Lessons for NPfIT from ‘wild ride’ to US failure

A study of the ‘wild ride’ towards a failed implementation of a new electronic medical record system found a ‘transient climate of conflict’ associated with the adoption of the new way of working.

The qualitative study, reported in the British Medical Journal, was completed during an implementation by Kaiser Permanente, the US’ largest non-profit healthcare system which is regarded as a model for cost-effective care and is watched closely by the NHS.

The study carried out in Kaiser Permanente’s facilities in Hawaii made seven key findings on its observation of staff as they used the new system:

• Users perceived the decision to adopt the EMR as flawed;

• Software design problems increased resistance;

• The system reduced doctors’ productivity, especially during initial implementation , which fuelled resistance;

• The system required clarification of roles and responsibilities which was traumatic for some individuals;

• A cooperative culture created trade offs at various times in the implementation;

• No single leadership style was optimal – a consensus building may lead to m ore effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation;

• The process fostered a counter climate of conflict which was resolved by the withdrawal of the initial system.

Authors of the study say it has "notable implications for health service providers contemplating adopting an EMR."

Implementation started in 1999 when two systems were examined – EpiCare by Epic Systems and the Clinical Information System (CIS) developed by Kaiser Permanente with IBM.

The report says that, after a 12 month delay related to the operating system, the first site started using the CIS in October 2000. In 2002 Kaiser hired a new chief executive who initiated a review of system choice and concluded that EpiCare had matured beyond the CIS. All Kaiser Permanente regions halted implementation of the CIS and began planning for EpiCare.

At that time, the BMJ paper says, a third of the company’s Hawaiian sites had implemented CIS fully and the rest had read only access, some with order entry functionality.

“For many,” say the authors, “the 28 month experience had been, to use a Hawaiian surfing metaphor, truly a ‘wild ride’.”

A clinician quoted in the research said: “What got docs here frustrated was nobody really seemed to listen. And they had to compromise their values and ethics to help the system work. That’s where I saw very amiable, nice quiet, people starting to talk stink behind the scenes.”

The researchers concluded: “Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points.”

In a commentary on the paper, Sheila Teasdale, strategic director of Primis+, the support service for NHS primary care information, praises the bravery of the authors in reporting a failure. She notes the lessons for the National Programme for IT and says the reasons for failure will come as no surprise for those working in health informatics.

She says the paper from Hawaii adds weight to that existing knowledge and says it is important to reinforce its messages.

“There are now encouraging signs of increasing involvement of clinicians proficient in information technology within the National Programme for IT and an increasing level of informed and constructive debate, which is being listened to by NHS Connecting for Health.

“This is a positive and welcome development and one which must be fostered throughout the NHS; we simply cannot afford for this implementation to fail.”