Structured documentation, change management, expectations and
concerns, user involvement.
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BACKGROUND
This is a study about the implementation of structured documentation at a clinic in
Stockholm. Previously documentation was done in an unstructured format and now
there are plans to change this to be more structured and to lay ground for future
features of extracting statistics from the EHR system. The study aims to follow the
implementation of structured documentation at an acute care clinic; to explore how
these changes affect the personnel and what their concerns and expectations are
when responsibilities and workflow are changing.
MARIA UNGDOM
Maria Ungdom is a clinic in Stockholm, where children/teenagers and their parents
can receive help for various drug and alcohol problems (1). They are specialised in
helping these patients and are part of the health care system in Stockholm County.
Multidisciplinary teams work at Maria Ungdom (MU) to treat patients with their
special knowledge about drug and alcohol problems within the younger group of the
population. They also offer help to not just the patients but also the families that
often in these cases are affected of the situation that the patient is in.
MU was established around 1960 and has from the beginning been unique in their
specialised care and cooperation with several specialists within the health care
system. They also have close cooperation with social workers and other instances
that work with children and teenagers with different types of problems and needs.
MU is for all under 20 years old (1) and can act as a youth clinic to seek council and
help. Patients over 18 years old (2) can receive care without anyone else knowing
while those under 18 years old can still receive help but then there legal guardian will
be informed.
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ORGANIZATION
The acute ward at MU has about 7 beds for full time care, investigation and
detoxification. MU´s acute care also has room for those that need sobering or a
specialized care for teens with complex care needs. Stockholm and surrounding area
consist of several MiniMarior (MM) that are smaller clinics spread out that can treat
patients. MU also has a specialized youth centre to offer counselling and care for
teenagers with different sexual and medical needs.
At MU there are several types of care professions that operate and deal with patients
in different stages. Examples of those can be; nurses, psychologists, auxiliary nurses,
family concealers, researchers and medical doctors (MD).
In total MU have 90 hired personnel and of those about 35 works at the acute care.
3 Medical doctors
20 Nurses
12 Auxiliary nurses
MU is led by a section manager and a medical manager. The acute ward is led by a
section manager and a nurse manager. Picture below illustrate the MU hierarchy;
10
Figure 1 Hierarchy Maria Ungdom (MU)
Most common is that a patient comes to MU´s acute care with either a referral from
one of the MM or being brought by the police.
ELECTRONIC HEALTH RECORD SYSTEM AT MARIA UNGDOM
Today at Maria Ungdom a system called Take Care (TC) is used for medical
documentation. TC was introduced 2008/09 and is today the main program for all
documentations by the medical professionals. Before TC a program called Melior was
Acting Section Head
Acute and daycare Unit
Assistant Head Nurse
Lifestyle reception for Girl and Boys
department Head midwife
MiniMariorna Head Nurse
MM Sthlm
Head Nurse
MM Södertälje
Salem Nykvarn
Head Nurse
Specialized Outpatient / Investigation Team Head
Nurse
Medical management responsibility as Deputy
Division Chief
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used. It is in TC that the new templates will be implemented and will be used on new
patient visit documentation template.
STRUCTURED DATA IN MEDICAL RECORDS
Yes and No or other short and very precise answers is something that the digital
world relies on. Strings of 0s and 1s builds up the language of computers and also
represent a switch between one choice and another (3; 4).
It is possible to distinguish data in how structured they are by dividing them into
structured, semi-structured and narrative. Structured data can be defined as
information that resides within fixed fields inside a record or file. Semi-structured
data does not need to conform to a formal structure of models but contains forms of
tags or markers that enforce a type of hierarchy. Narrative data are the opposite to
structured where uses field texts, such as stories, autobiography, journals, field,
letters or conversations (5).
Lots of time and resources have been put in around the world to go from paper
based documentation to an electronic system to input and output data about
patients. The transfer from paper to digital options has opened up new ways on how
the data can be represented and used in a more effective way (6). The computers
have also opened doors of ways to use the data by either letting the computer
analyse it and offer different kind of answers and tips to the users, called decision
support systems. Or extracting the data and use it for example statistics (6) in public
health research. The digitalization of health records also allows for en improved
efficiency in storage of journals that makes it easier to share and find specific data
faster. Even if all hospitals, clinics and other health care settings are sharing data
between each other, it is technology wise possible to do so. Today this is hindered by
either ethical and legal laws and also the fact that health care software are not setup
to communicate with each other between different formats and types of the data
files.
12
Structured data, known barriers
Clinician time for note completion
Difficulty to find out relevance and loss of information.
Well written narrative data can be easier for a reader to understand,
convincing and comprehensive.
Natural language fits narrative data entry more than structured data and can
have and can still allow for a fast data entry. (7)
Semi structured documentation to balance between the structured way and narrative
way is often used in today’s EHR systems. Semi structured data entry allow for a mix
of following predefined keywords and writing under predefined labels. With this way
it is meant to control the input to end up in specific places in the medical record and
the predefined keywords allow for the system to understand the input and
standardize it to all clinicians reading about the patient. When displaying data in
chunks in a semi structured way it helps readers to locate data more efficiently (6).
Some researchers claim that separate structured data entry from free text entry is
not good, that it is more efficient to try and combine them at one place and allow a
smooth switch between the two (7). Then it becomes important to be able to let the
computer system carry out tasks, such as decision support on the data that have
been entered. Doing this on non-structured data is much more difficult and can risk
the validity, compared to doing it on structured data where machine learning
techniques come to more effective use.
So while structured data is required to report clinical quality measures and exchange
data with other providers, many providers feel that capturing data in a structured
format limit their ability document medical visits in an efficient and effective way.
Often it is preferred to document using more flexible tools such as speech
recognition technology for free text documentation. Narrative notes can be a strong
positive factor to avoid the feeling of just cloning data between patients and making
the entry more personal about a specific individual.
13
An article about tension between structure and flexible documentation (8) argues
that the success of a good EHR system depends on how well it actually supports the
crucial part, documentation. This has led to a deployment of systems that prioritize
direct structured documentation, which lead to the question of how systems that are
not adapted to this will perform in reality. The authors recommend that healthcare
providers should be able to choose how they want to document based on their
workflow and need of content.
STRUCTURED DATA AT MARIA UNGDOM
The National Board of Health and Welfare have a project running that the
government initiated to coordinate national guidelines on how to work together with
information structured, to create the best possible conditions for a structured heath
care and documentation system. This project is part of the bigger investment in
national e-health (9).
Previously at MU, some parts of the documentation have been in a structured form.
For example the suicide risk evaluation, several keywords have been used to make
the assessment as clear as possible. This way of working is now expanded to the
whole documentation template. The keywords used in Take Care today were
implemented at the same time as the TC system was launched at MU in 2008/09. At
that time a physician was responsible to develop keywords, but MU has no
documentation on how this process was conducted. Also the keywords were at that
time not the big change for the staff, the change of EHR system was.
IMPLEMENTATION IN HEALTH CARE
There are several different ways of how to do good implementation in the health
care system. It all depends on what is going to be implemented, where and when.
Generally (10) a good implementation wants to avoid interrupting the workflow to
much. With too much change organisations can have internal problems like work
tasks gets interrupted and changed. It can also have an impact on the
customers/patients that get a different type of service because of a big change in the
organisation.
14
The meaning of implementation can be related to both technical and more towards
the organisation and working related. In both situations some key success factors are
(11)
1. Amount of resistance to change
2. Amount of training before and during transition
3. Amount of buy-in from stakeholders
4. Level of effective reporting and evaluation of outcome during and after
implementation
5. Effectiveness in dealing with breaks
So to be able to achieve above success factors a study (11) mention the importance
of making the objective of any new system or change to be very clear and
understandable for all that are affected by or related to the implementation. It also
mentions that all positive or negative issues must be predicted and communicated
efficiently. When implementing something new it is expected to encounter some
resistance and trouble, but it is important to continue striving for the pre-defined
goals, as these can be achieved once the problems related to the initial increase of
workload have been resolved and the technology adoption curve is completed. This
process can be seen in below picture (11).
Figure 2 Adoption Curve (11)
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In a study about barriers to adoption it was listed several barriers that could be
problematic during an implementation (12). For example it talked about
organizational resistance, cost and lack of capital and product/vendor immaturity.
The organizational resistance was mainly focused on physicians disruption of
workflow as a cause of the resistance with an risk of escalation to rebellion. This
could be big hinders in an implementation and lead to organization being afraid of
doing too big and radical changes. To avoid this, the article (12) promotes the
benefits of having a strong leadership, identifying key people within the personnel
that could be the cause of a potential escalation. The article did also talk about how
important it is to help the users overcome the barrier of being afraid of changes to
their workflow. In the article (12) it was presented that many physicians did change
their mind after overcoming the initial training barrier and then wondered how they
had managed with the old system. This can in return be reflected back to figure 2
were the adoption curve is at the beginning very steep and work load is increasing
and so is the resistance. However when the initial training barrier have been
breached it starts to be clearer what the new benefits are.
The other barriers mentioned in the article (12) were about cost and vendor
immaturity. Cost can be a barrier that leads to other barriers like the organizational.
Being low on funds can lower the quality of a project were resources is needed to be
saved, not being able to give uses early access and training or using personnel for
the project with the correct knowledge and skills. The third and last identified barrier
(12) was about vendors and how software’s have very bad adaption to how the
health care workflows are designed. It also mentions the problems of being able to
connect a brand new system to previously used system. With cost and vendors as
important barriers both will eventually lead to the importance of involving the uses
and that the users are the biggest barrier to breach to do an successful
implementation.
Another important factor to ensure success in implementation of health information
systems is of course usability. Research has shown that many systems have been
abandoned because of poor design and poor usability (13). The aim for these
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systems was to reduce medical errors or improve efficiency of workflow. Instead with
poor usability for the actual end-users the opposite was achieved. Usability means
specific users in a specific context that do a specific task, and therefore, to improve
usability during an implementation it is important to first identify the intended users
and what their needs are. Validating the proposed solution by involving members of
the intended user group before you design is also crucial (14).
So to overcome the barriers when doing an implementation involving the users in the
change management is an important factor (15). This can help to overcome
resistance, reduce needed training or make it more effective and efficient and
increased chance to successful buy-in.
A study comparing small and large implementations (16) describes how small scale
implementations appear to be unimportant in a political, demographic and economic
climate that focuses on radical long-term changes. However the article state that by
overlooking the small changes and not giving those the appropriate attention, it can
lead to future problems when larger changes and implementations are being done.
For example the study (16) shows that focusing on minor issues can strengthen the
user - management relationship that can be a key factor in larger implementations.
By increasing the relationship between user and management the process during an
implementation when the workload is increasing (figure 2) at the beginning can
reduce frustration, anger and stress when something new is being implemented.
IMPLEMENTING AT MARIA UNGDOM
From the management at MU, it have been found that they are not following any
specific method or technique when implementing new routines or other things that
change the workflow for the personnel. Neither do they have any routines to
document changes or evaluate how an implementation has been received.
While talking to the management for the acute care at MU, the impression that
implementation was something that previously have worked very well and that they
did not see a need for change in their way of working. An implementation at MU is
something that happens quite rapidly.
17
Methods that can be considered in an implementation can be the following.
Parallel adoption; a method for transferring between an old system to a new
system. The aim is to reduce risks by letting old and new run parallel
simultaneously for some period of time (17).
Pilot running; where a new thing is tested in a smaller section of an
organisation before it is launched at full scale (18).
Direct changeover; where a change is done directly and all the old is taken
out at the same time leaving nothing left. For example when an organisation
closes for a period of time to remove the old and install the new (19).
Neither strategy is specifically used at MU, rather they take parts that fit them best
for a specific moment.
A Swedish study about nurse’s expectations and experience of electronic health
record systems (20) says there is a big interest both national and international to
increase quality on the documentation and agree on one terminology being used
within nursing. At MU when implementing a more structured way of documenting, it
is interesting to understand if the templates are meet by a positive attitude or
negative. According to the study (20) the result after describing the nurse’s
expectations and experiences after working with digital health record system, that it
was perceived as an increase in patient safety and readability within the medical
records. However in this study it was also noted that the system used was not logical
and in need of further investment in education and system development. At MU this
is a related topic even though it is not about an implementation of a new system, but
rather an upgrade or change to a current system. In the study it was mentioned (20)
that the personnel asked for uniform work routines, well adapted keywords and
continuous information and education. This result will be interesting to compare to
the findings at MU to verify what concerns and expectations the personnel have
when changes are made.
An implementation process success rate can rely on the actual systems features and
ability to be implemented in the workflow where it is intended to be used (21). This
18
could mean that implementation techniques and methods need to take the final
users concerns and expectations into account when making decisions on design and
workflow changes before the actual implementation is initiated. The study about
nurse’s expectations and concerns (20) also mention a need of continuous
development of a system and a need to reduce time spent at the computer. At MU
this can be relevant in terms of continuous evaluation and development of templates
to ensure that keywords are up to date.
PROBLEM DESCRIPTION
Implementation in health care is a big topic and it is an area that is just increasing as
more and more countries are going over from paper documentation to fully embrace
medical records in a digital form. Some are more ahead while others still are at the
threshold (22).
At MU they are implementing structured documentation in their current EHR system
called Take Care and will therefor undergo some changes. The changes expected are
mainly for the personnel that daily work with the patients and that are doing the
documentation in the EHR system.
Research within this area has so far focused on larger implementation processes
where for example new EHR systems are being implemented with extensive
resources to their disposal. Little research have been found on smaller settings like
MU where small changes are being introduced; how minor changes are received by
the personnel and also how such continuous change management is handled by the
management. Many small changes are done regularly at clinics around the country.
As mentioned above some major success factors when doing changes at a work
place includes involvement of the actual end users (23). If users can have a say
during the development of a future change several risks of failure can be eliminated.
Implementation of structured documentation at MU has the potential to bring
changes to workflow and possible changes to the personnel responsibilities.
19
How to achieve successful implementations in the health care sector is big problem
and something that is researched often (11). Even if a project is small it have been
identified that it is vital to do it with high quality to avoid failure and mistakes along
the way. As mentioned before lots of research have been done on large
implementations and often where fully new systems are being implemented. There is
however a gap of knowledge regarding the smaller, day to day implementations and
changes that personnel and management are involved in often.
AIM
The main aim of this study is to explore the challenges of doing continuous, day to
day health IT implementations, by investigating the implementation of a structured
documentation template at one clinic. Focus lies on the personnel’s experiences of
the changes; what concerns and expectations they may have.
The study also aims to identify what potential problems and hinders can occur when
doing smaller implementations at clinics, and propose solutions/strategies for how
such issues could be avoided in similar implementation processes.
RESEARCH QUESTIONS
How was the small-scale implementation of structured documentation at Maria
Ungdom conducted and experienced by the personnel?
To answer above research question, the following sub-questions where used to break
down the larger research question.
o What experiences did the personnel have before the implementation?
o What experiences did the personnel have during the implementation?
o How was the structured documentation template implemented at Maria
Ungdom?
o What improvements can be done for future implementations?
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METHOD
This study will investigate the implementation process of structured documentation
by describing how a smaller health IT implementation is done in a specific case and
what expectations and concerns the personnel have.
DESIGN
The design chosen for this study is called a case study and is one of the major
designs within qualitative studies. A case study can be defined in several ways, for
example:
“That it can be defined as an intensive, holistic, description and analysis of a single
entity, phenomenon or social unit. Case studies are particularistic, descriptive and
heuristic and rely heavily on inductive reasoning in handling multiple data sources.”
(24)
Which could mean that a case study focus on a particular event, individual institution
or phenomenon. A case study itself is important for what it reveals about a specific
target. So a case study is a good design for practical problems (25; 26; 27). Case
studies can be classified in the following way, three types of case studies (25).
1. Intrinsic study – Interest in understanding a particular case. Where the case
itself is of primary interest in the exploration. The exploration is driven by a
desire to know more about the uniqueness of the case rather than to build
theory or how the case represents other cases.
2. Instrumental study – Interest in understanding something more general
than the case. To give an insight into a particular issue or build a theory.
3. Collective study – Interest in studying and comparing multiple cases in a
single research study. Can be defined as a multisite case study.
21
This study would fall under number 2 as this study have the interest of
understanding something more general and give an insight into a particular issue
For a case study, multiply methods can be used to collect data, Interviews,
observations, documents and questionnaires. In this study interviews and
questionnaires were used which will be further described below.
The final report should contain and describe the whole case and what smaller parts it
is built up from. The description of the case context should be rich and holistic.
OTHER OPTIONS
Other options for design of this study could be some of the other major qualitative
designs, for example Ethnography, Grounded theory or Action Research (28; 29).
Ethnography is the study of discoveries and description of culture of groups of
people.
Grounded theory is a study of development theories, describing how and why
and is usually used to generate a theory or test already previously grounded
theories.
Action Research is the study of trying to solve an immediate problem or a
reflective process. It requires to actively participating in an organizations
situation while doing research.
The three options above were considered less suitable for this study. This study does
not aim to generate a theory or test an already established which is the main
purpose of choosing a grounded theory approach. It did not suit to use ethnography
because of not being able to be that close to the personnel and the clinic. The
outcome of this study will be a description of the author’s analysis of how the
implementation was conducted and how it was received by the personnel. Action
research was considered but was not suitable since this study did not try to solve an
already identified problem and opportunity to participate in the organizations change
process was limited.
22
WHY A CASE STUDY
For this study it was most fitting to choose the design of a case study. With the aim
of investigating the personnel expectations and concerns within a specific setting, a
case study was the most suitable method to follow. More detailed this is an
instrumental study and my aim is to understand a particular case; the situation at MU
where structured documentation is being implemented and how that affects the
personnel in terms of expectations and concerns.
The figure below describes pros and cons with choosing a case study approach. For
this study the cons like being a time consuming method was still determined to be
realistic to use for this studies timeframe. The fact that the aim should not reach to
big conclusions did suit this study since it does not aim to reveal ground-breaking
results but instead highlight a potential problem.
Pro Cons
Powerful to portray and describe something
to outsiders of a subject and setting.
A time consuming method to collect,
organize and describe fully.
It is often done to make practical
improvements.
Content will become outdated fairly quickly
and needs to be maintained.
It is display problems and solutions in a
structured format with insights that a reader
can apply.
It is not beneficial if the aim is to reach
rigorous conclusions or point out precise
relationships between variables.
Table 1 Pros and Cons of case study method
SETTING
To make this study it was necessary to be located at MU sometime before being able
to identify the research questions and the data collection methods to use. This has
helped understand the situation at Maria Ungdom, how they work and what daily
routines they have. Background data have also been collected regarding their
previously implementation strategies and information how they run projects. This
was helpful to identify potential research areas and specify the research questions.
23
The size of this study is considered to be quite small, because of the limited
personnel that is being targeted in this study. The focus lies on their expectations
and the result of the study will rely on what the personnel are willing to share and
what they share.
PARTICIPANTS
In this study focus lies on the acute care clinic where 35 contracted personnel are
working in different time shifts. As described in the background several health care
roles are onsite, but the main group is nurses and auxiliary nurses. Those will be the
main group targeted in this study but all in the personnel was included and had the
chance to express their concerns and expectations.
The selection process is more described further down, but with a low amount of
potential participants and voluntarily participation. The selection process was based
on who is available and willing to participate or as it otherwise is called Accidental
sampling/convenience sampling/opportunity sampling. That can be described as a
recruitment process were subjects close at hand were selected. However this means
that it is not possible to make a generalization about the total population, only a
approximation.
TIMEFRAME
This study was sensitive to time since it followed the implementation process live at
MU. When arriving at MU the project was already initiated and plans for launch were
in motion. During the first period of time most of the time spent was put in on
literature review work and learn more in detail what Maria Ungdom is and how they
are working.
24
The study has been divided up in 3 major blocks or chapters.
Chapter 1. Literature review and preparations.
The initiation of the study starts with research and preparations. At this time MU
plans their APT meetings (personnel workplace meetings) with the personnel to
inform about coming changes and a date is set when to launch the templates.
Chapter 2. Data collection
Data collection were done parallel to when MU launched the templates, first
questionnaires were handed out right before the launch and after about 3-4 weeks
interviews could start.
Chapter 3. Data Analysis
MU have used the template for about a month and several in the personnel have
been interviewed and answered questionnaires. The collected data needs to be
analysed for the study.
Chapter 4. Writing
Finalizing the results and study after analysing the data. At MU the responsible
physicians ST (Residents Physician) period is about to end and project will be left
with MU management.
Figure 3 Timeframe for study and Implementation at Maria Ungdom
25
DATA COLLECTION
Interviews and questionnaires have been used to collect data. With the size of the
study and the strict timeframe it is important to understand the workload that each
collection method needs to be done correctly and to find the best form fitting the
research questions.
Observations were also considered as a method of collecting data for this study but it
was put aside after realising it would not be possible at the setting to do a full
observation. In addition, observations were less beneficial for finding the answers to
the research questions. Focus groups were another method that could have been
used but interviews were decided instead because of uncertainty of being able to
access lager groups of personnel at once for longer meetings.
QUESTIONNAIRES
About one week before the personnel starts to use the new structured templates a
questionnaire was handed out. The aim of the questionnaire was to collect data
about the personnel’s early concerns, expectations and knowledge about this
implementation and previous implementation processes at MU. An additional
Motivation to have early questionnaires was that it might trigger thoughts and
discussions about the subject within the personnel group that could be picked up
during later interviews. Reason for choosing questionnaires was because it seemed
most fitting for the setting the study is conducted in and that it would fit well with
the plan to make the personnel think about implementation and what it means to
them. Questionnaires fitted MU since data had to be collected during the personnel
working hours and therefor limited amount of time was available for interruptions.
The aim for this questionnaire was to collect exploratory information (30) that allows
for non-formal questions that can collect open ended data from the participants. The
questionnaire also contained formal standardised questions where the participants
simply give an answer by using pre-defined checkboxes. The risk of mixing is that
most might skip the free-text fields and not add any own comments except just
26
filling in the checkboxes. However, in combination with the interviews the
questionnaires will capture the intended information.
Some key principles to use when designing a questionnaire can be (31; 32):
Know what information is required to be gathered
Develop a response format
Arrange questions in an appropriate sequence
Finalize layout of questionnaire
Revise and get reviewed
In the creation of this studies questionnaire the online tool JotForm (33) was used. It
provides a simple user interface where easy to use forms can be setup. The
participants can then simply follow a URL to find it and fill it in. All answers collected
is then stored in individual PDF documents on JotForm website there are also tools
that provide rough translation and analyses of the data being collected.
The form also included information about the questions aim and the study goal and
that there were plans to conduct interviews further on. Before filling in the
questionnaire, the participants needed to check a checkbox confirming their
awareness that the information in the form would be used in this study. Participants
had to give consent to be able to hand in the form.
Figure 4 Questionnaire tool JotForm
27
As seen in the figure 4, the questions used for the form was designed as statements
where the participants could enter if they agree, do not agree or don’t know. Using
this way of asking (34) helps to clarify what the author of the questionnaire want to
extract and make the participant take a stand in what they think. It was considered
to use more than three options but that did not give a reasonable advantage over
the disadvantages when analysing the data where answers would need more
interpretation if they are “agree a little bit” or “maybe do not agree”.
Deciding to go with digital format where the link of the form was simply mailed out
to the participants was decided after also considering a paper form. Both have
advantages but in the end the digital form was preferred with the motivation of it
being more fair to the participants that work in shifts and not all can be meet up with
and be handed a paper in their hand. Handing it in their hand was required to ensure
that all actually get it and not trust and rely on others to hand it out. It would also
mean that the hand out would be spread out on a longer timeframe compared to
email where all get the same email and information at the same time. It is however a
risk with emails that not all are reading them, but this is a risk that will always be. At
Maria Ungdom they already use email as a form of handing out news and
information to their personnel and therefor everyone should read their email. Before
handing out the questionnaire got reviewed by management at MU to get feedback
and correct errors and rethink how some questions were formulated.
Analysing the data collected have been done using Microsoft excel (35; 36) where all
answers have been collected and structured to be counted and summarized. This has
helped to be able to construct the interview questions and see patterns within the
personnel. This can be translated into descriptive statistics (37) where data is
described with what it shows and summarize the meaning of the data.
INTERVIEWS
Two groups have been interviewed in this study, personnel working at the acute care
clinic and the management connected to the acute care clinic. Interviewing
management was a good source to understand the process behind the scenes that
28
lead to the implementation of structured documentation at MU. The interviews with
the personnel were more focusing on the changes that the implementation brought.
Semi-structured interviews were chosen (38; 39), which means that they are well
prepared with clear questions of what to ask for and what type of answers is being
looked for, but they also allow for an open discussion in case there are more topics
to talk about. The reason to not make them too structured is because the study
looks for people’s feelings about potential concerns and expectations. This means
that the interviews need to allow for spontaneous discussions and questions to catch
specific topics that individuals can be interested to share. Used interview guide can
be viewed in appendix 3.
“A qualitative research interview seeks to cover both a factual and a meaning level,
though it is usually more difficult to interview on a meaning level.” (40)
Interviews can be divided up in several types (41); they can be explained with the
following.
1. Unstructured interviews
Unstructured interviews can be more free flowing and open ended. They tend
to resemble an everyday conversation rather than an interview. It is an
interview without a set format but they can have some key questions
prepared beforehand.
2. Semi-Structured interview
Interviews that do include an outline of a topic or issue to be investigated,
but the interviewer is free to vary the wording and order of questions.
3. Structured Interview
This is to ensure that the same general areas of information are collected
from each interview. It provides a more focused conversation and approach
but can still allow for a small degree of freedom and adaptability in getting the
information from the interviewee.
29
Based on those types, this study will be using the semi-structured interview guide
approach where predefined questions have been created but with the intention of
not following them blindly and be open to how the conversation with the interviewee
is going. The time frame for each interview was approximately 20 minutes.
Each interview has been recorded using an Android smartphone and each
interviewee has signed a consent form where they agree to participate but are free
to leave the study at any point, and that they have had the opportunity to ask
questions about the study. All recordings will be fully anonymous and be treated with
care of the individual privacy; each file will be deleted at the end of this study.
The interviews were recorded and transcribed, in order to enable analysis and
identification of patterns. The analysing process will be utilizing the technique called
content analysis (42). Each interview will be broken down and divided into codes that
represent answers that the interviewees have given during the interviews. They can
then be used to find patterns and themes in the answers. The process of analysing
the interviews was done using the following steps:
Step 1: Reading all transcripts
After each transcript had been finished it was carefully read to later be read several
times at different speeds, with the purpose of learning the data and understanding
the meaning of what had been said during the interviews. This process gave ideas
and thoughts of what to later work on, some notes were made while reading.
Step 2: Finding meaning units
This is an extension of making notes from the previous step. The author interpreted
the conversation to be able to set labels to important sections that was relevant to
the study. Whole conversation sections, words or sentences could be marked in this
stage.
30
Step 3: Condensed meaning units and pairing
Identifying the meaning of previously marked data. Try to interpret the data and
understand what do they mean and find common themes that was paired with
similar sections, words and sentences.
Step 4: Theming
Combine into categories with similar meaning, feel and information. This was the last
step that resembles the result and with categories describing each finding from the
data collection. Codes were combined into categories with similar information and
meaning.
SELECTION PROCESS
Because of the low numbers of possible participants (n = 35) for this study and that
it is completely voluntary to participate, therefor convenience sampling were used.
Participants in questionnaires
It was decided to send out a letter with information with a link to the questionnaire
via email to the entire personnel group. Other methods for administrating the
questionnaire were considered but with the overwhelming benefits for the author to
get answers in a digital form they were put aside.
Only 8 questionnaires were submitted even after prolonging the deadline, despite
several reminders by the author and with the help of management at MU.
Table 2 and 3 display questionnaire participants’ roles at MU and what working hours
they had.
Working Hours Amount
Day 7
Night 0
Both 1 Table 2 Questionnaire participants working hours.
31
Role at Maria Ungdom Amount
Medical Secretaries 1
Nurse 6
Auxiliary Nurse 1
Physician 0 Table 3 Questionnaire participants role at Maria Ungdom
Participants in interviews
For the interviews the selection process was similar. First information was sent out to
all in the personnel via email, it had also been mentioned that interviews were to
happen in the information for the questionnaire. Then direct visits were made at the
acute clinic office, at specific hours that the management had highlighted as most
appropriate to ask if anyone would care to take part either direct or make reservation
some days ahead.
In total 9 interviews were made, 2 with management and 7 with personnel at MU.
Code Role
N1 Nurse
An1 Auxiliary Nurse
N2 Nurse
P1 Physician
N3 Nurse
N4 Nurse
N5 Nurse
M1 Management
M2 Management
Table 4 Participants in interviews
ETHICAL CONSIDERATION
This study has two groups that it investigates; personnel working with patients at MU
who are directly affected by the structured documentation implementation, as well as
the management who are responsible for the planning and leading the
implementation process.
32
All respondents involved in this study, personnel answering questionnaires and
participating in interviews, have been treated with respect to their daily work
routines. All participants can whenever they want request more information about
the study or freely decide if they want to stop being part of the study.
Collected data have been treated carefully and confidentially to ensure that no
participant´s identities are revealed. Data have been saved on local storage device
and backed up on a similar storage device.
LIMITATIONS
During the work with this study some unexpected hinders was occurring that forced
some changes to the focus of the study. Access to MU and how the implementation
of the template changed were some reasons to adapting to the setting to find the
most appropriate focus.
Other limitations during this study have been time and ability to get enough
participants for the data collection section. Reaching out with information and getting
back data on questionnaires was difficult and lead to changes in the approach of how
interviews were handled.
33
RESULT
The result has been divided up in three main sections where the first section
describes the events at MU during the implementation, with quotes from the
management and personnel.
The following three sections concentrate on highlighting findings from the
questionnaires and interviews done with personnel and management. This indicates
how the implementation affected the personnel, highlighting their expectations prior
to the implementation and experiences of the actual implementation process.
IMPLEMENTATION PROCESS AT MARIA UNGDOM
It all started with informal talks within the management and personnel that patient
get asked the same question several times by several different people within the
personnel. For example, a physician investigates what drugs the patient has been
using and then the same questions are repeated by a nurse. It was expressed that
this is not only double work, but can be a problem for patients who have to repeat
sensitive information several times during a visit.
Figure 5 Timeline of implementation process
34
Therefor it was decided that something needed to be done about this double
documentation and a more streamlined way of working and cooperating between the
work groups were needed. No formal decision was made, but when a physician who
had previous experience of implementing structured documentation was scheduled
to do his ST period at MU it lead to more formal discussions of whether structured
templates could be a solution to the double documentation issue.
As the physician’s ST period drew closer more plans were made and it was decided
to create new templates in the EHR system to let the personnel document in a more
structured way. The process started with planning of how to introduce structured
documentation at MU and how it would be done during the physician’s 3 months ST
period. A group of 4 people was setup that actively worked with this; the physician,
the assisting head nurse, an administrator and a consultant with a specialised
knowledge in this field that had previously worked at MU.
The template was designed by the physician before his ST period started. The early
plan was to introduce the new templates when the physician were in place at MU
and could give direct support to the implementation.
It was decided that in the middle of February would be a good time to launch, but no
specific date was set. With about one month left, information about the new way of
documenting was presented to the personnel at their APT meetings (regularly work
place meeting). It was presented with the main goal of reducing double
documentation at MU and would make it easier to extract statistic from the EHR
system in the future.
“How good the medical records are should not rely on who is doing the
documentation, it should be clear for the personnel no matter what profession they
have; what should I document, where and under what subject” (M2)
From the beginning there were no doubts that all personnel at the acute care would
start using the structured way of documenting at the same time. As the launch date
35
came closer it was finally decided that only the physicians would do it and not the
nurses or auxiliary nurses.
”We started with the physicians as we thought it is a small high educated group, that
is not as diverse as a big employee group can be” (M1)
First Monday in March was set as the implementation day when the old template
would be removed and the new one would be introduced for all physicians at MU.
Even though only the physicians were to use the templates created, all in the staff
had been informed about the changes at APT meetings. During these meetings, it
was expressed by all, that there is a need to fix the double documentation issue, and
that this issue is not solved by only letting physicians use the new templates.
When the templates were introduced it was meant to only give access to physicians
at MU and that the rest of the personnel would be working with the old system. All in
the personnel got access to the new templates that were meant for only the
physicians. This mistake was then not immediately corrected because of missing
permissions in the EHR system. The need of waiting for TC support to fix the
problem meant that all in the personnel had to use templates designed for physicians
and not for e.g. nurses that have more focus on welfare work at the clinic.
36
EXPECTATIONS BEFORE THE IMPLEMENTATION
The expectations before the templates had been launched were investigated with a
questionnaire that is presented in table 5 below.
Translation of questionnaire statements
A DA D
1 I think it will be a big difference to work with the documentation when the new templates have been introduced.
3 0 5
2 I think it is hard when changes occur. 0 8 0
3 I believe that the quality of the documentation will be worse. 0 7 1
4 I think it will be less work with the documentation after the
implementation. 4 0 4
5 I think double documentation at Maria Ungdom is a big problem. 7 1 0
6 I am well prepared on the changes that are about to happen. 3 3 2
7 I will not change may way of documenting. 1 5 2
8 I think that the changes won’t affect me. 0 5 2
9 I think the management listens to me when I have something to say about
planned changes. 6 1 1
10 I have been educated in documentation. 7 0 1
11 I have been educated in structured documentation. 3 4 1
12 I have been educated in using computers at Maria Ungdom. 3 5 0
13 I think that earlier implementation and changes at Maria Ungdom have
succeeded. 4 1 2
14 I think Maria Ungdom gives information to me in a good way about
planned changes. 6 1 1
15 I want more information and be more prepared about changes in work. 5 2 1
Table 5 Translation of questionnaire statements . Numbered column from left to right, agree, do not
agree, do not know. A = Agree to statement, DA = Do not agree to statement, D = don’t know.
In the questionnaire it was noted that it is evenly divided between the options (Table
5 gives an overview of the responses). Some in the group think that they have been
well prepared for the coming changes (n = 3) while some do not think so (n = 3)
and others simply don’t know (n = 2).
Acceptance to change
As seen in statement number 2 all have answered that they do not agree that it is
uncomfortable or hard to have changes in their workplace. In number 4 it is evenly
divided between don’t know and agree on that the new template will make the
documentation work easier and more simple. Also in number 8 about how the
change will affect the personnel, many believe that the change will affect them. None
37
agree to the statement in number 3 that the quality will be worse with the new
templates.
In statement number 15 many (n = 5) want more information and to be more
prepared when changes occur. In statement number 14 and 13 they do agree that
they still get information in a good way and that earlier implementations have been
done in a good way.
Education
Most seem to remember that they have been educated in documentation, in
statement 10. It is evenly spread and an uncertainty if they have got the education
about structured documentation, statement 11.
Problem Awareness
Number 4 and 5 are interesting, it shows that many agree on that double
documentation is a problem at MU and that this change with structured
documentation will reduce their workload.
EXPERIENCES DURING THE IMPLEMENTATION
After the implementation had begun, interviews with the management and personnel
were performed. The aim was to identify problems and hinders that occurred, to
explore concerns and their viewpoint of the project and to be able to propose
potential improvements for future implementations at MU and at other similar
settings.
Following themes have been identified and will be further described below:
Lack of information dissemination
Strong problem awareness
Poor adaption to user group
Acceptance to changes
Changes in responsibility
38
Lack of information dissemination
Comments in the questionnaire indicated that information about structured
documentation had been delivered by MU but no education in how to use it together
with the EHR system TC.
”Have been informed about structured documentation but no direct education or
training and do not know if one is needed” (Questionnaire)
There was some awareness that the documentation had problems and hinders that
had been discussed at MU for a long time. Structured documentation was not a term
that many knew about or had been prepared for. The only information that was
given about the coming changes to the documentation was during the APT-meeting
and not all in the staff force had been at that meeting. This was confirmed in the
later interviews.
“Eh…I think I never got it” (N1)
The interviews also highlighted the fact that those not attending the APT meetings
risked missing out on information about the implementation. However it was also
mentioned in the interviews that it can be considered the personnel’s responsibility to
make sure they know what have been discussed if not attending a meeting.
“I can have missed an APT meeting” (N2)
Strong problem awareness
A common theme during the interviews was that all recognized the fact that double
documentation was an issue at MU and that there was a need to structure who is
doing what and who is documenting under what categories. Among the nurses and
auxiliary nurses it was noted a bit of disappointment about not being included in the
launch and first version of the template that instead was designed towards the
physicians.
39
“I was relieved when I heard that changes were going to be made on the keywords
used, finally. Then I realised it only meant physicians and that not us Nurses from
the beginning” (N3)
“There are many keywords in the anamnesis that are not good and need changing”
(N5)
“First, a lot of positive feelings when I heard about it, but then it became a physician
template and I was a bit… what … is this how it should be, that is not good.” (N4)
Poor adaption to user group and clinical context
When the interviews started with the personnel, the new template had been used for
3-4 weeks. It was quickly noted that several interviewees mentioned that something
was not right.
It was also expressed that a risk factor could be that not all keywords would be easy
to collect and use and that the information could become harder to interpret
between colleagues.
“Suddenly one morning I just noticed that everything looked different and all seemed
a bit confused” (N2)
“It seems some mistake is made, the template came to us nurses and auxiliary
nurses. When we were informed about the changes at the APT meeting we were told
that the template was for the physicians and not us. After that we noticed that we
also had those templates available. It caused quite a lot of discussions within the
personnel, that the template does not really fit us.” (N4)
“I have noticed that many new keywords have showed up in my templates. Suddenly
strange headings like source of income and things that felt very irrelevant to the
children and teenagers that we work with” (N1)
40
The talks with the personnel did however not reveal any big frustration or irritation
about this, it was more of an acceptance and that they all believed that it would be
solved over time.
“I am trying to squeeze in my anamnesis even though the template is not working
for us. It is hard, but as far as I know it will go back to the old system soon.” (N2)
Some keywords were difficult to use in the acute clinic setting working with
teenagers and children. For example “accommodation form last 30 days” that was
expressed as hard to apply on teenagers, since teenagers can be in a situation where
they live with different parents each week. 30 days was also considered too short a
time period, it does not tell anything important compared to a longer period. Some
thoughts about the reason for these terms were mentioned during the interviews,
that they could come from clinics dealing with adults and not teenagers.
Acceptance to changes
When the template went live and all physicians and all in the personnel had access to
the templates and were forced to work with them, it meant that a nurse needed to
put data under categories and use keywords adapted for physicians. The nurses and
auxiliary nurses had to figure out how to push in their documentation under
keywords not fitted for their workgroup.
Information given by the interviewees did not give any kind of indication that the
care towards the patient had changed in terms of getting better or worse. A calm
feeling was given that their main focus was always towards the patient and that the
documentation was something that came second.
Changes in responsibility
On the question about changed responsibilities and new tasks in their daily work,
none answered that anything had changed.
41
“No, I don’t think so. We have had our normal dialog with the families and patients.
What we are doing now is more of trying to squeeze in a square into a circle. I do
not think anything have gone out over the patients.” (N4)
“No I am still thinking I have a big responsibility for the patients and that this focus
will not change.” (An1)
However during one APT meeting it was mentioned that there can be expectations
on the nurses and auxiliary nurses to know and understand the documentation and
be able to instruct new physicians in the way MU works. How this would be different
from today is not known.
42
DISCUSSION
During the work with the study, the implementation process at MU underwent
several changes that forced the study to change to still fit in the setting. For example
the initial plan of introducing the new documentation templates to all in the
personnel was reverted to only apply to the physicians. Then all in the personnel
anyway got access and worked in templates created for the physicians. This was
highlighted during the interviews with the personnel and that many had been forced
to use templates not adapted to them and their work tasks.
Being able to do a study at a clinic looking at a real life project and follow a group of
people is a good opportunity to give something back to the personnel and
management at MU, but also to external readers of the study. This study will be
valuable for the management of Maria Ungdom as well as other parties investigating
strategies of implementation and risk factors of doing changes at a workplace. The
data being collected are the personnel’s own thoughts about the changes being
made at their workplace.
The results can be transferred to other similar settings were changes in
documentation routines or more general changes in workflow are to be implemented.
The results highlight aspects in both the implementation process and give quotes
from personnel about their experiences during the process.
RESULT DISCUSSION
The results from this study indicate that the implementation was not a complete
success because of how the implementation process was conducted. Decisions made
on how it should be done were not followed and errors made were not fixed fast
enough and instead personnel were forced to work using templates that were not
designed for them.
43
Already from the beginning of this study it was a bit of a mystery to the author to
not being able to find any written time plan, risk analysis, plan with aim and goals for
this implementation. Along the way it was cleared up that this way of working at MU
is considered normal and there is not enough time to build a solid project plan.
Research made in Sweden (43) show that many failures of implementations are due
to the absence of feedback from end–users to the developers. It states that it is
important to incorporate the knowledge from the end users to prevent rejection of
new health information systems. Further the article talks about the importance of
involving both management and users in the implementation process. Early
education and training is also essential to quickly establish compatibility between the
new and old (43).
Having a plan is an easy way to defend and ensure that any type of implementation,
change or development can be operated more smoothly (44). Below are some key
factors that a well-established project plan can give;
More transparent organisation of work
A project plan makes the work become more open and it lets all being able to
question what is done, how it is done. This is good since risks can be eliminated
directly at an early stage.
More organized work
Those working in the project have it easier to understand and know what to do and
when to do it. All knowledge is not in one persons head, instead it is hared among
many.
Project Goals and aim
Defending the project is always needed. Outsiders that do not know why something
is done will ask questions. Then clear and stated goals can answer these questions
right away. The goals are also a tool for those working in the project to always
evaluate towards the goals if they are still on track or if deviations have been made.
44
For MU it could have helped to avoid the miss when templates were introduced to all
after decision had been made to not. A risk analysis could contain these risks and the
project team would be prepared for it and have already established actions to take to
correct or modify the process faster. In other words formative and summative
evaluation could have been used to identify users needs, especially since the result
show that they do understand the problem and want to have it fixed.
The lack of a written down plan became clearer when interviewing management
personnel and they did not know the process or how the work was conducted in the
project. Questions asked to the management were instead meet with “I don’t know”
and that “I trust that they have thought about that”. A project plan acts as a very
strong defence and Q&A towards the project, both for outsider readers and to those
involved (44).
Looking back to figure 2 and the adoption curve, MU is still in the early phase of
implementation were workload is slowly increasing because of the need of adapting
to the new template. Further on the workload will start to slow down when it
becomes a natural work task after having done it several times. So the gain of an
implementation is not seen until the newly implemented templates have been live for
quite some time. This can be important to know when doing an implementation that
most likely will be a though period of time during the implementation and the real
gain wont be seen until all have learned the new process and been able to let the old
one go.
When researching the expectations and concerns from the personnel it was found
that not many had anything directly negative to say. It was clear that they all had an
interest in the fact that documentation was going to change and that it did highlight
a problem of double documentation and a lack of structure of who is doing what,
what is documented using which keyword. At the same time however there were no
big reactions to the mistake of introducing templates not adapted for the larger
portion of the personnel force (nurses and auxiliary nurses). Comments presented in
the result that they had to squeeze in information under headings that were not
45
adapted did not give of any big feelings of frustration, more of an acceptance that
this is how it is and “I am sure this will be fixed soon”.
As a conclusion of the result after interviewing the personnel and combining the
analysis of the questionnaires, it feels appropriate to include the personnel more in
the process of actually developing the documentation routines at MU. Since it was
found that documentation issues have been an ongoing discussion for a longer
period of time and that double documentation is the major one. Including more than
a few of the personnel could be beneficial to be able to solve the problems faster and
with less risk of having to redo steps several times.
One potential option could be to setup a group that focus on the documentation and
propose changes to keywords and adaption to the TC templates so the work become
more efficient at this specific clinic. Having keywords that do not fit in to the patient
group can be confusing both for the personnel making the notes and future readers
of the medical records.
For this project it was personnel from management and health care workers that
participated in this project. No one from the IT department participated actively in
the group working with the project. They could have brought in some knowledge and
insight to this implementation, to possibly identify risks earlier and make the
implementation more smooth and successful.
METHOD DISCUSSION
Selecting this study it was early decided that this would defiantly be a qualitative
study. However thoughts and discussions were ongoing if a quantitative section
could be incorporated in the study and make it into a type of triangulation. At the
end to fit the time frame and the setting doing the study at it finally became a
qualitative study. The author’s interest was toward a qualitative study and this
affected the final decision as well. A case study meant that it was possible to work
alongside the implementation process and do an evaluation and analysis of the
process that MU applied. It felt best suited because it would give the result a display
46
of how the process had been looking and include the findings from the data
collection.
Strength of this study is that it gives an understanding an insight of the
implementation process at a small clinic and how it can work in real life. This is
especially true after confirming the findings that other ways of implementing were
used compared to what text books usually recommend.
The data collection process for this study was rather difficult. The plan was to collect
material from two data collection methods, interviews and questionnaires, but the
amount of participants in the questionnaire were very low and it made that data a bit
too weak. The reason for this have been debated and a conclusion is made that
manually handing out and visiting personnel with a paper questionnaire would have
been more successful than the online version was. Despite several reminders from
both author and with the help of people in the management not many participated in
the questionnaire. Some steps were taken according to literature (45) on how to get
a higher response rate. Further efforts could have been made when signs of a low
answer rate appeared, e.g. sending reminders, or printing a paper version of the
questionnaire and handing them out directly to quickly collect more responses.
However, since the questionnaire to collect data before the implementation, there
was not enough time to proceed.
FUTURE WORK
It would be very interesting to look further into smaller implementations of
structured documentation to see how others have done it, what problems they have
had. This could be done by doing a larger questionnaire towards several clinics and
go in deeper about if a project plan were used, were user testing used, how involved
were the users and what knowledge and competence could be found at each clinic.
In this study only a portion of the time that MU will spend on actually finalizing the
changes to the documentation routines were followed. When leaving MU the
implementation is still underway and the effect of it has yet to be revealed. One
47
month of letting the personnel work with the template is not enough to be able to
evaluate, do changes and updates to say that it is done. Looking at figure 2 the
adoption curve, MU are still in the early phase of implementation and have not yet
seen the benefits of their implementation.
A future study can look at what effects the changes on the documentation have
generated. If there are any new concerns within the personnel comparing the older
system to the new after 6 months to a year using new structured template. Also
investigating the goal of being able to extract more statistics from the EHR system
would be very interesting. Have the changes actually enabled this function in the
EHR system?
CONCLUSION
This study presents a result highlighting the lack of well established plan on how the
implementation should be conducted. The main finding of this study is that the
personnel did have a positive attitude and high expectations for this implementation.
They understood the problem that needed to be solved and wanted it to be solved.
Instead some disappointment was found when the implementation did not fulfil their
expectations and demands on solving the issue at hand. Could this be helped by
more support from higher up management and get more support and information
before launching a project.
48
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38. Dearnley C. A reflection on the use of semi-structured interviews.. Nurse Res 2005; 13(1).
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51
APPENDIX 1
Frågeformulär 1
Detta är en enkät ämnad till en forskningsstudie på Maria Ungdom av mastersstudenter från
Karolinska Institutet. I och med de förändringar som sker rörande dokumentation i Take Care,
kommer denna studie att samla och analysera de förväntningar och farhågor som finns bland
personalen på Maria Ungdoms akutavdelning.
Enkätens syfte är att väcka tankar och funderingar kring implementeringsprocessen av de nya
rutinerna rörande dokumentation i Take Care. Finns det förväntningar, farhågor eller annat.
Senare kommer ett urval av personer göras för kortare intervjuer.
Enkäten är anonym och materialet används för att analysera en grupp och inte en individ.
Insamlat material kommer endast användas till denna specifika studie och inte någon
annanstans.
* Jag samtycker och vill delta i studien. Jag är även införstådd i att mitt deltagande är helt frivilligt.
Är du fast anställd eller timanställd?*
Fast anställd Timanställd
Arbetar du natt eller dag?*
Natt Dag Båda
Vilken roll har du på Maria Ungdom?
Sjuksköterska Skötare Läkare Läkarsekreterare
Hur många år har du arbetat på Maria Ungdom?
[counter]
Hur väl stämmer följande påståenden på dig?
Stämmer
Stämmer
inte
Vet
Ej
Jag tror att det kommer bli stor skillnad att arbeta med
dokumentationen efter att de nya dokumentationsmallarna
har införts.
Jag tycker det är jobbigt att det sker en förändring.
52
Jag tror att kvalitén på dokumentationen kommer att bli
sämre.
Jag tror att det kommer bli mindre arbete med
dokumentation efter införandet.
Jag tycker att dubbeldokumentation på Maria Ungdom är ett
stort problem.
Jag upplever att jag blivit väl förberedd inför förändringarna
som ska ske.
Jag kommer inte ändra mitt sätt att dokumentera.
Jag tror att förändringarna i dokumentationen inte kommer
påverka mig.
Jag tycker att ledningen lyssnar på mig när jag har åsikter om
planerade förändringar.
Kommentarer?
Är det något du vill lägga till eller förtydliga gällande påståendena ovan?
Hur blir du informerad om nyheter och förändringar på Maria Ungdom?
Epost / Email APT Möten Anslag / Lappar
Stämmer följande påståenden?
Stämmer Stämmer
inte
Vet
Ej
Jag har blivit utbildad i dokumentation.
Jag har blivit utbildad i strukturerad dokumentation.
Jag har blivit utbildad inom datorkunskap av Maria Ungdom.
53
Jag tycker att tidigare implementeringar på Maria Ungdom
har gått bra.
Jag tycker att Maria Ungdom informerar mig på ett bra sätt
om förändringar som ska ske.
Jag vill ha mer information och bli mer förberedd innan en
förändring i mitt arbete sker.
Kommentarer?
Är det något du vill lägga till eller förtydliga gällande påståendena ovan?
Har du några positiva eller negativa förväntningar på införandet av strukturerad dokumentation?
Positiva eller Negativa förväntningar eller farhågor på strukturerad dokumentation
eller implementerings processen?
[SUBMIT]
Implementering = införandet eller introducerandet utav strukturerad dokumentations mallar i
Take Care.
Förväntningar = vad har du för tankar om att det nu sker en förändring i dokumentationen.
Positiva eller negativa. Tankar på att det införs och på vilket sätt det införs.
Farhågor = ser du några risker eller negativa biefekter som kan uppstå i och med att man
inför strukturerad dokumentation och på sättet som det införs på.
54
APPENDIX 2
Questionnaire 1
This is a questionnaire directed toward a research study at Maria Ungdom by a master student
from Karolinska Institute. Because of planned changes in the way medical records are
documented in Take Care will this study collect data on expectations and concerns regarding
these changes. The target group of this questionnaire is the personnel at the acute care at
Maria Ungdom.
The aim of this questionnaire is to collect thoughts about the implementation process of the
new routines concerning documentation in Take Care. What expectations and concerns are
there regarding this. Later a set of interviews will take place. The questionnaire is anonymous
and all data will be used to analyse a group, not and individual. Collected data will only be
used for this specific study.
* I agree to above information and want to participate in this study. I am also aware of that my participation is voluntary.
Are you on permanent or hour based employment?*
Permanent Hour based
Are you working night or day?
Night Day Both
What role do you have at Maria Ungdom?
Nurse Auxiliary Nurse Physician Medical Secretary
How many years have you worked at Maria Ungdom?
[counter]
How true are following statements for you?
Stämmer
Stämmer
inte
Vet
Ej
I think it will be a big difference to work with the documentation when the new templates have been introduced.
I think it is hard when changes occur.
I believe that the quality of the documentation will be worse.
55
I think it will be less work with the documentation after the
implementation.
I think double documentation at Maria Ungdom is a big problem.
I am well prepared on the changes that are about to happen.
I will not change may way of documenting.
I think that the changes won’t affect me.
I think the management listens to me when I have something to say about planned changes.
Comments?
Is there something you want to add to the above statements?
How do you get information about news and changes at Maria Ungdom?
Email APT Meetings Notes, posters
How true are following statements for you?
Stämmer Stämmer
inte
Vet
Ej
I have been educated in documentation.
I have been educated in structured documentation.
I have been educated in using computers at Maria Ungdom.
I think that earlier implementation and changes at Maria Ungdom
have succeeded.
I think Maria Ungdom gives information to me in a good way about planned changes.
I want more information and be more prepared about changes in work.
Comments?
56
Is there something you want to add to the above statements?
Do you have any positive or negative expectations on the implementation of structured documentation?
Positive or negative expectation or concerns on structured documentation
implementation process.
[SUBMIT]
57
APPENDIX 3
Interview questions to Maria Youth
To the staff ( nurses, attendants , physicians, medical secretary ) .
This is an interview to find out what concerns and expectations that have existed before you
started using the new way of working and how these expectations and concerns have
changed now that it's been live for about 3 weeks .
1. What was your first thought when you found out that there would be changes in the
way you document in Take Care ?
a. How did you find out that there should be any change ?
b. Did you find out that it was about structured documentation directly ?
c. Did you have any expectations of what it would mean to document in a
structured way ?
d. Did you see any risks or did you have any concerns in that it would be a
change in the documentation ?
2. What is your experience of change at Maria Youth already ?
a. Do you think you will be informed in a good way ?
b. Do you think there have been changes and introductions of new ways of
working in a good or bad way ?
c. What problem occurred before?
3. Now that you have worked with the new way to document, what do you think now
about it?
a. Have there been any changes in your way of working ?
b. Have you been given new tasks or responsibilities and demands on you
changed?
c. Does it work good or bad?
d. Do you think it was important that this was introduced ?
e. Do you think that the quality of care provided to patients has changed in any
way?
Each question may have additional follow-up questions where more "why" "what" "how" in
demand to bring out more details on possible answers given .
58
APPENDIX 4
Interview questions to Maria Ungdom
Till personalen (sjuksköterskor, skötare, läkare, läkarsekreterare).
Detta är en intervju för att ta reda på vilka farhågor och förväntningar som har funnits innan
du började använda det nya sättet att arbeta samt hur dessa förväntningar och farhågor har
ändrats nu när det har varit live i ca 3 veckor.
1. Vad var din första tanke när du fick reda på att det skulle göras förändringar i sättet
ni dokumenterar i Take Care?
a. Hur fick du reda på att det skulle införas någon förändring?
b. Fick du reda på att det handlade om strukturerad dokumentation direkt?
c. Hade du några förväntningar på vad det skulle innebära att dokumentera på
ett strukturerat sätt?
d. Såg du några risker eller hade du några farhågor i och med att det skulle bli
en förändring i dokumentationen?
2. Vad är din erfarenhet av förändringar på Maria Ungdom sedan tidigare?
a. Tycker du att du blir informerad på ett bra sätt?
b. Tycker du att det har skett förändringar och införanden av nya arbetssätt på
ett bra eller dåligt sätt?
c. Vad för problem har uppstått tidigare?
3. Nu när du har arbetat med det nya sättet att dokumentera, vad tycker du nu om det?
a. Har det skett några förändringar i ditt sätt att arbeta?
b. Har du fått nya arbetsuppgifter eller har ansvar och krav på dig förändrats?
c. Funkar det bra eller dåligt?
d. Tycker du att det var viktigt att detta infördes?
e. Tror du att kvalitén på vården till patienterna har förändrats på något vis?
Varje fråga kan ha ytterligare följdfrågor där mer ”varför” ”vad” ”hur” frågas för att få fram
mer detaljer om eventuella svar som ges.
59
APPENDIX 5
Centre for Health Informatics at the Department
of Learning, Informatics , Management and Ethics
(LIME ) , Karolinska
Consent form
Participation of health and social care staff and management in the interview linked to the
master's thesis by a student at Karolinska Institutet " joint master 's program in health
informatics ."
I have verbally been informed of the interview study's purpose ; identifying expectations and
concerns among staff at Maria Youth emergency department during the implementation of
structured documentation , and also examine how the implementation has proceeded and how
it may have influenced Found expectations and concerns .
I have had the opportunity to ask questions about the study , what it is about, why it is done so
on. I am also aware that my participation in this study is completely voluntary and that I may
at any time terminate my participation without giving any reason . I understand in the absence
of remuneration for participating in the study.
I also agree that the interview will be recorded and have been informed that all recordings will
remain confidential and will be deleted at the conclusion of the study .
I have informed the above named participant on the design of the study.
60
APPENDIX 6
Centrum för Hälsoinformatik vid Institutionen
för Lärande, Informatik, Management och Etik
(LIME), KI
Samtyckeblankett
Deltagande av vård och omsorgspersonal och ledning i intervju kopplad till masteruppsats av
student på Karolinska Institutet ” joint master's programme in health informatics”.
Jag har muntligen blivit informerad om intervjustudiens syfte; att identifiera förväntningar
och farhågor bland personalen på Maria Ungdoms akutavdelning under implementeringen av
strukturerad dokumentation, samt även undersöka på vilket sätt implementeringen har gått till
väga och hur den eventuellt kan ha påverkat funna förväntningar och farhågor.
Jag har haft möjlighet att ställa frågor angående studien, vad den handlar om, varför den görs
osv. Jag är även medveten om att mitt deltagande i studien är helt frivilligt samt att jag när
som helst kan avbryta mitt deltagande utan att ange några skäl. Jag är införstådd i att det inte
utgår någon ersättning för att delta i studien.
Jag samtycker även att intervjun spelas in och har fått information om att alla inspelningar
behandlas konfidentiellt och kommer att raderas vid avslut av studie.
Ort och datum: Deltagarens underskrift: Namnförtydligande
…………….... …………………………… ……………………
Jag har informerat ovan namngivna deltagare om utformning av studien.
Ort och datum: Studierepresentantens underskrift: Namnförtydligande:
……………… …………………………… ……………………