Master's Programme in Health Informatics
Spring Semester 2014
Degree thesis, 30 Credits
Dealing with existing data in legacy systems when transitioning between
Electronic Health Records in three Swedish counties
Author: Mina Makar
Author: Mina Makar
Main supervisor: Professor, Gunnar Klein, Informatics, Örebro University
Co-supervisor: Dr. Maria Hägglund, Health Informatics
APPENDIX Centre, Karolinska Institutet
Examiner: Associate Professor, Nabil Zary,Center for Learning and Knowledge, Karolinska Institutet
Master's Programme in Health Informatics
Spring Semester 2014
Degree thesis, 30 Credits
Affirmation
I hereby affirm that this Master thesis was composed by myself, that the work
contained herein is my own except where explicitly stated otherwise in the text.
This work has not been submitted for any other degree or professional
qualification except as specified; nor has it been published.
Stockholm, 16th of May 2014
__________________________________________________________
Mina Makar
ii
Master's Programme in Health Informatics
Spring Semester 2014
Degree thesis, 30 Credits
Dealing with existing data in legacy systems when transitioning
between Electronic Health Records in three Swedish counties
Abstract
Background: Transitioning from one Electronic Health Record system (EHR) to
another has become a necessity for many healthcare organizations. Compared to
transitioning from paper-based systems to EHRs, very little has been published
about transitioning between two EHRs.
Objective: To understand more about the different approaches used for managing
the data in the legacy systems when transitions took place and to investigate the
opinions of the users regarding this.
Methods: Interviewing both decision makers from the Swedish county councils
where the study took place who either led or took part in the transitions and from
the corresponding vendors who took part in the transitions (total of 7 interviews).
A questionnaire targeting three user categories (specialist doctors, resident doctors
and nurses) was administered and 53 responses were received.
Results: Using the legacy systems and the new ones under a certain period,
accessing the information in the legacy systems via a link (to a database) that
connects the new system with the data exported from the legacy system and
manually entering the data to the new system were the three main identified
approaches that had been used. Automatic data transfer is currently infeasible
given the architectural differences between the systems. Although relatively long
time has passed since the transitions took place, 75% of the users who responded
to the questionnaire are still dependent on the information from the legacy
systems and 60% of the users expressed having no or very slight influences on the
decisions made regarding the legacy information.
Conclusion: Until automatic data transfer becomes feasible, the currently existing
approaches and new ones to deal with the legacy information are in need to be
developed. Users of the EHRs should be actively and continuously included in the
transitioning-related decisions.
Keywords:
Transition, Legacy Systems, Medical Records Systems, Electronic Health
Records, Qualitative Research, Sweden
iii
Acknowledgements
The author would like to express deep gratitude to:
Professor Gunnar Klein: You’ve been a huge source of knowledge, inspiration
and support. I learned and I’m still learning much from you!
Professor Sabine Koch: Thank you for all your help and support!
Dr. Maria Hägglund: A great teacher and a wonderful person!
All the wonderful people I interviewed: You’ve contributed immensely to my
knowledge. This study would have been infeasible without your valuable
contribution.
The respondents to the questionnaire: Thank you for allocating some of your
precious time to answer.
Finally, a big thanks for my family and friends for being there whenever needed!
iv
Table of Contents
Glossary/List of abbreviations………………………………………….VI
List of figures…………………………………………………….……..VI
List of tables…………………………………………………….………VII
1. Introduction………………………………………………………............1
1.1. Electronic Health Records………………….………………...........1
1.2. Healthcare system in Sweden…...…………………………………2
1.2.1. Stockholm County……………………………………............3
1.2.2. Uppsala County…………………………………………….…3
1.2.3. Östergötland County………………………………………….4
1.2.4. EHRs in Sweden………………………………….……..........5
1.2.5. Transition in Stockholm, Uppsala and Östergötland…………8
1.3. Current state of the knowledge about EHR transitions……...……..9
1.4. Study aims and objectives………………………………………...12
2. Methods…………………………………………………….………....…12
2.1. Research Methodology……………………………………………13
2.2. Research Approach………………………………………………..17
2.3. Study Setting………………………………………………………17
2.4. Data Collection Tools……………………………………………..18
2.4.1. Semi-structured Interviews…………………………………..18
2.4.2. Questionnaire………………………………………………...22
2.5. Data Analysis……………………………………………………...29
2.5.1. Semi-structured interviews…………………………………..29
2.5.2. Questionnaire………………………………………………...30
2.6. Ethical Considerations…………………………………………….30
3. Results……………………………………………………………………31
3.1. Approaches to information handling in transitions between EHRs.31
3.1.1. Decision makers……………………………………………...32
3.1.2. Types of Decisions/Approaches……………………………...33
v
3.1.3. No Automated Data Transfer………………………………...34
3.1.4. Why automated transfers are difficult……………………......34
3.2. Users experiences and opinions of the transition strategies….………35
3.2.1. Respondents characteristics………………………………….35
3.2.2.
Respondents experiences with the legacy and the new systems…...36
3.2.3. Usage of the legacy system…………………………………..37
3.2.4. Respondents’ opinions regarding how the information in the
legacy systems should be dealt with upon transition to new
ones…………………………………………………………..39
3.2.5. Influence on the already done transitions……………………42
4. Discussion………………………………………………………………..43
4.1. Strategies to deal with the legacy data…………………………….43
4.2. EHR users perspectives……………………………………………44
5. Conclusion……………………………………………………..………...50
References…………………………………………………………...……….51
Appendices ……………………………………………………….………….a
Appendix A – Letters, Interview Questions & Questionnaire……………….a
Appendix B – Illustrative Images……………..……………….…………….g
Appendix C – Tables…………………………………………………….…...j
Appendix D – Graphs………………………………………………………..v
vi
List of Abbreviations:
1. CDSS – Clinical Decision Support System
2. CGM – CompuGroup Medical
3. CPOE – Computerized Physician Order Entry
4. EBP – Evidence Based Practice
5. EHR – Electronic Health Record
6. ICT – Information and Communications Technology
7. LIO – Östergötland County Council
8. LUL – Uppsala County Council
9. SALAR – Swedish Association of Local Authorities and Regions
10. SCB – Statistiska Centralbyrån (Statistics Sweden)
11. SLL – Stockholm County Council
List of Figures:
Figure 1: Some benefits of EHRs in healthcare………………………….........................2
Figure 2: Stockholm, Uppsala and Östergötland Counties……………….……………...4
Figure 3: Percentage of users of the available EHRs in Sweden, 2013….. ……………..6
Figure 4: COSMIC in Swedish County Councils………………………….…………….7
Figure 5: Takecare in Swedish County Councils…………………………………...……8
Figure 6: The prepared interview questions…………………………………………….16
Figure 7: Number of daily responses…………………………………………………....32
Figure 8: Number of respondents from each professional group………..........................33
Figure 9: Female to Male respondents…………………………………………………..33
Figure 10: Respondents using/not using the legacy systems……………………………36
Figure 11: Checked information categories by the respondents ………………………..37
Figure 12: Chosen information types in contrast with each other………………………39
Figure 13: Influence of respondents on the performed transitions………………...……40
vii
List of Tables:
Table 1: The 4 dominant EHRs in Sweden in 2012 & 2013……………………………..6
Table 2: Official Swedish authorities’ names and websites……………………………..13
Table 3: List of interviewees, their roles and their current positions……………...…….17
Table 4: User-information blanks and the respective provided choices……………..…..20
Table 5: Constructed questionnaire translated to English…………………………..……21
Table 6: List of recipients of the questionnaire…………………………………..………25
Table 7: Respondents’ age groups…………………………………………………….…34
Table 8: Amount of users with respect to experience with the legacy system……….….34
Table 9: Amount of users with respect to experience with the new system……….…….35
Table 10: Periodicity of usage of the legacy systems by the respondents……………….35
Table 11: Information that is searched for using the legacy systems ………………...…36
Table 12: Choices from the proposed solutions………………………………………….37
Table 13: Choices of the types of information that should be transferred……………….39
Table 14: Respondents’ influence on the already done transitions………………………40
viii
1. Introduction
1.1.
Electronic Health Records
Electronic Health Records (EHRs) can be defined as “Repository of patient data
in digital form, stored and exchanged securely, and accessible by multiple
authorized users.” [1].
The benefits of EHRs in modern healthcare extend way beyond just effectively
storing and retrieving patient data [10]. EHRs enhance communication between
different healthcare professionals [2-4] in addition to enhancing communication
between patients and healthcare professionals via portals that are connected to the
EHRs [5,6].
Studies have shown that medical errors are decreased owing to the usage of EHRs
that have integrated Clinical Decision Support Systems (CDSS) and
Computerized Physician Order Entry systems (CPOE) [7-9,12,13]. Using EHRs
with CDSS also has a positive impact on patient safety not only because of the
decrease in drug-related prescription errors, but also due to the support of
Evidence Based Practice (EBP) [11].
Reducing costs and better support for conducting research using the electronically
stored data are also other aspects that successful implementation and usage of
EHRs can result in. [3,4]. Improving previously mentioned aspects leads
consequently to improving the quality of the provided health care service. [4,15]
1
Figure 1: Some benefits of EHRs in healthcare
1.2.
Healthcare system in Sweden
Sweden is a country that is administratively divided into 21 counties which
contain 290 municipalities “kommuner”[15,16]. A county council “landsting” is
responsible for collective functions within the respective county e.g. public
transport. Healthcare administration is also decentralized and is one of the
responsibilities of the county council [17,18]. County councils are responsible for
both hospitals and primary care. According to the report “eHealth in Swedish
County Councils” published in 2012 by the Center for eHealth “Center för
eHälsa”, private hospitals are not common in Sweden which makes the county
councils responsible for around 95% of the existing hospitals. Primary care is
more privatized and around 40% of the primary care is delegated to private
entities that are tied by contracts with the county councils [19]. On the other hand,
municipalities are responsible for local functions e.g. schools. Child, elderly and
disabled care are the responsibilities of the local municipalities [17,19].
2
1.2.1 Stockholm County
According to Stockholm County Council’s website (available in Swedish)
Stockholm County is composed of 26 municipalities “kommuner” [21].
The population of Stockholm County as estimated by Statistics Sweden
“Statstiska Centralbyrån” (SCB) in 2013 as 2,163,042 which represents
approximately 22.42% of the population in Sweden making Stockholm County
the most populous in Sweden. Stockholm municipality has the highest population
with 897,700 followed by Huddinge municipality with 102,557 [22].
The amount of primary care centers “vårdcentraler” in Stockholm County is 235
centers according to the search done using the national healthcare guide
(www.1177.se) [23]. Stockholm County Council’s website states that there are 7
emergency hospitals in the county which are: Danderyd hospital, Karolinska
university hospital, Norrtälje hospital, Sankt Erik eye hospital, Sankt Göran
hospital, Södersjukhuset (Stockholm South General Hospital) and Södertälje
hospital [24,25].
1.2.2 Uppsala County
The Swedish Association of Local Authorities and Regions (SALAR) states that
Uppsala County is composed of 8 municipalities (available only in Swedish) [26].
According to SCB, the population of Uppsala County is 345,481 which represents
3.58% of the population in Sweden. Uppsala municipality has the highest
population (205,199) followed by Enköping municipality (40,656) [22].
Upssala County Council’s website (LUL), states that there are 26 (The number
represents both private primary care centers and county council owned ones) primary
care centers all over the county in addition to 2 hospitals which are Akademiska
university hospital in Uppsala municipality and Lasarettet hospital in Enköping
municipality (only in Swedish) [27,28].
3
1.2.3 Östergötland County
Östergötland County is composed of 13 municipalities (only in Swedish) [29].
The population of the whole county is 437,848 representing 4.53% of the
population in Sweden. Linköping has the highest population with 150,202
followed by Norrköping with 133,749 [22].
Searching for primary care centers in Östergötland using (www.1177.se) resulted
in 44 primary care centers in the County [30]. Östergötland County Council’s
website (LIO) states that there are 3 hospitals in the county which are: Linköping
university hospital, Vrinnevis hospital in Norrköping and Lasarettet hospital in
Motala [31].
Figure 2: Stockholm, Uppsala and Östergötland Counties
4
1.2.4 EHRs in Sweden
The adoption of EHRs in primary care dates back to the early 1990’s [19].
Although the adoption of EHRs in primary care started that early, it wasn’t until
the early 2000’s that hospitals driven by county councils began to use EHRs.
According to the report “National eHealth - the strategy for accessible and secure
information in health and social care “ prepared and published in 2010 by the
Center for eHealth “Center för eHälsa” and the Swedish Ministry of Health and
Social Affairs, the National eHealth Strategy was developed in 2005 and adopted
in 2006 [20].
The 2013 “Ehealth in the County Councils” yearly report by Lars Jerlvall and
Thomas Pehrsson designates 4 main EHRs that dominate the Swedish market
which are [31] (available in Swedish):
COSMIC (By Cambio Healthcare Systems)
Melior (by Siemens)
TakeCare (By CompuGroup Medical, CGM)
System Cross (By Evry)
The same report also demonstrates the amount of users of each of these systems
with respect to the amount of users (in primary care and hospitals) of EHRs all
over the country (estimated at 223,548 users) which is as follows (highest to
lowest) :
1. COSMIC: 26.7% (approx.60,000 users)
2. Melior: 25.9% (approx. 55,000 users)
3. TakeCare: 20.6% (approx. 45,000 users)
4. System Cross: 10.6% (approx. 25,000 users)
5
Figure 3: Percentage of users of the available EHRs in Sweden, 2013 (Adapted from the
report Ehealth in county councils [31])
Comparing the “Ehealth in the County Coucils” report from 2012 [19] with the
one from 2013 [31] regarding the percentage of users of the 4 dominant systems
in the Swedish market we notice the following changes:
Table 1: Comparison between the 4 dominant EHRs in Sweden in 2012 and 2013
Amount of users in 2012 (total
Amount of users in 2013 (total
217,361 users)
223,548 users)
1. Melior: (27.6% or approx. 60,000
1. COSMIC: (26.7% or approx.60,000
users)
2. COSMIC: (25.8% or approx.
55,000 users)
3. TakeCare: (19.4% or approx.
40,000 users)
4. System Cross: (11.0% or approx.
25,000 users)
users)
2. Melior: (25.9% or approx. 55,000
users)
3. TakeCare: (20.6% or approx. 45,000
users)
4. System Cross: (10.6% or approx.
25,000 users)
6
The amount of users increased by 6,187 users from 2012 to 2013 (approx. 3%
increase).
The changes also show that Melior lost approx. 2% of its market share and at the
same time both COSMIC and TakeCare gained 2% of the market share (approx.
1% increase in market share to each system) making COSMIC the system with
the highest market share in Sweden.
Cambio Healthcare Systems global website
(www.cambio.se/en/) lists down the county
councils in Sweden that use COSMIC as
follows [32]:
Jönköping County Council
Uppsala County Council1
Kronoberg County Council
Västmanland County Council
Värmland County Council
Kalmar County Council
Östergötland County Council2
Jämtland County Council
Figure 4: COSMIC (green) in Swedish County Councils
Whilst COSMIC seems to be more widely spread in different counties, as of 2013,
TakeCare has only 2 counties as customers which are [31]:
1
2
Included county in the study
Included county in the study
7
Stockholm County Council3
Dalarna County Council
Knowing the size, population and the amount of
healthcare centers in Stockholm County though
would easily clarify why TakeCare has the 3rd
position among the most dominant systems in
Sweden.
Figure 5: Takecare (yellow) in Swedish County Councils
1.2.5 History of transitioning of EHRs in Stockholm, Uppsala and
Östergötland
A. Stockholm:
”There’s no central decision from the County Council regarding TakeCare” states
the report (only in Swedish) prepared by the County council’s auditors
“landstingsrevisorerna” published by SLL in 2008. What the report mentions is
that TakeCare gained ground gradually in Stockholm based on the feedback
provided by the users which led organizations like Karolinska University Hospital
3
Included county in the study
8
to decide in July 2004 that TakeCare will replace all the other documentation
applications that existed by then [33].
B. Uppsala
The introduction of COSMIC in Uppsala County dates back to 2003 [34] when
the LUL decided to introduce COSMIC in the whole County.
By the time the decision was taken, some primary care centers had already been
using EHRs, while Akademiska University Hospital had been using a paper-based
documentation system (only in Swedish) [35].
C. Östergötland
Since 2008, COSMIC has been the used system in both primary care and hospitals
in the County [36].
The transition included primary care centers which had been using other EHRs
and Linköping University Hospital which had paper-based documentation system
(only in Swedish). [37]
1.3 Current state of the knowledge about EHR transitions
There are many reasons for transitioning from legacy systems to new ones.
Interoperability is one the most important ones that led many county councils to
the decision of transitioning in order to facilitate sharing of information within the
county [38]. Other possible reasons might be outdated systems, inability to
support certain features by the legacy systems or even merging or separation of
healthcare organizations.
9
The challenges related to transitioning to EHRs are not new. Healthcare
organizations faced such challenges when transitioning from paper based systems
to electronic based ones. Economic barriers in the form of high costs of
purchasing vendor-supplied EHRs was regarded as one the major obstacles that
adoption of EHRs was facing [47].
Attitudes towards EHRs among the users have always been a huge concern for
decision makers when they decide to adopt EHRs. Studies have been conducted to
investigate the reasons for the negative and resisting attitudes towards EHRs
among healthcare professionals showed that reluctance to using pre-defined
clinical guidelines (or what is referred to sometimes as “cookbook medicine”),
fear of new technologies and worries about patient-clinician relationship are
among the reasons for the restating attitudes. The impact on workflow is one of
the aspects that both decision makers and healthcare professionals expressed their
concerns about when transitioning from paper-based to electronic-based record
systems took place. Consequently, studies agreed that successfully managing the
changes in workflow related to transitioning to EHRs would result in a successful
implementation [48-50].
On the other hand, one of the factors leading to an unsuccessful implementation of
an EHR in a healthcare setting were a paper-based system had been used is failure
to digitalize the data in the paper health records. Described as a both time
consuming and resource demanding process, digitalizing the legacy paper-based
data either through manually entering them to the new EHR or through scanning
the records (or parts of them) and making them accessible via the new system is a
crucial process to avoid being dependent on paper documents after transitioning
from paper records to EHRs takes place [47].
Although transitioning from legacy EHRs to newer ones in the previously
mentioned counties and even other counties is not new, searching for studies that
were done either during the transition itself or studying the effects afterwards
10
showed that such studies were lacking. Moreover, very few amount of studies
worldwide which address transitioning from one legacy EHR to another exist
compared to the amount of studies addressing transitioning from paper-based
documentation systems to electronic-based ones [39-43].
This leaves many unexplored aspects that are related to transitioning between two
EHRs. One of the explored aspects was safety. Performed between 2008 and 2009
in an ambulatory clinic with 17 participants (physicians), the study highlights that
transitioning between two EHRs may result in some safety threats and
recommends further studying and understanding of such threats [40].
Very similar results were shown by another study conducted in 2009 and included
19 physicians in an ambulatory clinic that tried to study the physicians
experiences not only regarding safety issues, but also their attitude towards the
new EHR. In addition to expressing that the new EHR didn’t improve the safety,
the participants showed somewhat negative attitudes towards the new EHR due to
its complexity [39].
Trying to investigate the satisfaction among users on a wider scale (at 6
ambulatory clinics with 197 participants) after transitioning between two EHRs,
there was a slight degree of satisfaction with the transition mostly owed to the
satisfaction with the new features that the new EHR offers compared to the old
one. The same study shows that there was also a considerable degree of
dissatisfaction which the study owed to being dissatisfied with certain features
and inability to complete certain tasks using the new EHR [42]
As noticed, the previously mentioned studies concentrate only on ambulatory
settings. This makes up for even fewer studies that have hospitals in scope. In an
attempt to investigate the expectations of hospital staff when transitioning from a
CPOE (not a full EHR) to a new EHR, the attitudes and expectations of the
11
hospital staff were generally positive (with the exception of nurses who showed
less positive attitude) [44].
Moving on to an even wider scope, decision makers were included in another
study that aimed at describing the plans and decisions made while transitioning
from a legacy system to a new one which showed that there are many challenges
related to transferring the data from the legacy EHR to the new one due to the
differences in how both systems are structured [41].
The previously mentioned studies concentrated on the aspects of one group only
at a time (either decision makers or users). A study that combines the aspects of
both groups was not found. Vendors were also not present in the previously
mentioned studies as participants which leaves the perspectives of an important
group that is involved in the transitioning processes unexplored.
1.4 Study aims and objectives
The aim of this study is to highlight the different approaches by which the
information in the legacy systems are dealt with when transitioning from legacy
EHRs to newer ones, opening up the doors for more in-depth studies of the effects
of using such approaches and even studies about the transitioning process itself.
There are many aspects to be studied in this newly explored field. Therefore the
existing patient information in the legacy systems was chosen as the main aspect
of this study as there’s a little that s known about this very important aspect.
To be able to fulfill the aim of this study, the following objectives have been
addressed:
Investigating whether the existing data in the legacy EHRs are transferred
to the new ones or not.
Understanding the different plans by decision makers to handle the data in
the legacy systems
12
Investigating the users’ opinions regarding how the data in the legacy
systems were and should be dealt with
Based on the aims and objectives of this study, the main research question is
How were the existing patient information in the legacy systems dealt with when
transitioning to new EHRs?
Two sub questions are also to be addressed in order to meet the study aim and
objectives which are
What were the strategies that the 3 counties adopted regarding the legacy
data?
What are the users’ opinions regarding those strategies and their vision of
an ideal one?
2
2.1.
Method
Research Methodology
Exploratory research was chosen for this study due to the following factors:
Few studies addressing the same topic have been conducted
Ability to test different hypotheses
Exploratory research provides a better understanding of the problem(s)
rather than offering a solution/solutions which suits the fact that this is a
newly explored field
The following goals were set as the ultimate benefit of deploying exploratory
research in this study
13
Gaining background knowledge about the field of transitioning between
two EHRs
Providing a better insight on the feasibility of similar or related future
studies
Highlighting the importance of further studies in the field
When planning for this study took place, several hypotheses regarding the
strategies (or solutions) that the selected counties used in order to deal with the
legacy data were discussed. Using exploratory research allowed the author to test
those hypotheses and even develop new ones throughout the course of the study.
As the study continued, more refining of the objectives of the study were obtained
resulting in more concrete research question(s) that were to be answered.
The amount of participants in the study wasn’t high, but in alignment with the
study aims and objectives would help to test the feasibility of similar future
studies and open the doors to new ones in this field.
The research methodology can be defined as “The way to systematically solve the
research problem”. This could be also interpreted as the different steps that are
followed in order to understand and solve the research problem(s) [45].
Based on the aims and objectives of the study, the steps that were followed are:
Ground information
In this step, scientific databases, particularly PubMed and SpringerLink, and in
very rare cases Google Scholars were used in order to:
Obtain more information about EHRs (usage, implementation and effects
on various aspects of healthcare)
14
Find similar or related studies that directly or indirectly handle the topic of
transitioning from one EHR to another
Since the study is done in 3 Swedish counties, official Swedish authorities’
databases (illustrated in the table below) and healthcare portals were searched in
order to obtain documents and information about:
Administrative divisions in Sweden
Swedish counties in the scope of the study
Healthcare system in Sweden
Primary care centers and hospitals in the counties in scope
Vendor-supplied EHRs in the Swedish market and their distribution
History of the transition of EHRs in the counties in scope
Table 2: Official Swedish authorities’ names and websites
Acronym
SLL
Authority’s Name
Stockholm County Council
Website
http://www.sll.se/
Stockholms Län Landsting (Swedish)
LUL
Uppsala County Council
http://www.lul.se/
Landstinget i Uppsala Län (Swedish)
LIO
Östergötland County Council
http://www.lio.se/
Landstinget i Östergötland (Swedish)
SALAR
Swedish Association of Local
(English
Authorities and Regions
Abbreviatio
Abbreviated to SKL (Sveriges Kommuner
n)
och Landsting) (Swedish)
SCB
Statistics Sweden
http://www.skl.se/
http://www.scb.se/
Statistiska Centralbyrån (Swedish)
1177.se
Care Guide
http://www.1177.se/
Vårdguiden (Swedish)
15
CeHis (now
Center for eHealth
called Inera) Center för eHälsa i Samverkan (Swedish)
http://cehis.se/doku
mentarkiv/
Complementary information was also obtained from the respective vendors’
official gateways about:
The market share and distribution of EHRs in Sweden
History of the transition of EHRs in the counties in scope
Interviews
Owing to the facts that this study is not concentrating on one particular healthcare
organization (hospital or primary care center) within a particular county but rather
having a wider scope (on the level of county councils) and that the chosen topic to
address in terms of the transition itself is existing patient information in the old
systems as a whole (not one particular module e.g. medication, vaccination, lab
results, notes, patients’ personal information…etc.), two categories of people to be
interviewed were identified:
IT personnel from the county councils’ sides who led/took part in the
whole project of transitioning from the legacy to the currently existing
(new by then) EHRs
Project/team leaders from the respective vendors’ sides who led/took part
in the transition from the legacy systems to their own products
The level on which this study is conducted, nature of the research question (being
qualitative than quantitative), desired in-depth information from decision makers
and the flexibility that semi-structured interviews provide, all contributed to
picking semi-structured interviews for this stage [51]
16
Questionnaire
To be able to fulfill the objective of investigating users’ (Although there are
different categories of users who use EHRs, for the purpose of this study, users
are only limited to doctors (residents and specialists) and nurses (regardless of
specialty)) opinions regarding the transition with respect to how the patient
information was dealt with, constructing and sending out a questionnaire was
chosen as the next step following the interviews. Whilst interviews provide more
in-depth information about a certain topic, questionnaires provide answers from a
wider scale of respondents that are difficult to cover using interviews given the
same period of time.
2.2.
Research Approach
Provided the aims, objectives and research question(s), qualitative research [52]
was chosen as the approach of choice. The main scope of the study is to describe
how the information in the legacy systems were dealt with before, during and after
transitioning to new ones through describing the different solutions and decisions
made by the 3 county councils regarding the patient information that existed in the
legacy systems. In addition to that, providing an insight on the defined users
groups’ opinions regarding those solutions and their vision of optimal
solution/solutions. This means that the amount of information itself is out of the
scope of this study which clarifies why qualitative rather than quantitative
research is suitable for this study.
2.3.
Study Setting
Context
A. Stockholm
Properties
26 municipalities
2,163,042 inhabitants
235 primary care centers (private and county-owned)
7 county-owned hospitals
17
TakeCare is the dominant system in the county
Transition to TakeCare started in early 2000’s and
ended in 2007
B. Uppsala
8 municipalities
345,481 inhabitants
26 primary care centers (private and county-owned)
2 county owned hospitals
COSMIC is the dominant system in the county
Transition to COSMIC started in 2003 and ended in
2008
C. Östergötland
13 municipalities
437,848 inhabitants
44 primary care centers (private and county-owned)
3 county owned hospitals
COSMIC is the dominant system in the county
Transition to COSMIC started in 2005 and ended in
2008
2.4.
Data Collection Tools
2.4.1. Semi-structured Interviews
Guiding questions
A list of guiding questions composed of seven questions were prepared and
reviewed prior to conducting any of the interviews. The questions were saved into
a Google document™ and were checked before and during conducting the
interviews (same file for both categories). Since the interviews were conducted in
a semi-structured fashion, not all the prepared questions were used while
18
conducting the interviews and some questions were created and adapted on the
spot based on the answers of the interviewees. The questions were prepared in
English at first, but were translated to Swedish to be able to use them during the
interviews as all the interviews were conducted in Swedish. The questions were
reviewed and refined by the author’s supervisor before using them.
Figure 6: Screenshot taken from Google Docs™ showing the prepared interview
questions
Identifying and connecting with the interviewees
Convenience sampling was used to be able to identify the people to be
interviewed from both categories, emails were sent to the respective county
councils and the vendors briefly describing the author’s background, the study, its
aims and objectives and the characteristics of the desired people to be
interviewed. A list of names and email addresses of the people fulfilling the
characteristics of interviewees from both categories was obtained and the
identified people were contacted which led to scheduling of the interviews.
19
Description of the participants
Different county councils have different strategies when it comes to the
transitioning process. Whilst in Stockholm the transition was done gradually and
on different levels, in both Uppsala and Östergötland it was a central county
council decision that lead to the transition which led to the existence of one
distinct project in each of Uppsala and Östergötland counties to plan and operate
the transition. Consequently, a main project leader for each project existed in
those counties. In Stockholm County, more than one project leader existed to
work on more specific processes related to the transition.
On the other hand, vendors work in teams without assigning one particular project
leader for each distinctive transition.
These factors led to using the previously mentioned categories as the selection
method for the interviewees who are represented in the following table:
Table 3: List of interviewees, their roles and their current positions
County
Organization
Role during transition Current position
Östergötlan
LIO
Project leader
Business Area
Manager
d
IT Center in
Östergötland County
Council
Uppsala
LUL
Project leader
IT Manager and
Strategist in Uppsala
County Council
Stockholm
SLL
Project leader
IT Management
Leader
Stockholm County
20
Council
Administration
Stockholm
SLL/Karolinska
Team leader
Hospital
Management Leader
Ehealth and strategic
IT at Karolinska
University Hospital
Stockholm
SLL/Karolinska
Team leader
Hospital
System Manager
Ehealth and strategic
IT at Karolinska
University Hospital
Doesn’t
Cambio
apply
Healthcare
Cambio Healthcare
Systems
Systems, Sweden
Doesn’t
CGM
Team leader
Team leader
apply
Business Developer at
Implementations
Specialist at CGM,
Sweden
Conducting the interviews
A total number of 7 interviews were conducted with both categories under the
period of March and April 2014. No particular category was contacted and
interviewed during a particular period, but interviews with both categories were
done simultaneously under the designated period.
All the interviews were conducted in Swedish which makes it easier for the
interviewees to speak freely about the projects they were involved in without
worrying about the language barrier since they are more used to using Swedish
terms and phrases on a professional level rather than English ones. This also
contributes to getting more valid and deeper information.
21
A total of 6 interviews were conducted face-to-face in the offices of the identified
people. One interview was conducted on the phone based on the request of the
interviewee.
All the seven conducted interviews (either face-to-face ones or the one on the
phone) were digitally recorded and stored using a mobile digital recorder and the
obtained files were stored locally on the mobile device in addition to sending a
copy to the author’s computer which was also backed-up using the cloud service
Dropbox™. The interviewees were orally asked before conducting the interviews
themselves for permissions to record the conversations on the conditions of using
the recorded files only for the purpose of the study and they all orally agreed to
that.
The period of each interview varied between 30 minutes and 60 minutes.
2.4.2. Questionnaire
Construction of the questionnaire
Early in April 2014, a questionnaire composed of 6 questions was prepared using
Google Forms™ for reviewing. All parts of the questionnaire (description,
purpose, questions and guiding hints) were prepared in Swedish and were
reviewed by a native Swedish speaker for grammatical and contextual errors. A
7th question was added later on after receiving supervisor’s feedback. The
questionnaire starts by giving the respondents a brief description of the study, its
aims, objectives and that the received data would be used as part of that study.
The description is followed by 4 user-related information blanks which are to be
filled by choosing only one of the pre-provided choices. All the four blanks are
mandatory to fill out using only the provided choices in order to proceed with the
22
rest of the questions and consequently submit the answers. These are illustrated in
the following table:
Table 4: User-information blanks and the respective provided choices
Blank
Provided choices
Actual
Participants
County
Stockholm
Uppsala
Östergötland
Age Group
Gender
Profession
Under 30
1
30-39
12
40-49
11
50-59
18
60+
14
Male
19
Female
37
Specialist (doctor)
19
Resident doctor
15
Nurse
22
The seven questions that follow the user-information blanks were (with the
exception of questions number 4 and number 6) mandatory to answer which
means that the respondent must pick an answer/answers to each of the 5 questions
in order to be able to submit the answers. The questions and the provided choices
and hints are illustrated by the following table:
Table 5: Constructed questionnaire translated to English
Question
Type
Answers
23
1. How long had you
been using the
Categorical
Less than one year
scale
1-2 years
legacy EHR? *
2-5 years
Hint: Only consider the
5+ years
system you had had exactly
before the transition
2. How long have you
been using the new
Categorical
Less than one year
scale
1-2 years
EHR? *
2-5 years
5+ years
3. Do you still use the
legacy system (e.g.
Categorical
No
scale
Yes, once a month
via a portal) to get
Yes, once a week
information about
Yes, at least once a day
the patients? *
4. If you answered
Checklist
Patient personal information
yes to the previous
Referrals
questions, what
Notes
is/are the
Lab results
type/types of
Medication
information that
Warnings
you search for
Other (activates a blank for
using the legacy
the respondent to list down
EHR?
the other category/categories
Hint: Check all the
that he/she searches for)
categories that apply
5. When transitioning Categorical
between legacy and
scale
Everything must be
transferred (from the legacy
new EHRs takes
to the new system)
place, how do you
Chosen information
24
think the
categories must be
information in the
transferred **
legacy system
Somebody should manually
should be dealt
write a summary of the most
with? *
important information in the
new system
Use both systems (the
legacy system to read
information and the new one
to input new data) at the
same time during a defined
period of time
Get access to the
information in the legacy
system via a portal that
connects it with the new
system
Nothing is to be transferred
and it’s better to start with
an empty health record
6. If you picked the
Checklist
Patient personal information
choices that is
Referrals
marked with ** in
Notes
the previous
Lab results
question, can you
Medication
specify the 3 most
Warnings
important
Other (activates a blank for
information
the respondent to list down
categories that you
the other category/categories
would like to be
that he/she thinks is/are
25
important )
transferred?
Hint: Only check 3 boxes!
7. Have you
experienced that
Multipoint
The scale starts from 0
scale
which is tagged “No
your workgroup
influence” up to 5 which is
influenced the
tagged “Huge influence”
decision of how the
information was
dealt with when the
transition took
place?*
Questions marked with (*) mean that they are mandatory
Administration of the questionnaire and recruitment of participants
After finalizing the questionnaire based on the received feedback, it was ready to
be sent out.
There were 3 conditions upon which the participants were eligible to take part in
the study which are:
Being a licensed doctor (resident or specialist) or a registered nurse from
any department who works in a healthcare organization (primary care
center or a hospital in one of the counties of Stockholm, Uppsala or
Östergötland
Had used the legacy system for at least a period of less than a year up to
more than 5 years
Having used the new system for at least a period of less than a year up to
more than 5 years
26
Obtaining a list of users who fulfill these conditions was extremely difficult owing
to the facts that the study doesn’t take place at any particular healthcare
organization (hospital or primary care center) within the counties in scope, but
rather includes the ones which performed the transition from the legacy to the new
EHRs and that the situation of some of the private primary care centers was
unclear in terms of which EHRs they use/used and whether they performed a
transition or not (unlike the ones run by the county councils)
The questionnaire was designed to allow only the users who fulfill the previously
mentioned conditions to participate in the study through limiting the answers of
the questions about profession, duration of the legacy system usage and the
duration of the new system usage to definite choices that are identical with the
desired participants characteristics and making these questions mandatory to
answer in order to submit the responses.
To be able to administer the questionnaire, the following steps have been
followed:
Using the Swedish Care Guide (1177.se) portal in order to obtain some
email addresses of the primary care centers in Stockholm, Uppsala and
Östergötland
Using the respective county councils’ websites which in many cases host
homepages of the primary care centers run by the county councils to
obtain contact information of the primary care centers
Using a provided mailing list that is composed of resident and specialist
physicians in General Medicine and Emergency Care
Contacting the Swedish Medical Association to help send out the
questionnaire
These steps resulted in sending out the questionnaire to the recipients described in
table 6:
27
Table 6: List of recipients of the questionnaire
Stockholm
67 primary care centers (25 private primary
care centers and 42 primary care centers run
by Stockholm county council)
68 physicians in General Medicine in the
Western suburbs of Stockholm
38 physicians in Emergency Care, Söder
Hospital (Södersjukhuset)
11 physicians in General Medicine, Danderyd
Hospital (Danderyrds sjukhus)
Uppsala
10 private primary care centers
24 General Medicine specialists
Östergötland
4 primary care centers
Together with the link leading to the questionnaire, the emails sent out to the
formerly mentioned organizations/people contained a brief introduction of the
author, study, the type of users that the questionnaire is directed to (doctors and
nurses who had the used the legacy EHR and have been using the new one) and a
request to share the questionnaire with other colleagues that they think fulfill the
conditions of participating in the study. (See Appendix A for these documents)
The respondents had to answer the questions and enter the required personal
information as described before and then press submit. Provided that all the
mandatory questions and blanks were filled, the submission would take place and
the respondents would receive a confirmation message saying “Your response has
been submitted”. No further information such as results were displayed to the
respondents after the submission.
28
The identities of the respondents and their contact information (emails, phone
numbers…etc.) were not recorded or saved to keep the questionnaire anonymous.
2.5.
Data Analysis
2.5.1. Semi-structured interviews
The seven recorded interviews were transcribed. The first 3 interviews were
transcribed directly after conducting and recording them while the other 4 were
transcribed at a later stage.
Transcriptions were written by the author in English directly from the recorded
sound files in Swedish. Online translating tools were used in order to get the
accurate translations of some of the words that were difficult to translate.
The transcriptions were then further analyzed to find patterns that are to be used
as material for the results of this study. This means that writing the transcriptions
and analyzing the data took place between late March and early May 2014.
2.5.2. Questionnaire
The data obtained from the respondents were exported automatically to an Excel
sheet created via Google Spreadsheet™ which was synced and connected to the
questionnaire so that once the respondent submits his/her answers, the answers
29
were added to the excel sheet. The author was notified via email once any new
submissions were done which allowed the author to check and validate the added
answers as soon as they were submitted.
Response rate was difficult to calculate due to the fact of lacking the amount of
eligible users that the questionnaire reached to. As from the 28th of April 2014
until the 14th of May 2014, the number of received responses was 53.
The obtained data were continuously checked and validated from the time of
administration until no more submissions were accepted and analyzed by
categorizing the received data using the available tools in Google Spreadsheet™
which allow the author to view the results (as a whole or selected categories) in
graphical representations. (For more information about the used software
throughout the different stages of the study, please check Appendix C)
2.6.
Ethical Considerations
Patient data were not obtained, used or even included in this study. The
participants in this study didn’t receive and weren’t promised any forms of
compensation in return for being interviewed or for responding to the
questionnaire. Relevant information about the study was presented to the
interviewees when they were approached to schedule the interviews and more
detailed information was presented orally before conducting the interviews. The
questionnaire respondents also received information prior to their participation
both in the invitation email and in the introduction to the survey. All the
participants (either interviewees or questionnaire respondents) were not given any
information about the data obtained from one another in order to ensure more
neutral and objective obtained information.
The study doesn’t by any means try to reflect on any differences between the
commercially available EHRs in Sweden (either the currently used or the old
30
ones). No comparisons between individuals’ opinions when it comes to the
systems themselves were discussed in this study either with the decision makers
or the users. The reasons for picking one commercially available system to
another are also not a subject of this study.
No funding or compensations were received from any organizations in return to
including them in the study.
The facts that Sweden has a very competitive market and that there are many
players in EHR market in Sweden required that some of the obtained data that
could be associated to the vendors were not included in the study.
The identities and contact information of the seven interviewees were not revealed
here, but can be revealed upon a clarified request.
The identities of the respondents to the questionnaire were hidden due to the
anonymous nature of the questionnaire. Their identities cannot be revealed for any
reasons.
3. Results
3.1.
Approaches to information handling in transitions between
EHRs
This section is concerned with the different approaches by which the 3 counties in
scope decided to handle the information in the legacy system and the reasons
behind the decisions
31
To avoid any unnecessary comparisons between the approaches of the 3 county
councils and to avoid any system-related associations with the chosen approaches,
the results in this section are displayed together without categorizing them based
on the county.
3.1.1. Decision makers
The question of how to deal with the information in the legacy systems is brought
up early upon making the decision to change the EHR systems.
Prior to the implementation of the new system, a decision/decisions regarding
how to deal with the patients information that existed in the legacy system is/are
made. The decision(s) is/are made by individuals from the respective county
council supported by internal (from the county council and/or the healthcare
organizations run by the county council) or external consultants.
“We only provide advice when needed, but it’s purely the county council’s
decision how to deal with the information in the old system” said one of the
interviewees who works for one of the vendors. This was also confirmed by the
other interviewee from the other vendor who also added “We work closely with
the county councils, but we don’t make decisions on their behalf.”
This implies that vendors comply to the plans made by the county councils
regarding how the information in the legacy systems are going to be dealt with
before, during and after the implementations of the new systems.
There are some major factors that influence the decisions:
Economical
Time-related
Staff-related
32
Technical
The choice of a certain vendor is not at all a factor that influenced the decisions.
3.1.2. Types of Decisions/Approaches
A. Using the two systems at the same time
This was done through extending the license of the legacy system to a certain
period, often several years that extends beyond the implementation and start of
usage of the new system.
That allowed the users of the EHRs to have access to both the legacy and the (by
then) new systems on the conditions of using the legacy system to view the
information they required and use the new one to input new data.
B. Exporting some/all of the data in the legacy system to a database
The exported data are accessible through a gateway (link) that connects the
database to the new system so that when and if a patient’s information existed in
the old system, it’d be accessible to the user of the EHR in the newly formed and
stored record in the new EHR via that link.
C. Manual data entry
Manual data entry could be regarded as either an approach itself or a consequence
of choosing one of the previously mentioned approaches.
Manual data entry as an approach itself was applicable when none of the
previously mentioned approaches were followed. This meant assigning particular
individuals in the healthcare organizations under a definite period of time to
33
manually re-enter some of the information that existed in the old system to the (by
then) totally empty new system.
Upon choosing either A or B approaches, manual data entry is regarded as a
consequence or a complementary step to either choices by which the users of the
new EHR would copy and manually enter some of the data that were relevant to
them from the legacy system or the database to which the data from the legacy
system were exported to the respective records in the new system.
3.1.3. No Automated Data Transfer
“It is extremely difficult to do an automatic data transfer” replied one of the
interviewees from the one of the vendors when asked about the possibilities of an
automated transfer.
The same person owed the difficulty of applying automatic data transfers to the
architectural differences between the old and the new systems. To demonstrate the
difficulty of doing an automatic transfer, the interviewee said that they were
working on performing a transition from an old system to a new one both owned
by the same vendor and even with that, an automated transfer was very difficult
because of the architectural differences between the two systems.
“Architectural differences don’t allow for automatic transfers” confirmed the
other interviewee from the other vendor who attributed this as the main obstacle
to performing such procedure.
3.1.4. Why automated data transfers are difficult
Investigating whether automatic data transfers are difficult or impossible to
perform led to realizing that although architectural differences between the legacy
34
and the new systems stand against automatic transfers, there are some other
procedures to be done in order to avoid manual data entries.
An example of how manual data entries could be avoided was to export all the
data from the legacy system to a database and importing the data from that
database to the new system. As much as it sounds simple, this is difficult to
achieve.
“Why wasn’t/isn’t this applied?” asked the interviewer
“It requires a lot of skilled programmers, time and money which are not easy to
obtain” added the interviewee.
3.2.
Users experiences and opinions of the transition strategies
A total of 53 responses were received from the beginning of receiving responses
on the 28th of April 2014 until no more responses were accepted on the 14th of
May 2014. The number of daily responses is represented in the following
diagram:
35
Figure 7: Number of daily responses
3.2.1. Respondents characteristics
The 53 respondents were divided among 3 groups according to their professions
which are: specialists (doctors), resident doctors and nurses. The number of
respondents from each group was as following:
16 specialists (30% of the respondents)
15 residents (28% of the respondents)
22 nurses (42% of the respondents)
Figure 8: Number of respondents from each professional group
37 of the respondents (70%) were females and 16 (30%) were males
36
Figure 9: Female to Male respondents
The most dominant age group among the respondents is 50-59 making up 34% of
the respondents followed by 60 + and 30-39 (23% each). The number of
respondents according to the predefined age groups is presented in table 7
(arranged in a descending order):
Table 7: Respondents’ age groups
Age group
User(s)
Percentage
60+
12
23%
50-59
18
34%
40-49
10
19%
30-39
12
23%
Less than 30
1
2%
3.2.2. Respondents experiences with the legacy and the new systems
The amount of time which the respondent users (from all the 3 categories) had
used the legacy system is presented in table 8 (arranged in a descending order
according to the number of users per category):
37
Table 8: The amount of users with respect to experience with the legacy system
Year(s)
User(s)
Percentage
5+
29
55%
2-5
11
21%
1-2
8
15%
Less than 1 year
5
9%
The amount of time which the respondent users (from all the 3 categories)
used/have been using the new system is presented in table 9 (arranged in a
descending order according to the number of users per category):
Table 9: The amount of users with respect to experience with the new system
Year(s)
User(s)
Percentage
2-5
23
43%
5+
21
40%
Less than a year
8
15%
1-2
1
2%
3.2.3. Usage of the legacy system
The respondents were asked if they still used the legacy system to get information
about the patients and 13 respondents (25%) answered “No”. The rest of the
respondents (75%) answered “Yes” which means that they still use the legacy
38
systems to obtain information about the patients. The respondents were also asked
to specify how often they used the legacy systems from 3 given choices which
were: once per month, once per week or at least once a day.
The periodicity by which users check the legacy systems is presented in table 10:
Table 10: Periodicity of usage of the legacy systems by the respondents
Answer
Number
Percentage
Once per month
17
32%
Once per week
12
23%
At least once a day
11
21%
Figure 10: Respondents using/not using the legacy systems
The respondents (who said that they still use the legacy systems) were also
prompted to specify the type(s) of information they try to obtain from the legacy
systems. They were given 6 predefined choices in addition to a 7th choice that
allows the respondents to specify other type(s). The respondents were allowed to
check one or more of the provided choices. This resulted in:
Table 11: Information that is searched for using the legacy systems by the respondents
39
Type of information
Number of picks
Personal Information
14
Referrals
24
Notes
35
Lab Results
24
Medication
30
Warning
15
Other
3
Notes
ECG
(Electrocardiogram)
Figure 11: Checked information categories by the respondents in contrast with each
other
3.2.4. Respondents’ opinions regarding how the information in the legacy
systems should be dealt with upon transition to new ones
The respondents were given 6 choices to pick only 1 from. The choices were
based upon the solutions that the county councils already used in addition other
relevant solutions. Whilst 0 users picked the choice of “Nothing is to be
transferred and it’s better to start with an empty health record”, the proposed
40
solutions were picked in the following manner (arranged in descending order
according to the amount of users):
Table 12: Respondents’ choices from the proposed solutions
Solution
Amount of Users
Percentage
Chosen information categories
16
30%
16
30%
11
21%
6
11%
4
8%
must be transferred
Get access to the information in
the legacy system via a portal
that connects it with the new
system
Use both systems (the legacy
system to read information and
the new one to input new data)
at the same time during a
defined period of time
Everything must be transferred
(from the legacy to the new
system)
Somebody should manually
write a summary of the most
important information in the
new system
The respondents were also asked to specify the 3 most important types of
information that they think should be transferred from the legacy systems to the
41
new ones (based on selection the choice “Chosen information categories must be
transferred” which was chosen by 30% of the respondents). Medication and
warning were the highest picked by 26 % and 23 % of the respondents
respectively. Responses arranged in descending order according to the amount of
the users picking them were as following:
Table 13: Respondents’ choices of the types of information that should be transferred
from the legacy to the new systems
Type of information
Amount of
Percentage
Notes
users
Medication
23
26%
Warning
21
23%
Notes
14
16%
Lab Results
13
14%
Personal Information
7
8%
Other
5
6%
Assessment,
ECG, Acute
Notes, Epicrisis
Figure 12: Chosen information types in contrast with each other
42
3.2.5. Influence on the already done transitions
A question on how the respondents felt regarding their influence on the transitions
that took place in their respective workplaces was asked and the respondents were
given a scale ranging from zero (no influence) to 5 (huge influence). Whilst 1 user
picked the highest number in the scale (5 “huge influence”), a total of 32 users
picked the lowest number in the scale (0 “no influence”). According to the
respondents, their influence was as following:
Table 14: Respondents’ influence on the already done transitions
Users
0
1
2
3
4
5
32
10
4
5
1
1
19%
8%
9%
2%
2%
Percentage 60%
Figure 13: Influence of respondents on the performed transitions
43
4. Discussion
Planning how the information in the legacy systems is dealt with is an integral
part of planning the whole transition. The three included counties had different
approaches on how to deal with the information. The reasons for picking different
approaches are owed to economical, technical, time-related or staff-related
reasons. Whilst legacy data were not ignored or gotten rid of when transitioning
took place, some of the legacy data were not transferred to the new EHRs.
4.1.
Strategies to deal with the legacy data
Three main approaches were found:
Using the two systems at the same time during a certain period
Exporting some/all of the data in the legacy system to a database
Manual data entry
With the third option (manual data entry) being also a complementary stage of
using the other two approaches in order to re-enter the required missing (but
relevant) data in the newly structured records in the new systems, it can represent
a burden to some of the users of the EHRs, knowing that they would have to
check another resource of information, try to retrieve the data that they require
and then input it into a system that is relatively new to them.
In this material, essentially no information was transferred automatically other
than list of patients and a parallel use for a long period dominates as the solution
with very little being manually entered.
Automatic data transfer was in this material claimed to be infeasible due to the
product related differences of the architectures of the systems [41] and the fact
that trying to do automatic transfers using other possible methods as exporting the
44
data to a database and importing it to the new system could be difficult and
expensive. The product related differences are hard to control by the county
councils or even by the vendors themselves because different generations and
origins of systems development has led to architecturally diverse systems.
However, possibly future systems using standard EHR architectures for the
information using archetypes may give some hope that automatic data transfers
could be developed and performed.
4.2.
EHR users perspectives
The respondents to the questionnaire were experienced users who had spent much
time using the legacy EHRs (55% of the users had used the legacy systems for
more than 5 years and 21% of them had use the legacy systems for 2-5 years), the
users who have been using the new systems are also experienced users (40% have
been using the new systems for more than 5 years and 43% have been using the
new systems for 2-5 years). Also, the transitions in all the 3 counties were not
recently performed but several years back so the expressed opinions are quite
mature.
It is noteworthy that as many as 75% of the respondents still use the legacy
systems to obtain information about the patients and that 21% of them do this on
daily basis. There is therefore obviously a need for the legacy data that was not
transferred.
The types of information the participants seek in the legacy systems varied a lot
between the respondents with very slight dominance of “Notes” with 24%
followed by “Medication” with 21% and then “Lab Results” and “Referrals” with
17% each. The existence of mixed sought information categories without a highly
dominant one can be attributed to the fact that different user categories (nurses,
residents and specialists) which responded to the questionnaire might have
45
different priorities in terms of the needed information, but it also implies that all
the previously mentioned categories of information in the legacy systems are still
valuable to the users in contrast to each other.
Having been asked about how they think the information in the legacy systems
should be dealt with upon performing transitions to new ones, the respondents
gave quite mixed answers to the preferred approaches. All the respondents agreed
that starting with an empty new EHR isn’t at all a preferred approach which was
demonstrated by 0 users choosing the option “Nothing is to be transferred and it’s
better to start with an empty health record”. Apart from that, there was an equal
amount of users (with 30% each) who preferred that chosen information
categories should be transferred from the legacy to the new systems or having
access to the legacy system using a portal in the new system. 21% of the
respondents preferred the option of using both the legacy and the new systems at
the same time for a certain period of time. Keeping in mind that the options of
either having access to the legacy system via a gateway in the new one or using
both systems at the same time for a certain period imply that users prefer having
access to the legacy systems while working with the new ones. Only 11%
preferred the option of transferring all the data from the legacy to the new
systems. This might be attributed to the awareness of the users of the difficulties
in performing that and/or the availability of other more feasible choices in the
questionnaire or maybe that the users don’t want a lot of unnecessary information
in the new systems which would make it more complicated to use the new
systems.
A very limited number of respondents (8%) preferred the choice of summarizing
the most important contents in the legacy systems and transferring those
summaries to the new ones. Having different priorities in terms of the most
important required information, it is understandable that this solution could be
regarded as an unpractical for many users. Moreover, doing this during the
transition is extremely difficult as suggested by an earlier study [41].
46
Once again, mixed preferences when it comes the 3 most important categories that
the respondents who picked the option of chosen information categories should be
transferred from the legacy to the new systems is noticed. “Medication” was
regarded as the most important (26%), followed by “Warning” (23%) while
“Notes” come in the 3rd place (16%). The rest of the categories received also
noticeable amounts of picks which also implies that different user categories have
different priorities in terms of relevant information for them.
A study showed that there was a slight tendency of satisfaction among the users of
the new EHR and attributed that to the new features in the new EHR compared to
the old one and highlighted that the users who were dissatisfied had problems
completing certain tasks using the new EHR [42].
Including users of the EHRs in the transition process is extremely important not
only for the acceptance of the new systems, but also for acceptance of the
provided solutions.
When asked about the degree of influence they had on how the information was
dealt with when the transition took place, 60% of the respondents expressed that
they had zero influence on that and only 4% expressed having slightly high or
huge influence on it. The mixed opinions regarding how the information should
be dealt with according to the users can also confirm that they didn’t have much
influence on the whole process.
Study Limitations
Although much information was obtained from the decision makers in the county
councils and the relevant personnel working for the vendors, more interviews with
people from both categories would have given a richer in-depth insights on the
transition processes and how the information was dealt with.
47
Guiding questions were used to conduct the interviews, but it was difficult to
receive answers to many of them owing to the facts that relatively long time had
passed since the transitions had been performed which makes it difficult to
remember the exact dates of initiating and executing the transitions and that in
Stockholm County in particular, the transitions were done gradually and not in a
centralized manner (as in Östergötland and Uppsala). Moreover, some key actors
who took part in either planning or executing the transitions particularly from the
vendor’s sides weren’t available as they no longer work for the respective
vendors.
Investigating the reasons upon which the choices of the selected approaches by
each county council were made could have contributed a lot to the study, but that
requires a lot of decision makers to be involved in the study which was not
feasible given the limited amount of time.
Inability to identify the amount of users who used both the legacy and the new
systems in all the 3 counties was also another drawback that contributed to
diffusely sending out the questionnaire and allowing the recipients to be filtered
through the questionnaire itself. If the users had been identified, more answers in
general and more specific data (e.g. specialty-related data) would have been
obtained. Interviewing the users would have also contributed to identifying more
concrete reasons for choosing the preferred approaches.
One of the major reasons for choosing 3 different counties which switched to 2
different popular commercial EHRs was the possibility of generalizability of this
study. Having received limited amount of interviews and responses to the
questionnaire puts this possibility at stake, yet doesn’t cancel the fact that the
study provides a step forward in terms of exploring the field of transiting between
two EHRs.
48
Finally, lacking enough time and resources to perform such relatively big study
contributed to limitations regarding the used methods.
Future Research
The results from this study represent a very small step towards exploring different
aspects that are related to transitioning between EHRs. A qualitative study that
includes the users who used the old systems and are currently using the new ones
by which more in-depth information could be obtained through conducting
interviews with them to gain more understanding about the information categories
that are important for them and their visions of the ideal ways by which patient
information should be dealt with when such transitions take place.
One of the most interesting methods to be potentially used is “Impact
Assessment” [46] where the transition process itself would be followed while
being performed and an assessment before and after the transition would be made
regarding one or more aspects such as the users’ attitudes and the ways the
transition and how the information was dealt with affect different aspects related
to the provided service (safety, timeliness, quality, efficiency) and even the
healthcare providers’ workflows. The need for studies concentrating on different
organizational aspects and change management related to the transition is high
and this was experienced during conducting the interviews with the decision
makers from the county councils who always tried to highlight the different
organizational aspects affected by the transition and how they tried to manage
them.
49
5. Conclusions
This study had the aims of understanding how the data of the legacy EHR systems
are dealt with when transitioning from such systems to new ones and to
investigate the users’ opinions regarding the same issue. Decision makers from
three Swedish county councils were interviewed together with personnel from the
corresponding EHR vendors. User opinions from nurses, resident doctors and
specialists were collected using a web based questionnaire.
Three different approaches were identified for dealing with the information in the
legacy systems with a period of several years of parallel access to the legacy
system was the dominating approach with no automatic transfer of data and very
limited manual data entry of legacy data.
With more clients becoming in need of replacing their old EHRs, clients and
vendors need to work together for developing solutions to deal with the data of the
legacy systems since a majority of the users actually think there are several
important types of data that should be available after transition.
Users have mixed and different preferences when it comes to how they see the
information in the legacy systems should be dealt with and at the same time feel
that they have no or very little influence on the decisions on how to deal with the
information. This requires more attention from the decision makers who should
include users (not only the IT enthusiasts) when making such decisions.
It is definitely clear that more studies in this field are required in order to
understand the effects on health care quality and patient safety of such transitions
without the legacy data in different types of healthcare services.
50
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57
Appendices
Appendix A
Example of an invitation letter to the interviewees
a
Invitation letter to take part in the questionnaire
b
Guiding interview questions
c
Questionnaire (in Swedish)
d
e
f
Appendix B
Some benefits of EHRs in healthcare
g
Stockholm, Uppsala and Östergötland counties
h
TakeCare (yellow) and COSMIC (Green) distribution in Sweden
i
Appendix C
Comparison between the 4 dominant EHRs in Sweden in 2012 and 2013
Amount of users in 2012 (total
Amount of users in 2013 (total
217,361 users)
223,548 users)
1. Melior: (27.6% or approx.
1. COSMIC: (26.7% or approx.60,000
users)
60,000 users)
2. COSMIC: (25.8% or approx.
2. Melior: (25.9% or approx. 55,000
users)
55,000 users)
3. TakeCare: (19.4% or approx.
3. TakeCare: (20.6% or approx. 45,000
users)
40,000 users)
4. System Cross: (11.0% or
4. System Cross: (10.6% or approx.
25,000 users)
approx. 25,000 users)
Official Swedish authorities’ names and websites
Acronym
SLL
Authority’s Name
Stockholm County Council
Website
http://www.sll.se/
Stockholms Län Landsting (Swedish)
LUL
Uppsala County Council
http://www.lul.se/
Landstinget i Uppsala Län (Swedish)
LIO
Östergötland County Council
http://www.lio.se/
Landstinget I Östergötland (Swedish)
SALAR
Swedish Association of Local
(English
Authorities and Regions
Abbreviatio
Abbreviated to SKL (Sveriges Kommuner
n)
och Landsting) (Swedish)
SCB
Statistics Sweden
http://www.skl.se/
http://www.scb.se/
j
Statistiska Centralbyrån (Swedish)
1177.se
http://www.1177.se/
Care Guide
Vårdguiden (Swedish)
CeHis (now
Center for eHealth
called Inera) Center för eHälsa i Samverkan (Swedish)
http://cehis.se/doku
mentarkiv/
List of interviewees, their roles and their current positions
County
Organization
Role during transition Current position
Östergötlan
LIO
Project leader
Business Area
Manager
d
IT Center in
Östergötland County
Council
Uppsala
LUL
Project leader
IT Manager and
Strategist in Uppsala
County Council
Stockholm
SLL
Project leader
IT Management
Leader
Stockholm County
Council
Administration
Stockholm
SLL/Karolinska
Team leader
Hospital
Management Leader
Ehealth and strategic
IT at Karolinska
University Hospital
Stockholm
SLL/Karolinska
Team leader
System Manager
k
Hospital
Ehealth and strategic
IT at Karolinska
University Hospital
Doesn’t
Cambio
apply
Healthcare
Cambio Healthcare
Systems
Systems, Sweden
Doesn’t
CGM
Team leader
Business Developer at
Team leader
Implementations
Specialist at CGM,
apply
Sweden
User-information blanks and the respective provided choices
Blank
County
Provided choices
Stockholm
Uppsala
Östergötland
Age Group
Under 30
30-39
40-49
50-59
60+
Gender
Male
Female
Profession
Specialist (doctor)
Resident doctor
Nurse
l
Constructed questionnaire translated to English
Question
1. How long had you
been using the
Type
Answers
Categorical
Less than one year
scale
1-2 years
legacy EHR? *
2-5 years
Hint: Only consider the
5+ years
system you had had exactly
before the transition
2. How long have you
been using the new
Categorical
Less than one year
scale
1-2 years
EHR? *
2-5 years
5+ years
3. Do you still use the
legacy system (e.g.
Categorical
No
scale
Yes, once a month
via a portal) to get
Yes, once a week
information about
Yes, at least once a day
the patients? *
4. If you answered
Checklist
Patient personal information
yes to the previous
Referrals
questions, what
Notes
is/are the
Lab results
type/types of
Medications
information that
Warnings
you search for
Other (activates a blank for
using the legacy
the respondent to list down
EHR?
the other category/categories
Hint: Check all the
that he/she searches for)
categories that apply
5. When transitioning Categorical
Everything must be
m
between legacy and
scale
transferred (from the legacy
new EHRs takes
to the new system)
place, how do you
Chosen information
think the
categories must be
information in the
transferred **
legacy system
Somebody should manually
should be dealt
write a summary of the most
with? *
important information in the
new system
Use both systems (the
legacy system to read
information and the new one
to input new data) at the
same time during a defined
period of time
Get access to the
information in the legacy
system via a portal that
connects it with the new
system
Nothing is to be transferred
and it’s better to start with
an empty health record
6. If you picked the
Checklist
Patient personal information
choices that is
Referrals
marked with ** in
Notes
the previous
Lab results
question, can you
Medications
specify the 3 most
Warnings
important
Other (activates a blank for
n
information
the respondent to list down
categories that you
the other category/categories
would like to be
that he/she thinks is/are
transferred?
important )
Hint: Only check 3 boxes!
7. Have you
experienced that
Multipoint
The scale starts from 0
scale
which is tagged “No
your workgroup
influence” up to 5 which is
influenced the
tagged “Huge influence”
decision of how the
information was
dealt with when the
transition took
place?*
Questions marked with (*) mean that they are mandatory
List of recipients of the questionnaire
Stockholm
67 primary care centers (25 private primary
care centers and 42 primary care centers run
by Stockholm county council)
68 physicians in General Medicine in the
Western suburbs of Stockholm
38 physicians in Emergency Care, Söder
Hospital (Södersjukhuset)
11 physicians in General Medicine, Danderyd
Hospital (Danderyrds sjukhus)
o
Uppsala
10 private primary care centers
24 General Medicine specialists
Östergötland
4 primary care centers
Utilized software, their usage and availability
Name
Description
Usage
Available at
Smart Voice
Free mobile
To digitally record and
https://play.google.com/sto
Recorder™
application
store the conducted
re/apps/details?id=com.and
interviews
rwq.recorder
Google
Free web-
To write down and use
https://drive.google.com/#a
Documents
based word
the guiding questions
ll
™
processor
before and while
conducting the
interviews
Google
Free web-
To create and
https://drive.google.com/#a
Forms™
based form-
administer the
ll
creating
questionnaire sent out to
software
the users
Google
Free web-
To store and analyze the
https://drive.google.com/#a
Spreadsheet
based
received responses
ll
s™
Excel™-
through the
like
questionnaire
software
Google
Free web-
To store and administer
https://drive.google.com/#a
Drive™
based
the previously described
ll
document
files
storing
p
platform
Paint.net™
Open-
To form, digitally edit
source
and enhance some of
software for
the provided figures
editing of
(maps, screenshots and
digital
illustrative figures)
http://www.getpaint.net/
photos
Dropbox™
Free (but
To back up all the
also paid
obtained data files in
option is
addition to other
available)
materials (books and
cloud
articles) used in this
storing
study
https://www.dropbox.com/
space
Google
Free web-
To translate some words https://translate.google.com
Translate™
based
and phrases from
translation
Swedish to English that
utility
existed in the interviews
/
and the questionnaire
and to check the
translation of the
prepared guiding
questions
Lexin ™
Free web-
To translate and double
http://lexin.nada.kth.se/lexi
based
check the translations
n/
translation
provided by the
utility
previously mention
provided by
translation tool
The
Institute for
q
Language
and
Folklore
and Royal
Institute of
Technology
(KTH)
Respondents’ age groups
Age group
User(s)
Percentage
60+
12
23%
50-59
18
34%
40-49
10
19%
30-39
12
23%
Less than 30
1
2%
The amount of users with respect to experience with the legacy system
Year(s)
User(s)
Percentage
5+
29
55%
2-5
11
21%
1-2
8
15%
Less than 1 year
5
9%
The amount of users with respect to experience with the new system
Year(s)
User(s)
Percentage
2-5
23
43%
5+
21
40%
r
Less than a year
8
15%
1-2
1
2%
Periodicity of usage of the legacy systems by the respondents
Answer
Number
Percentage
Once per month
17
32%
Once per week
12
23%
At least once a day
11
21%
Information that is searched for using the legacy systems by the respondents
Type of information
Number of picks
Personal Information
14
Referrals
24
Notes
35
Lab Results
24
Medication
30
Warning
15
Other
3
Notes
ECG
(Electrocardiogram)
Respondents’ choices from the proposed solutions
Solution
Amount of Users
Percentage
Chosen information
16
30%
16
30%
categories must be
transferred
Get access to the
s
information in the
legacy system via a
portal that connects it
with the new system
Use both systems (the
11
21%
6
11%
4
8%
legacy system to read
information and the
new one to input new
data) at the same time
during a defined period
of time
Everything must be
transferred (from the
legacy to the new
system)
Somebody should
manually write a
summary of the most
important information
in the new system
Respondents’ choices of the types of information that should be transferred
from the legacy to the new systems
Type of information
Amount of
Percentage
Notes
users
Medication
23
26%
t
Warning
21
23%
Notes
14
16%
Lab Results
13
14%
Personal Information
7
8%
Other
5
6%
Assessment,
ECG, Acute
Notes, Epicrisis
Respondents’ influence on the already done transitions
Users
0
1
2
3
4
5
32
10
4
5
1
1
19%
8%
9%
2%
2%
Percentage 60%
u
Appendix D
Number of daily responses
Number of respondents from each professional group
v
Female to Male respondents
Respondents using/not using the legacy systems
w
Checked information categories by the respondents in contrast with each
other
Chosen information types in contrast with each other
x
Influence of respondents on the performed transitions
y