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Managing the Gradual Transition from Paper Managing the Gradual Transition from Paper toto

Electronic Patient Record (EPR) – Electronic Patient Record (EPR) – A Case StudyA Case Study

ByBy

Nina Boulus –Thesis submitted Nina Boulus –Thesis submitted as part of the Masters degree as part of the Masters degree in Dept of Informatics, UiO, in Dept of Informatics, UiO,

May 2004May 2004

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Thank you NinaThank you Nina To highlight the different challenges To highlight the different challenges

a large scale project faces in a large scale project faces in implementing the electronic patient implementing the electronic patient record in Rickshospitalet, a national record in Rickshospitalet, a national hospital in Norway.hospital in Norway.

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Why I chose the above case Why I chose the above case study for the class? Reasonsstudy for the class? Reasons

1.Many frameworks and theories are used 1.Many frameworks and theories are used particularly ANT which describes how, where and particularly ANT which describes how, where and to what degree the technology influences human to what degree the technology influences human behaviour (Monterio,2000) and behaviour (Monterio,2000) and

particularly when trying to understand the roles particularly when trying to understand the roles and meanings of artifacts in social world or in and meanings of artifacts in social world or in work then this perspective creates a light on how work then this perspective creates a light on how human and non-human elements are intertwined human and non-human elements are intertwined and together creates heterogeneous socio-and together creates heterogeneous socio-technical network. This is important from the technical network. This is important from the anthropological perspective.anthropological perspective.

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c. Moreover the author of the above c. Moreover the author of the above case study instead of restricting to case study instead of restricting to one framework or a theory has one framework or a theory has discussed the case study in various discussed the case study in various perspective thus giving us a deeper perspective thus giving us a deeper understanding of how technology is understanding of how technology is interlinked to its context.interlinked to its context.

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Reasons for choosing the case Reasons for choosing the case studystudy

2. Helps us to develop a deeper 2. Helps us to develop a deeper understanding of the socio technical understanding of the socio technical aspects of the complexities and aspects of the complexities and challenges that emerge from the challenges that emerge from the implementation of the EPR implementation of the EPR

3. Describes the strategies to 3. Describes the strategies to manage the gradual transition to manage the gradual transition to digital record from the manual paper digital record from the manual paper based records.based records.

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What is an EPR?What is an EPR? An Electronic Patient Record (EPR) - An Electronic Patient Record (EPR) -

electronic medium for storing clinical electronic medium for storing clinical information.information.

Replicates the structure that is used Replicates the structure that is used in the paper based record and it in the paper based record and it accumulates all the information that accumulates all the information that is relevant for the treatment and is relevant for the treatment and nursing of a patient.nursing of a patient.

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Why an EPR ?Why an EPR ? Seen as a solution for various problems in the Seen as a solution for various problems in the

health care organizationhealth care organization Increased demand for efficiency and quality as Increased demand for efficiency and quality as

transformation is taking place from ‘Public transformation is taking place from ‘Public sector’ to ‘Business culture’. sector’ to ‘Business culture’.

Increased focus on costs saving and Increased focus on costs saving and documenting activities, efficient use of resources documenting activities, efficient use of resources and benefits.and benefits.

Not only to reduce the physical size of the paper Not only to reduce the physical size of the paper records but to centralise and merge the paper records but to centralise and merge the paper based records into EPR.based records into EPR.

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. Motivation for doing the above . Motivation for doing the above case study by the researchercase study by the researcher

Proved to be a highly challenging task in spite of Proved to be a highly challenging task in spite of huge funding spent on the process of huge funding spent on the process of implementation by national and international implementation by national and international agencies.agencies.EPR had great visions : To support managed care EPR had great visions : To support managed care logic, redesign of work processes and improved logic, redesign of work processes and improved quality of care ( Nilsson, Grissor and quality of care ( Nilsson, Grissor and Aanestad,2002) Aanestad,2002)

EPR were expected not only to replace the old EPR were expected not only to replace the old fashioned, messy and inadequate paper records fashioned, messy and inadequate paper records but to fundamentally transform and improve but to fundamentally transform and improve medical care ( Dick & Steen,1991 in Nilsson et medical care ( Dick & Steen,1991 in Nilsson et al,2002,p2).al,2002,p2).

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Motivation for doing the above Motivation for doing the above case study by the researchercase study by the researcher

However the transition to EPR has proved However the transition to EPR has proved to be long and complex process where to be long and complex process where many goals have not yet been met and many goals have not yet been met and also it has not conveyed any dramatic also it has not conveyed any dramatic changes or effectiveness.changes or effectiveness.

Thus the complexity and the decrease in Thus the complexity and the decrease in the expectations of the hospitals from the the expectations of the hospitals from the EPR. EPR.

EPR provides an opportunity to study the EPR provides an opportunity to study the issues of scaling large information issues of scaling large information infrastructuresinfrastructures

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Theoretical frameworkTheoretical framework Actor Network Theory (ANT) Actor Network Theory (ANT)

which is also used as a which is also used as a methodological theory to view methodological theory to view information infrastructures.information infrastructures.

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Brief introduction of Actor Brief introduction of Actor Network TheoryNetwork Theory

ANT as a methodological theory has been used in ANT as a methodological theory has been used in this case study to understand information this case study to understand information infrastructures (IIs) .infrastructures (IIs) .

Main reason for choosing this theory - ANT Main reason for choosing this theory - ANT provides a framework for the socio-technical provides a framework for the socio-technical aspects and views the technology as an actor on aspects and views the technology as an actor on par with other actorspar with other actors

This theory is important in the sense that it This theory is important in the sense that it provides theoretical concepts for documenting a provides theoretical concepts for documenting a complex and heterogeneous socio-technical work complex and heterogeneous socio-technical work practice with many actors.practice with many actors.

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Actor Network TheoryActor Network Theory

Heterogeneous socio-technical network

Non-humanHuman

Focuses on the relations and interplay between these elements, rather than each actor separately.

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Brief introduction of Actor Brief introduction of Actor Network TheoryNetwork Theory

It brings forth to light how new technology It brings forth to light how new technology affects and interacts with the various affects and interacts with the various actors and vice versa indicating a mutual actors and vice versa indicating a mutual interaction process.interaction process.

This theory has the advantage of viewing This theory has the advantage of viewing both the human and non human actors as both the human and non human actors as linked elements in the networks linked elements in the networks ((heterogeneous actor networks) heterogeneous actor networks)

And more than focusing separately on And more than focusing separately on each element the focus is on the interplay each element the focus is on the interplay and relations between these elements.and relations between these elements.

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(Cont..)Brief introduction of (Cont..)Brief introduction of Actor Network TheoryActor Network Theory

As pointed out by Latour (1987) these As pointed out by Latour (1987) these heterogeneous actors in the network are heterogeneous actors in the network are constituted by various concerns, different constituted by various concerns, different degrees of power and different degrees of power and different perceptions towards the technology and perceptions towards the technology and its benefits.its benefits.

More important is there should be stability More important is there should be stability and alignment in the network and to and alignment in the network and to achieve that there should be an achieve that there should be an agreement among the different actors agreement among the different actors (Latour, 1999)(Latour, 1999)

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In brief ANT ….In brief ANT …. Provides a better understanding of Provides a better understanding of

the network’s complexity, helping us the network’s complexity, helping us to see how borderline issues and to see how borderline issues and inscriptions are hidden in the links inscriptions are hidden in the links between the various actors.between the various actors.

Provides a deeper understanding of Provides a deeper understanding of the process of translations and the process of translations and motivations of heterogeneousmotivations of heterogeneous actors. actors.

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What is an Information What is an Information infrastructure?infrastructure?

Information infrastructures are more than Information infrastructures are more than just the physical facilities that are used to just the physical facilities that are used to transmit, store, and process information transmit, store, and process information ( data ,voice and images).( data ,voice and images).

According to Hanseth and Monteiro,1997, According to Hanseth and Monteiro,1997, information infrastructure is a vast field information infrastructure is a vast field that covers all kinds of use and use areasthat covers all kinds of use and use areas. .

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What is an Information What is an Information infrastructure?infrastructure?

involves political, social, organisation, involves political, social, organisation, human aspects and issues – from the human aspects and issues – from the development of industrial at national, development of industrial at national, regional or even the global level. regional or even the global level.

Unlike isolated IS of the past IIs are Unlike isolated IS of the past IIs are considered as the ‘next generation’ of considered as the ‘next generation’ of information systems(IS) as it will information systems(IS) as it will encompass the integration of large encompass the integration of large number of systems.number of systems.

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Reason for selecting the above Reason for selecting the above perspective to view EPRperspective to view EPR

– Helps to understand the patient record Helps to understand the patient record in a broader framework than the in a broader framework than the traditional information systems. traditional information systems.

– Rather than understanding the systems Rather than understanding the systems as single elements in an isolated fashion as single elements in an isolated fashion which are developed for specific which are developed for specific purposes and are used by homogeneous purposes and are used by homogeneous group they are described as elements in group they are described as elements in a larger infrastructure, including both a larger infrastructure, including both technological and social actors.technological and social actors.

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Reason for selecting the above Reason for selecting the above perspective to view EPRperspective to view EPR

– An infrastructure is a socio-technical An infrastructure is a socio-technical network, which includes more than just network, which includes more than just technological components .It includes technological components .It includes actors, knowledge, use situation and actors, knowledge, use situation and procedures around them.procedures around them.

– Infrastructures are heterogeneous in the Infrastructures are heterogeneous in the sense that they include elements of sense that they include elements of different qualities, humans and different qualities, humans and computers.computers.

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anti-reductionist perspective of anti-reductionist perspective of ecologies…ecologies…

– Important to view infrastructure as a Important to view infrastructure as a shared irreducible unit which includes shared irreducible unit which includes heterogeneous and tightly heterogeneous and tightly interconnected components ,such as interconnected components ,such as humans, technological components, humans, technological components, organizations and institutions thus organizations and institutions thus making it impossible to understand making it impossible to understand infrastructures as separate and infrastructures as separate and independent entities.independent entities.

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Key features of IIsKey features of IIs They evolve continuously through extensions and They evolve continuously through extensions and

improvements and over a period the improvements and over a period the infrastructures develop the scope of including infrastructures develop the scope of including new applications and the number of users and new applications and the number of users and use areas increases giving it the feature of being use areas increases giving it the feature of being ‘open’ and ‘scaled’.. ‘open’ and ‘scaled’..

There is no time frame for development leaving it There is no time frame for development leaving it open(no defined beginning or ending), open(no defined beginning or ending), Hanseth,2002).Hanseth,2002).

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Key features of IIsKey features of IIs Also infrastructures are developed Also infrastructures are developed

through extensions and through extensions and improvements of the installed base. improvements of the installed base. In other words infrastructures are In other words infrastructures are never built from scratch but rather never built from scratch but rather developed by interrelating and inter developed by interrelating and inter connecting existing components.connecting existing components.

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Implications for ChangeImplications for Change Unlike in traditional information systems there is Unlike in traditional information systems there is

complexity and unpredictability in IIs.complexity and unpredictability in IIs.

Traditional IS design is different from the design Traditional IS design is different from the design of IIs in several perspectives.of IIs in several perspectives.

Traditional ISs design methodologies focus on the Traditional ISs design methodologies focus on the development of a closed systems meaning single, development of a closed systems meaning single, isolated and stand alone systems (Hanseth, isolated and stand alone systems (Hanseth, 2002).and design phase follows a closed time 2002).and design phase follows a closed time frame which is supposed to have pre-defined frame which is supposed to have pre-defined start and ending time frame(Orlikowski,1996)..start and ending time frame(Orlikowski,1996)..

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(Cont..)Implications for Change(Cont..)Implications for Change IIs do not have to be built from the scratch IIs do not have to be built from the scratch

but built upon the installed base.but built upon the installed base. As a result, the role of the installed base As a result, the role of the installed base

becomes crucial as it heavily influences becomes crucial as it heavily influences the design of the new elements.the design of the new elements.

When implementing complex Information When implementing complex Information infrastructure it is best to adopt an infrastructure it is best to adopt an evolutionary approach.evolutionary approach.

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Implications of adopting Implications of adopting evolutionary approachevolutionary approach

In evolutionary approach the installed base In evolutionary approach the installed base is seen as a design starting point is seen as a design starting point (Hanseth,1996). (Hanseth,1996). As a result,sub-networks are being changed As a result,sub-networks are being changed following step-wise incremental changes at following step-wise incremental changes at alignment, while aligning the new alignment, while aligning the new components with the rest of the network. components with the rest of the network. This increases the chances for a successful This increases the chances for a successful transition over time between stability and transition over time between stability and flexibility(change) for the different flexibility(change) for the different components(Hanseth, Monteiro, Halting components(Hanseth, Monteiro, Halting 1996). 1996).

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Importance of transition strategiesImportance of transition strategies

Information infrastructures have to gradually evolve and Information infrastructures have to gradually evolve and scale through extensions and improvements ,in order to scale through extensions and improvements ,in order to meet the new requirements. But scaling an information meet the new requirements. But scaling an information infrastructure as pointed out by Montiero is neither trivial infrastructure as pointed out by Montiero is neither trivial nor automatic but a process caught in a nor automatic but a process caught in a dilemma(Monteiro,1998,p230) involving pressure for dilemma(Monteiro,1998,p230) involving pressure for change and at the same time demanding negotiation and change and at the same time demanding negotiation and balance against the conservative influence of the existing balance against the conservative influence of the existing installed base.installed base.

Changing a large and complex infrastructure, such as Changing a large and complex infrastructure, such as the medical information infrastructure is profoundly the medical information infrastructure is profoundly challenging. challenging.

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Why it is challenging?Why it is challenging? The challenge lies not in changing paper- The challenge lies not in changing paper-

based records in to electronic media but based records in to electronic media but how the process of change and the how the process of change and the evolution itself will be managed.evolution itself will be managed.

Thus a transition strategy should be a Thus a transition strategy should be a descriptive plan which outlines each descriptive plan which outlines each evolutionary step including negotiations evolutionary step including negotiations about how big changes can or have to be about how big changes can or have to be made, where to make them, and when and made, where to make them, and when and which sequence to deploy them which sequence to deploy them (Monteiro,1998,p.230)(Monteiro,1998,p.230)

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Information infrastructure theory applied Information infrastructure theory applied to EPR studies from different perspective to EPR studies from different perspective

of the researchersof the researchers Various studies have been conducted Various studies have been conducted

that analyse and describe information that analyse and describe information infrastructure-infrastructure-

How record plays a role as an How record plays a role as an organsational infrastructure, how it organsational infrastructure, how it serves various aims as well as allowing serves various aims as well as allowing interplay and coordination of different interplay and coordination of different worlds(Berg and Bowker,1997).worlds(Berg and Bowker,1997).

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Information infrastructure theory applied Information infrastructure theory applied to EPR studies from different perspective to EPR studies from different perspective

of the researchersof the researchers EPR is not only a complex project in their EPR is not only a complex project in their

work but also highlighted the resources work but also highlighted the resources beyond the record itself (Ellingson and beyond the record itself (Ellingson and Monteiro,2000).Monteiro,2000).

EPRs as part of large, complex, EPRs as part of large, complex, interconnected and irreversible interconnected and irreversible networks(Hanseth and Monteiro,1997).networks(Hanseth and Monteiro,1997).

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Information infrastructure theory applied Information infrastructure theory applied to EPR studies from different perspective to EPR studies from different perspective of the researchersof the researchers

– Lundberg(2000) in her study of digitalization of Lundberg(2000) in her study of digitalization of radiological practices have emphasized the radiological practices have emphasized the importance of network and information importance of network and information infrastructure perspectives.infrastructure perspectives.

– Considering the above views it becomes clear Considering the above views it becomes clear that there is a need for Information Infrastructure that there is a need for Information Infrastructure perspective and many researches have perspective and many researches have contributed with insightful studies of the contributed with insightful studies of the challenges and strategies for designing challenges and strategies for designing information infrastructure..information infrastructure..

– There are researchers who also stress on the There are researchers who also stress on the implications of implementing II and rather than implications of implementing II and rather than just present II as a challenge.just present II as a challenge.

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Information infrastructure theory applied Information infrastructure theory applied to EPR studies from different perspective to EPR studies from different perspective

of the researchersof the researchers– Since currently EPRs in the Norwegian Health Care Since currently EPRs in the Norwegian Health Care

have been developed and implemented with have been developed and implemented with traditional IS thinking many hospitals are struggling to traditional IS thinking many hospitals are struggling to integrate these complex and rigid systems with other, integrate these complex and rigid systems with other, both existing and newly developed systems, in order both existing and newly developed systems, in order to expand and create a sufficient IIs.(Nilsson et to expand and create a sufficient IIs.(Nilsson et al,2002,p6).al,2002,p6).

– The above authors emphasize that there is a need to The above authors emphasize that there is a need to analyse the existing body of knowledge regarding analyse the existing body of knowledge regarding how to develop such technologies, and to study the how to develop such technologies, and to study the implications of the Information Infrastructure implications of the Information Infrastructure perspective(Nilsson et al,2002)perspective(Nilsson et al,2002)

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IT & Work PracticeIT & Work Practice In order to understand how the electronic patient In order to understand how the electronic patient

record affects the medical work, knowledge should record affects the medical work, knowledge should be firstly acquired about the organization of the be firstly acquired about the organization of the medical work practice, cooperative work in teams medical work practice, cooperative work in teams and the use of the artefacts in the medical work.and the use of the artefacts in the medical work.

Support the design of systems that are adapted to Support the design of systems that are adapted to the existing work practice in a better way than the the existing work practice in a better way than the traditional information system design.traditional information system design.

For that the author uses the theoretical framework For that the author uses the theoretical framework by applying work practice oriented concepts such by applying work practice oriented concepts such as ‘ as ‘ situated practice of use”situated practice of use” and emphasize the and emphasize the useuse aspect in situated practices. aspect in situated practices.

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IT & Work PracticeIT & Work Practice It is a dynamic reflexive process where information It is a dynamic reflexive process where information

infrastructures are also locally shaped and re-invented through infrastructures are also locally shaped and re-invented through situated practice of use situated practice of use

(The Boomerang effect in Design and Use of Information Infrastructures: Evidence from a Global (The Boomerang effect in Design and Use of Information Infrastructures: Evidence from a Global company, Rolland,K,2002b, Draft submitted to the Information and Organisation journal).company, Rolland,K,2002b, Draft submitted to the Information and Organisation journal).

Rolland’s concepts helps us to explore not only the complex Rolland’s concepts helps us to explore not only the complex interplay that exists between context dependent and situated interplay that exists between context dependent and situated practices of uses and various process of innovation of practices of uses and various process of innovation of Information infrastructures but also the implications that result Information infrastructures but also the implications that result out of it.out of it.

Using the perspective of information infrastructures one can see Using the perspective of information infrastructures one can see how the community of practice( i.e, organization, people)is how the community of practice( i.e, organization, people)is ordered, how information is retrieved and changed etc.ordered, how information is retrieved and changed etc.

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Research methodsResearch methods Qualitative research methods:Qualitative research methods:

– Helping to understand people and social and cultural phenomena.Helping to understand people and social and cultural phenomena.– The researcher does not try to control or predict, but rather to The researcher does not try to control or predict, but rather to

understand the social worldunderstand the social world– Natural settingsNatural settings– Employs various methodsEmploys various methods

Weaknesses:Weaknesses:– Possibilities of different interpretations of the same phenomenaPossibilities of different interpretations of the same phenomena– Limited possibilities for generalizingLimited possibilities for generalizing– Time consumingTime consuming

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The empiriacl Field workThe empiriacl Field work 19 Interviews19 Interviews 14 sessions of observations (39 hours)14 sessions of observations (39 hours) 5 DocuLive courses (18 hours)5 DocuLive courses (18 hours) Pre-ward meetings Pre-ward meetings Shadowing sessionShadowing session Various formal and informal meetingsVarious formal and informal meetings

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Empirical MaterialEmpirical Material

The implementation process of The implementation process of DocuLive EPR DocuLive EPR Parkinsons caseParkinsons case

Internal electronic referral lettersInternal electronic referral letters The scanning projectThe scanning project

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Implementing the EPRImplementing the EPR1. The development and implementation 1. The development and implementation phasephase2. The adaptation phase2. The adaptation phase3. The impact and effect of the EPR 3. The impact and effect of the EPR

The author of the study looked on several aspects:The author of the study looked on several aspects:– The use of the systemThe use of the system– Changes in the work practiceChanges in the work practice– Learning and discoveringLearning and discovering– Complexities and challengesComplexities and challenges– Advantages and disadvantagesAdvantages and disadvantages

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Parkinsons caseParkinsons case

Illustrates the socio-technical infrastructure that cross Illustrates the socio-technical infrastructure that cross disciplines, ISs, and work practices.disciplines, ISs, and work practices.

A complex and long process- interdisciplinary from A complex and long process- interdisciplinary from various departmentsvarious departments

Mapping pre-operative and post-operative Mapping pre-operative and post-operative procedures, and patient care processes.procedures, and patient care processes.

Includes a detailed narrative description and graphical Includes a detailed narrative description and graphical representation.representation.

Shows how the medical practice is highly complex, Shows how the medical practice is highly complex, dynamic, distributed, and regulated.dynamic, distributed, and regulated.

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Internal Electronic ref.lettersInternal Electronic ref.letters

A pilot-project between the A pilot-project between the NEV(neurology) and the physiotherapy NEV(neurology) and the physiotherapy department.department.

– The work practice beforeThe work practice before

– The altered work practiceThe altered work practice

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Paper-based referral letterPaper-based referral letter

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The Work Practices BeforeThe Work Practices Before

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Electronic-based referral letterElectronic-based referral letter

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The work practices after:The work practices after:

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Internal Electronic ref. lettersInternal Electronic ref. letters

Challegnes:Challegnes:– Division of labourDivision of labour– It became important to distinguish between:It became important to distinguish between:

””Requested by”/vs./ ”signature”Requested by”/vs./ ”signature”””The person treating” /vs./ ”the person The person treating” /vs./ ”the person

responsible for the treatment”responsible for the treatment”

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The Scanning ProjectThe Scanning Project

Implies scanning a huge amount ofImplies scanning a huge amount of papers that are in the central archive, and papers that are in the central archive, and

integrating them in the EPR.integrating them in the EPR.– Motivations Motivations – Scanning strategy Scanning strategy – Expected challengesExpected challenges– Initial experience Initial experience

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Analysis 1Analysis 1 The installed base carries heritageThe installed base carries heritage The installed base had to gradually evolve and The installed base had to gradually evolve and

scale through extensions and improvementsscale through extensions and improvements The hybrid installed base- lead to the need for The hybrid installed base- lead to the need for

integrationintegration One way to integrate the various IT One way to integrate the various IT apply apply

gatewaysgateways

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Analysis 2Analysis 2 The transition process is not merely a transformation of IIs.The transition process is not merely a transformation of IIs. The transition is rather mutual, dynamic, and reflexive The transition is rather mutual, dynamic, and reflexive

transformation process of both II and situated practice of use. transformation process of both II and situated practice of use. Therefore Therefore Hold infrastructural focus together with a work Hold infrastructural focus together with a work

practice orientation and practice orientation and useuse focus. focus.

The parkinsons case explores the complexity of the work practice.The parkinsons case explores the complexity of the work practice. The transformation to the EPR:The transformation to the EPR:

– No radical changes in the traditional sequence of activites.No radical changes in the traditional sequence of activites.– Changes only in the performance of the activities and in the Changes only in the performance of the activities and in the

interdependencies.interdependencies.

static objectsstatic objects

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(Cont..) Analysis(Cont..) Analysis 2 2 Work practice is linked and supported by a Work practice is linked and supported by a

long chain of artefacts.long chain of artefacts. Inscriptions identified in the paper-based Inscriptions identified in the paper-based

record.record. The paper-based recordThe paper-based record part of a larger part of a larger

infrastructure that accumulates a group of infrastructure that accumulates a group of boundary objects.boundary objects.

Paper-based referral letters are more than justPaper-based referral letters are more than just

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Analysis 3Analysis 3 Translating paper-based to electronic records Translating paper-based to electronic records

implies that the coordination role of the paper implies that the coordination role of the paper document will be lost, and must be replaced by document will be lost, and must be replaced by the IS.the IS.

Managing a gradual transtion can be done by Managing a gradual transtion can be done by conducting extensions and improvements of conducting extensions and improvements of the installed base, and identifying borderline the installed base, and identifying borderline issues and establishing gateways.issues and establishing gateways.