The Electronic Health Record System [product x]

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The Electronic Health Record

System [product x]

A study about the expected benefits of

[PRODUCT X] for hospitals

Author: Roberto Postma

Rijksuniversiteit Groningen

Faculty of Management and Organization Specialty Business Development

First supervisor: dr. R.T.A.J. Leenders

Second supervisor: dr. M.A.G. van Offenbeek Deventer, July 2007

The author is responsible for the contents of this thesis. The copyrights of this thesis rests with the author. No part of this paper may be reproduced without the prior permission of the author or [COMPANY X].

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Preface

This report describes the study about the expected benefits of [PRODUCT X] for hospitals. The study is written on behalf of [COMPANY X]. At the same time, this study is my master thesis for the study management and organization, specialization Business Development at the Rijksuniversiteit Groningen.

During the research period, I have worked at [COMPANY X]. For me this was an inspiring experience. In my spare time, I often developed (web-based) ICT-applications. This learned me that ICT can be an important way to optimize the work organization of organizations. In this study, I wanted to combine the knowledge of my management and organization study with my interest in ICT, which resulted in this project. I found it interesting to see how

[COMPANY X] works when large ICT-systems must be implemented. During my period here, I have learned much about this.

The research period (and the writing of this study) has been a longer process than I initially expected it to be. I have learned that it is difficult to say something in general about the functionalities and the benefits of large ICT-systems. Additionally I have learned much about the (complex) organization of the Dutch healthcare and the ICT-architecture of hospitals. I found it interesting to work on a topic of current interest. This is also what the cover of this report refers to; in newspapers the progress, the expectations, the risks et cetera of EHR-systems have been discussed on a regular basis. In the end I am happy with the end-product, and for [COMPANY X]I think this study still is useful.

I want to thank [PERSON 1] and [PERSON 2] for the assignment and the access to the organization [COMPANY X]. I also want to thank [PERSON 3], who has been my supervisor at [COMPANY X]. Thanks for the discussions the supervision and the feedback you have provided. I also want to thank all employees of [COMPANY X] that I have met and worked with. It was nice to work at the [PRODUCT X] department.

Besides the people of [COMPANY X], I want to thank some people from my university. In the first place I want to thank dr. Ranga. The greatest part of my research she has supervised me. Unfortunately she stopped working at the Rijksuniversiteit Groningen, which meant that she could not finish the supervision of my research. Nevertheless I have learnt much from the discussions we had and the feedback she provided. I also want to thank dr. Leenders and dr. van Offenbeek, respectively my first and second supervisor of the faculty of

Management and Organization. Thanks for the discussions we had, and the feedback you have provided.

With this thesis, there comes an end to my study. I want to thank my friends and family for their invaluable support in my study time and especially during the writing of this thesis.

Groningen, July 2007 Roberto Postma

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Management summary

This thesis is about the benefits of [COMPANY X]’s Electronic Health Record system (named [PRODUCT X]) for hospitals. This EHR-system is developed by a the German company X, and for more than one year, [COMPANY X]has the exclusive right to sell [PRODUCT X] to Dutch hospitals. [PRODUCT X] is an ICT-system with the philosophy to “keep all information

in one platform and make access as simple as possible”. [PRODUCT X] is a system in which

the medical information of all the patients of the hospitals should be stored digitally, no matter what the format is. The product [PRODUCT X] is more than only software. The implementation of [PRODUCT X] also requires a rethink of the ICT-architecture and re-design of the hospital’s work system.

In order to be better able to sell [PRODUCT X] to Dutch hospitals, [COMPANY X]wants to know what the benefits of [PRODUCT X] are, compared to the current EHR-systems in hospitals.

In this study, the following research question was answered: “What benefits can be expected

for hospitals when they would implement [PRODUCT X]?

The introduction of [PRODUCT X] by [COMPANY X] can be seen as market development. At the moment no(t much) proven demand exist for [PRODUCT X]; this has to be ‘created’. This means a period for [PRODUCT X] in which there are many uncertainties, high risks and low revenues. In this stage it is important to perform a good market analysis and to have a good marketing strategy.

[PRODUCT X] is an driven innovation for hospitals. Implementing ICT or integrating ICT-systems in huge organizations often is very difficult. One study already speaks of the disease named ‘multiple informatiose’ that hospital organizations suffer from: too little information is available in too many ICT-systems that are not very well linked together. When [PRODUCT X] is successfully implemented in a hospital, this hospital might ‘rewrite the rules of the game’: this might be the first hospital that fully operates with an advanced EHR-system. To successfully manage technological innovations, it is important to balance the technological innovations with organizational innovations. Organizational innovation is also necessary to capture the benefits of the technological innovations.

An important issue is the diffusion of (ICT-driven) innovations. The following five characteristics affect the diffusion of innovations: relative advantage, compatibility,

complexity, trialability and the observability of the innovation. In this context the stakeholders analysis is also relevant: the diffusion of the ICT-innovation will be higher if the organization knows which stakeholders must be managed and what their interests are.

When we think about market development, It is also helpful to divide the market in

innovators, early adopters, early majority, late majority and laggards. The theory is that it is relatively easy to sell (technological) products to innovators and early adopters. These people like new technology, but these two groups only represent a small part of the market. The major part of the market is the early and late majority (this is the ‘mainstream market’). To sell to the early majority, a chasm has to be crossed. Early adopters pose different requirements on the product than early majority buyers do. Early adopters like new

technology and want to realize a competitive advantage for their organization. Early majority buyers buy new technology when there are good references of the new technology, to avoid a mis-purchase. This is a chasm, which needs special attention for [COMPANY X]. Crossing the chasm is difficult and needs special attention. When crossing the chasm, first a small part of the market must be dominated. When this is done successfully, this can function as a springboard to the rest of the market.

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Management summary

Another theory in the technology adoption literature is the existence of network externalities. If network externalities exist for [PRODUCT X], this means that the value of [PRODUCT X] increases as more hospitals use [PRODUCT X] or a compatible system. When hospitals actively use [PRODUCT X] for the exchange of patient data, network externalities are likely to exist for the hospital.

The introduction of new technology in organizations is often difficult. The technology acceptance model explains why organizations do or do not accept new technology. In the technology acceptance model, the variables ‘perceived usefulness’ and ‘perceived ease of use’ are important determinants of the acceptance of new technology. The perceived usefulness of a product is the extent to which the user thinks that the technology helps to increase the job-performance. The perceived ease of use is the degree to which users expect the technology to be free of effort. When [PRODUCT X] is implemented it is important that the perceived usefulness and the perceived ease of use are high. If [PRODUCT X] will not be accepted in a hospital the implementation will be a waste of investments.

Benefits of [PRODUCT X]

The benefits of [PRODUCT X] can be grouped in four categories: 1. Higher availability of patient-data

When the medical record is fully digitalized, it is always available in a readable format (given secure back up systems and procedures). This prevents doing things twice. Medication registration and the registration of diagnoses can be done centrally. Also the EHR-system can easily be accessed from multiple locations.

2. Better support for the physician by the EHR-system

Intelligent alerts can help physicians when wrong input is entered, or as a warning for physicians (e.g. when drugs are prescribed that are against guidelines of the current research). The financial registrations (DBC registrations) can be done automatically by the EHR-system. Clinical pathways can help plan and standardize the care process. There are more possibilities to work evidence based, and to work according to protocols. Management information for physicians can help to make visible the successes and failures of treatment methods.

3. Benefits for the supporting department

Looking up medical records, filling them with results and making sure that the physician has the complete medical record in time to a large extent is not necessary anymore. To a large extent, the necessary information can be found in the EHR-system. The dictation of letters is not necessary anymore, so supporting staff don’t have to transcribe dictates. Less duplicate administrations have to be performed, and requests for test can be done digitally.

4. Improved care for patients

Some physicians expect that a higher quality of care can be expected when

EHR-systems are used. Because of the direct availability of the medical record, admissions to the hospital can be avoided, advice of physicians can be given earlier and expert

systems can help physicians. Also some physicians stated that an EHR-system opens possibilities for patients to see and/or do things on the internet (e.g. make appointments, check waiting times).

When we look at the current functionalities of EHR-systems, most hospitals use a first generation EHR-system and some hospitals use second generation EHR-systems. In one hospital included in the study, only at the specialty of Cardiology, an EHR-system was in use with third generation functionalities. In this respect it can be said that in EHR-systems usage, Dutch hospitals appear to be behind hospitals in the United States of America and Germany, where third generation systems already are in use, and fourth and fifth generation EHR-systems are developed.

It is difficult to create financial measures to determine the benefits of [PRODUCT X]. In the study it was visible that ‘bottom line functionalities’ like instant availability of the medical

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Management summary

record, easy retrieval of patient lists and patient records and support for creating letters are often mentioned as important. Other functionalities like clinical pathways, intelligent alerts and communication via the internet were mentioned less often. This is in line with findings in literature, where a main point is that the paper-based working in hospitals should be

replaced.

In this study, it is argued that the acceptance of [PRODUCT X] by hospitals is crucial. The expected benefits listed in this study make visible what hospitals find important about EHR-systems. Meeting these expectations can help to create acceptance of [PRODUCT X]. The acceptance however, cannot be guaranteed: There are studies in which it was tried to implement an advanced system, which became a failure: end-users rejected the EHR-system.

This study has focused on the expected benefits of [PRODUCT X]. The implementation of [PRODUCT X] also has disadvantages and risks for hospitals. The work organization is changed, which means that new things have to be learned, tasks and responsibilities change and a rethink must occur about the responsibility for the storage of the medical record. Another disadvantage is that the implementation of [PRODUCT X] is risk full. For the implementation, there is high functional uncertainty, high conflict potential, quite high technical uncertainty, relatively high resistance potential and the material preconditions can also be a risk factor; if too little resources are available, the implementation may fail.

Especially for early adopters, it can be said that the implementation may be difficult, because many things have to be developed for the first time.

It is important to acknowledge that the implementation of an EHR-system like [PRODUCT X] is a complex project, with high risks of failure. Implementing [PRODUCT X] may be difficult, but it is not likely to be impossible. In other countries, examples exist of successful

implementations, and in the Netherlands an example is found at the [HOSPITAL X]’s department of Cardiology where an advanced EHR-system is in use.

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Contents

Chapter 1: Introduction

§ 1.1 Introduction

This thesis is the result of the study I performed on behalf of [COMPANY X] ([COMPANY X]). The study and this thesis together means the end of my study Organization and

Management at the Rijksuniversiteit Groningen.

The purpose of the study, is to explore what the benefits are for hospitals to work with [PRODUCT X]. [PRODUCT X] is the Electronic Health Record System (EHR-system) that [COMPANY X] wants to sell to the Dutch market.

[PRODUCT X] is an EHR-system that replaces the need for the paper-based medical record. The philosophy of [PRODUCT X] is: “keep all information in one platform and make access

as simple as possible”1_{. This EHR-system, is a computer based patient system, in which all}

patient records are stored digitally.

[PRODUCT X] is software that intends to realize what is formulated in [PRODUCT X]’s philosophy. Nevertheless, the product [COMPANY X] offers, is more than only the software. The product [PRODUCT X]

• Software

[PRODUCT X] is software that makes available all medical information of hospitals. [COMPANY X] can deliver the required software to make [PRODUCT X] working. E.g. an Oracle database is used as well as several other software. Together with the hospital (the customer) [COMPANY X] determines what software can be re-used, and what additional software is required to be able to use [PRODUCT X].

• Hardware

The use of [PRODUCT X] also requires linkages to other (ICT-)systems in the hospital. Sometimes it is necessary (or wise) to purchase some new ICT systems. Together with the hospital [COMPANY X] investigates the ICT-architecture to see what extra hardware is necessary. [COMPANY X] has several partnerships in hardware and software, that can offer a solution for the hospital’s needs. All systems (hardware and software) must be configured and adjusted to the specific situation of the hospital. This is what [COMPANY X] will be actively involved in when [PRODUCT X] will be implemented in a hospital.

• ICT-expertise

When [PRODUCT X] will be implemented, (but also in case of trouble or when upgrades are necessary), [COMPANY X] supports hospitals to implement [PRODUCT X] and to help hospitals to keep [PRODUCT X] working in the hospital. This requires ICT-expertise, not in the last place because of the fact that [PRODUCT X] stores patient-records. These data are important, and should under no circumstances be lost. Additionally these data should not be unavailable (often) for medical specialists. Also the patient-data stored in [PRODUCT X] must be protected for privacy reasons. Intruders should not be able to have access to [PRODUCT X]. [COMPANY X] offers the ICT knowledge to make sure that [PRODUCT X] is a safe environment to store the patient data in.

• Consultancy

[COMPANY X] consults hospital-organizations when [PRODUCT X] is implemented. When hospitals want to work with [PRODUCT X], this means more than ‘doing the same tasks with another software application’. It means a redesign, or in any case a

reconsideration of the work organization. It is important to know how the current work processes of hospitals are, and how they should be if [PRODUCT X] will be in use. The consultants of [PRODUCT X] advise hospitals about how hospitals can use their

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Introduction

resources optimally and how schedules of the several hospital departments can be best aligned with each other.

• Training of end-users

Especially at the implementation of [PRODUCT X], users of the system (physicians, medical administrative assistants) are trained about the use of [PRODUCT X].

Sometimes these training sessions lead to adjustments of how [PRODUCT X] is used (adjustment of the configuration of [PRODUCT X]).

• Helpdesk / Service desk

Customers of [PRODUCT X] can call the helpdesk if [PRODUCT X] doesn’t function correctly. Additionally sometimes there are patches and upgrades available. For questions about this or problems, customers can call the helpdesk.

In short: [PRODUCT X] is a software package that supports physicians in doing their work. What the exact role of [COMPANY X] and the role of the hospital organization is, depends on the agreement between [COMPANY X] and the hospital. Implementations can differ between several hospitals. Some hospitals might only choose for [PRODUCT X] to be able to only view all medical data (possibly with the future plans to extend [PRODUCT X]). Other

hospitals might (possibly after a successful pilot-period) choose to work with [PRODUCT X] hospital-wide, with all functionalities this product offers. There is space to choose for

hospitals. Some hospitals start with only one or a few specialties (with limited or full

functionalities), some hospitals might want to make a completely new step with [PRODUCT X]. [COMPANY X] advises hospital management in how the implementation can be done best. It is a process of negotiation to define a way to implement [PRODUCT X]. There is no blueprint.

Above it is described what the product is that [COMPANY X] offers with the product [PRODUCT X]. It is also important to know what [PRODUCT X] does.

[PRODUCT X] stores (and makes visible) medical information like:

• Test-results of the patients

• Letters sent within the hospital and letters sent to and received from other care delivery organizations.

• Diagnoses of the physician, and the status of the treatment, including medications

• Digital images or videos

As visible in the philosophy of [PRODUCT X], it intends to give access to all available medical information (for authorized users) in an easy way. [PRODUCT X] also makes it possible to work in a more standardized way. Current medical processes are analyzed, and when evidence based medicine is at hand, standardized care paths can be developed and used in the software as well.

Currently if patients visit the hospital, most hospitals will create a paper-based record, that stores all patient-data. When the patient has visited the physician, the physician can write his notes and thoughts here, and test-results are also stored in the paper-based medical record. People often think hospitals are digitalized to a large extent. The reality is that hospitals to a large extent still use paper-based medical records, next to a number of digital systems. A more precise definition of an EHR-system will follow in chapter 2. At this point it is important to know that the EHR-system [COMPANY X] offers is an advanced EHR-system because it is an EHR-system designed to work paperless in the entire hospital, that already works in 130 German hospitals

In publications about EHR-systems (in magazines and on the internet) it can be read that many people have high expectations of EHR-systems. When these kind of systems are implemented correctly, this would result in a higher quality of care, higher efficiency for hospitals etcetera. At the same time the implementation of an EHR-system is a complex

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Introduction

process, where the hospital risks the expense of much money to a system that is not satisfactory for the end-users. For more than one year ago, [COMPANY X] has chosen to bring [PRODUCT X] systems to the Dutch market. In order to be better able to demonstrate the benefits for hospitals to decision makers of EHR-systems for hospitals, this study was conducted.

§ 1.2 Initial motive of the study

In 2004 [COMPANY X] ([COMPANY X]) performed a study to investigate the possibilities to grow at the Hospital Information Systems (HIS) market and the Electronic Health Record (EHR-system) market (Jager and Dirkes, 2004). An important conclusion of this study was the EHR-product [COMPANY X] offers, cannot be used to meet the future requirements of the healthcare market. At the moment [COMPANY X]’s product, named [PRODUCT X], is the Hospital Information System with limited EHR functionalities.

In this study, a few strategic directions were suggested, of which looking for a strategic partner, was one. This is what [COMPANY X] has done, and now for more than one year, [COMPANY X] has started a strategic partnership with [company x}. The partnership means that [COMPANY X] has the exclusive right to introduce the product [PRODUCT X] on the Dutch market. In Germany, the Electronic Health Record system [PRODUCT X], is

implemented in over 130 hospitals, and with this strategic partnership [COMPANY X]wants to copy this success to the Dutch market.

Over the last few years, there are developments in the information systems of hospitals. In many hospitals, there is a shift from working on paper to a situation that is fully digital. However an EHR-system that fully replaces the need for a paper-based medical record, can be seen rarely, or not at all. [COMPANY X] as a supplier of ICT solutions is interested in what the benefits are for hospitals if [PRODUCT X] is implemented. Therefore this study was initiated.

§ 1.3 ICT in Healthcare

Every hospital is responsible for its own ICT-policy. At the same time, the government wants a nation-wide network to be developed to enable patient record sharing. To realize this, a set of standards have been developed, that all hospitals must meet to join this network.

Hospitals have to meet the program of requirements of a ‘Goed Beheerd Zorgsysteem (GBZ)’2_{. This is a document in which the requirements of hospital’s ICT-systems are listed.}

These requirements must be met to connect to the (future) nation-wide network). Hospitals are free to choose their own ICT-suppliers, or to develop their own ICT-systems. But for the nation-wide network it is required that all patient-data is available digitally, and that the GBZ requirements are met. These requirements are meant to develop a secure and reliable network.

For many years there have been discussions about the (dis)advantages of ICT in healthcare. According to Spaink (2005: 11), the rise of the Electronic Health Record systems in the Netherlands (EHR-system) started about ten years ago. In 1996 the Council for Public Health and Health Care (in Dutch named: RvZ: Raad voor de Volksgezondheid en Zorg) advised the government on the subject information technology in Healthcare3_{. The conclusions were that}

healthcare insufficiently used the possibilities of ICT to make healthcare more efficient and cheaper. In this advice the importance of good dissemination of information was

emphasized, and that an EHR would provide better accessibility, and complete information about the patient. At that point the exact shape was not clear yet, (e.g. there were thoughts about introducing a care chip card for everyone which now is implemented in Germany) but this point can be seen as the start of the EHR-systems in the Netherlands. In November

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Introduction

2003 the program ‘Sneller Beter’4_{was started by the Ministry of Health, Welfare and Sport}5_.

The goal of this program is to start several (benchmark) studies to improve the healthcare sector. The necessity of Electronic Health Record systems, is underlined by the following studies:

• Bakker (2004) claims that many possibilities exist to provide higher quality care at lower costs. Bakker in his capacity of TPG CEO, was asked by Hoogervorst, Minister of Health, Welfare and Sport to look at the healthcare sector, and give advise on possible

improvements in healthcare logistics. In this report, one conclusion is that by improving patient logistics, cost savings of 2-3.5 million euro can be realized in a time period of 3-5 years. Unfortunately it remains unclear how he has computed this amount of cost

savings.

• A qualitative study performed by TNS Nipo (Hentenaar, 2003) studied patients who had experienced medical errors to learn more of errors in medical information exchange. Many examples of medical errors caused by poor information exchange are

demonstrated in this study. Patients mostly think errors occurred due to bad reading of the medical record and due to bad communication. Among the consequences were the provision of wrong drugs or wrong treatments.

• A related quantitative study (Foekema and Hendrix, 2004) concludes that 6.1 % of all Dutch inhabitants aged 18 plus, have experienced medical errors caused by poor information exchange. The medical mistakes also have financial consequences. The conclusion is that the costs related to medical mistakes are circa € 1.5 billion in a year. A majority of the respondents noted that these errors could easily have been avoided when an EHR-system would have been used. Medical errors in this study varied from very innocent to very tragic ones. Noteworthy is that 92% of the respondents that experienced medical errors are very positive about the development of an EHR-system.

• Another study, performed by WINAp (scientifical institute for Dutch pharmaceutics), suggests that there are 90.000 avoidable hospital intakes due to avoidable medical mistakes. This study estimates that the costs for this are € 300 million a year6_.

These studies suggest that the use of a central EHR-system for the hospital, will provide possibilities to reduce the number of errors made by information exchange.

In literature and in publications, it is often mentioned that there is much room for

improvement in hospitals if an EHR-system would be implemented in a hospital (see for example the studies above). This however is only one side of the story. The implementation of an EHR-system also is complex and risk full. The implementation of [PRODUCT X] for hospitals means the implementation of a large system, that must be connected to several sub-systems. Additionally, all medical specialist must work with this EHR-system, which is a difficult implementation and change management challenge. For [COMPANY X], as the supplier of [PRODUCT X] this also requires much effort and resources. Next to the implementation problems, in literature there is a general debate about the disadvantages EHR-system implementations. In chapter 5, the disadvantages and the risks of EHR-system implementations will be discussed briefly. This study mainly focuses on the expected benefits of [PRODUCT X] for hospitals.

§ 1.4 Relevance of the study

With several studies and initiatives (NICTIZ, the project Sneller Beter’), the government stimulates hospitals to work with an EHR-system. Their interest is to enable a nation-wide network for the exchange of electronic medical records as soon as possible. This network is

4_{http://www.snellerbeter.nl} 5_{http://www.minvws.nl}

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Introduction

necessary to enable all connected hospitals, to view the medical information of their patients stored anywhere in the Netherlands.

The current EHR-systems of hospitals are not suitable for a connection to this nation-wide network. To connect to this network, it is necessary that hospitals work fully digital. Therefore at this moment, [COMPANY X] sees an opportunity for their EHR-system [PRODUCT X], that enables hospitals to work fully digital. For [COMPANY X] it is now important to communicate the benefits of [PRODUCT X] to hospitals. Most hospitals (physicians, management) know that in the coming years, they have to choose for one EHR-system. Therefore it is important for [COMPANY X] that they are able to explain the benefits of [PRODUCT X] for hospital. A number of hospitals have already started selection-groups, that look for what EHR-system is suitable for their hospital. For hospitals there are a few options:

• Hospitals can try to extend their current systems to an EHR-system

• Hospitals can choose a completely new EHR-system

In the search for literature for this study it became clear that many people have high expectations of the possibilities of EHR-systems (Physicians, patients, EHR-suppliers, the government). On the other hand, there are hardly any publications that describe the benefits that can be realized when such an EHR-system is implemented. Therefore this study was initiated, with the purpose to identify the benefits for hospitals when they use [PRODUCT X]. Target group of the study

For the study, there are two target groups:

• One target group is [COMPANY X] (department [PRODUCT X]), especially the marketing department. The next 5 years are challenging years for the [PRODUCT X] department of [COMPANY X]. In these years it will become clear if this department succeeds to

implement [PRODUCT X] on the Dutch market. This study is performed to know better what the benefits of EHR-systems are, and to be better able to demonstrate these benefits to hospitals.

• The Rijksuniversiteit Groningen, as this study also is my master thesis for Organization and Management, specialization Business Development. The relevance in this light, is that this study contributes to the general knowledge of the benefits of EHR-system implementations in hospitals. Additionally the study must demonstrate that I am able to study a practical problem in a scientifically sound manner.

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Theoretical framework

Chapter 2: Theoretical Framework

In this chapter, a theoretical framework is constructed to use insights from literature for the study. In § 2.1, in short the position of [COMPANY X] is placed in the context of the literature. In § 2.2, literature is reviewed on organizational development issues in literature. This

concentrates on the organizational developments hospitals face when they would implement [PRODUCT X]. In § 2.3, the diffusion of innovations is discussed, in order to have a more detailed insight in what can help hospitals to have the whole hospital use [PRODUCT X]. In § 2.4 a more precise definition of the term EHR-system is given, to be able to distinguish between [PRODUCT X] and other EHR-systems available on the market. Finally § 2.5 discusses international literature on EHR-system implementations.

§ 2.1 Market development

The subject of this study is a Business Development problem. Earlier, [COMPANY X] has noticed that there is a market for EHR-systems. Since about a year ago, [COMPANY X] wants to match the needs of these customers with [COMPANY X]’s EHR-system:

[PRODUCT X]. Ansoff (1965) developed the Growth Vector Matrix, in which the corporate strategy of an organization can be visualized.

In terms of Ansoff’s Growth Vector Matrix, [COMPANY X] follows a ‘market development‘ strategy with the introduction of [PRODUCT X] on the Dutch market.

• Product

[PRODUCT X] is a product of [COMPANY X] that already is used in hospital environments on a regular basis

• Market:

The market is new for [COMPANY X]. (Before the time [COMPANY X] offered [PRODUCT X], [COMPANY X] could not offer a product to customers who wanted to implement an advanced EHR-system)

In terms of the product life cycle (Levitt, 1965) the product [PRODUCT X] is in the market development stage.

Market

penetration development Product Market development Diversification Present New Present New Product M is si on (m ar ke t)

Figure 2.1: Ansoff’s Growth Vector Matrix

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On the Dutch market, there is no (or not much) proven demand for this product. In this stage, according to Levitt (1965: 82), generally demand must be ‘created’. It is a stage with many uncertainties and high risks. High investments have been made for [PRODUCT X], and still are made, while revenues of the product are still low. Investments in [PRODUCT X] are the adjustments of the [PRODUCT X] software, to make it suitable to the Dutch market (including the translation of the software), promoting the EHR-system on ICT & Healthcare exhibitions, sales activities, setting up pilots at hospitals interested in [PRODUCT X] etcetera. High investments are made, while there are no (or a few) customers of [PRODUCT X]. However, [COMPANY X] runs the risk that the product [PRODUCT X] will not be accepted by the market. If [COMPANY X] realizes to create the demand, and the product is implemented in hospitals (customers), in later stages, these investments will be returned. Levitt (1965: 82) states that many products don’t get of the ground, so to achieve the next stages of the product life cycle, decisions and actions now are very important.

Chun and d’Arbeloff (2004) present a figure that shows what the causes of new product failure are (see figure 2.3). For the introduction of [PRODUCT X] on the Dutch market, this is relevant for [COMPANY X], to not make the same mistakes.

Figure 2.2: Product Life Cycle Source: Levitt (1965: 82)

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For a successful introduction of [PRODUCT X], it is important to acknowledge the causes of new product failures as displayed in the figure. In this study, the factors ‘inadequate market analysis’ and ‘competitive strength or reaction’ are covered.

§ 2.2 Organizational development

Because of the fact that [COMPANY X] wants to introduce [PRODUCT X] in hospitals, it is also important to look in the literature on what the organizational consequences and requirements are of the implementation of an EHR-system like [PRODUCT X]. Such an implementation means a (re)design of the hospital-organization.

How people (and authors on this topic) think about organizational development differs to a large extent. This depends on their images of real life. Morgan (1996: 4-7) underlines this in his book ‘images of organization’, where he discusses different images of organizations. One image is the organization as a machine. In this metaphor efficiency is important, and the way to achieve this is a focus on planning, organizing, and controlling. An other image is to see organizations as brains, where information processing is important, as well as learning and intelligence. Another image he describes is an organization as a political systems. This metaphor focuses on the disparate interests of people in organizations, and the role of power in organizations.

These images represent different views of organizations. Different views are necessary to understand the complexity of organizations. Morgan states that all theory is a metaphor, and that the challenge is to become skilled in the art of using metaphors. Therefore for the purpose of this study, it is important to include relevant theories about organizational

development. This is in accordance with de Leeuw’s point of view (1997: 8), he states that for years people looked for one integral approach of organization and management issues, which failed. It is important to include different theories (and not one integral theory, because then this theory would be as complex as the reality to be understood).

Figure 2.3: Causes of new product failure Source:

http://ocw.mit.edu/NR/rdonlyres/Mechanical-Engineering/2-96Fall-2004/C0EE7CF7-E3EE-4590-8EB0-A306C342A43C/0/2_96_r_dmgt.pdf

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Hitt, Ireland and Hoskisson (2001: 17-21) mention how important technology has been in the development of organizations. They argue that technology alters the nature of competition in the following ways:

• Increasing rate of technological change and diffusion

Technologies are replaced quickly by newer technology. Organizations that are able to apply technology in the market may gain a competitive advantage.

• The information age

There are dramatic changes in information technology in the recent years. This is visible in the usage of computers, cellular phones, internet email and other (wired or wireless) networks. In the future this trend will continue: The declining cost of information

technologies (relative inexpensive computing power and linkage via networks) has high potential.

• Increasing knowledge intensity

Knowledge is most important in the information society. Being competitive, depends on the extent to which the organization can transform intelligence into usable knowledge. Although we might not be used to speak about hospitals in terms of being competitive, these developments are also relevant for hospital organizations. These are the contextual

developments of organizations. Organizations (Hospitals) can also benefit from the opportunities that changing technologies offer.

Wijnen, Renes and Storm (2001: 45) use an integral model of organizations, developed by Weggeman (1992) to analyze the internal organization. One can see whether there is consistency between the goals that are set and the way things are organized and realized, but also the strong and weak points of one of these three elements can be used to take improvement initiatives. If we think about the introduction of [PRODUCT X] in hospitals, the ‘organize’ part of this model is the most important aspect we look at. The introduction of this EHR-system will have great impact on the way things are organized in the hospital.

As visible in the ‘organize’ part, a change in one of the six elements has consequences for all other elements in the model. This model shows the dynamics of organizational change. For each of the elements in the integral model of organizations much literature is available. This will not be discussed in great detail here. For the purpose of the study we concentrate on

Figure 2.4: The integral model of organizations

Source: Weggeman (1992) in Wijnen, Renes and Storm (2001: 45). Set goals

• Orientation

• Inspiration

Realize

• From research until service

• From human resources until logistics Strategy Personnel Systems Management style Culture Structure Organize

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why organizations want to or should change and what themes in literature are important in this context.

ICT in organizations

An [PRODUCT X] implementation constitutes an ICT-driven change for the organization. Not only hospitals deal with the question of how internal work processes can be optimized. On the contrary, many organizations face the same challenges and questions. That is the question of how ICT can be used to optimize their work processes.

The implementation and/or integration of ICT-systems, is often difficult. This can be seen clearly when two organizations merge. Reasons for mergers often are to realize economies of scale, to share knowledge and to maintain your position in a market with high competition (strategic considerations). In order to realize these benefits, it is very important to think about how integration of ICT-systems should occur. Research suggest that many mergers and acquisitions fail (measured in the decline of shareholder value). One reason for this, is the failure to integrate the ICT-systems of the different organizations. (Laudon and Laudon, 2000: 567).

When we look at hospitals with this in mind, it is clear why good application of ICT for hospitals is difficult.

• Hospitals often are huge organizations, with many different medical specialties

• Often every specialty has its own ICT-facilities (often next to hospital-wide systems)

• Many hospitals are the result of one or more mergers, each with their own ICT-systems.

In a study of Royal Haskoning (2005: 5) the following problems in hospitals are listed about information systems in hospitals:

• Often there is too much or too little information available

• In hospitals, innumerous ICT-systems can be found which cannot be linked to each other

• Often information is missing at places where it is needed

• Much unnecessary and double entry of data occurs

This study names hospitals having these characteristics, hospitals that suffer from the disease ‘multiple informatiose’. This study suggests that this ‘disease’ has serious medical, organizational and financial consequences.

Innovation

A reorganization of the internal organization of hospitals would be necessary to recover from the disease. An interesting theme in this context is innovation. In literature this is often seen as important for organizations. In the year 2003 the government even set up an innovation platform, with the goal to strengthen the innovative power of the Netherlands to stay internationally competitive7_.

The urgency of being an innovative organization depends on the industry the organization is in. In some industries, organizations that do not innovate are out of business very quickly; in other businesses, this is not the case. However, unexpected innovations can rewrite the ‘technical or economical rules of the game’. In the figure below, it is made visible what organizational responses are needed given the (un)certainty of the environment.

7_{http://www.innovatieplatform.nl/}

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When this figure is applied to Dutch hospitals and the introduction of EHR-systems, it can be said that this is an environment with relatively low uncertainty. When a hospital is late with the introduction of an EHR-system, there often is little or no rivalry that forces hospitals to innovate or that threatens the survival of the hospital organization. The y-axis is about the question if new responses are needed. This can be a point of discussion, but given the many publications about the necessity of EHR-systems, it can be argued that many people think that new responses may be needed. This is important for the [PRODUCT X] department of [COMPANY X]. If [COMPANY X] manages to successfully implement [PRODUCT X] in a number of hospitals, they might ‘rewrite the rules of the game’, and other hospitals may also want to implement this EHR-system.

Tidd, Bessant and Pavitt (2005: 17-18) underline the necessity innovation for organizations. Their point is that organizations can only survive if they are prepared to renew their products and processes on a continuing basis. But it is important to maintain some balance the drive to be innovative as organization and the need to incorporate the innovation in the

organization. This is made visible in the following figure:

Low uncertainty

Placid environments and stable industrial structures which new entrants can exploit through technological change to ‘re-write the rules of the game’. Examples include telephone banking and insurance

Fast changing environments – e.g. IT, biotechnology, etc where major re-drawing of industry structure is taking place. Innovation is essential for old players to survive, but new

opportunities also emerging.

Placid environments where the need for innovation may not be perceived as high. Stable conditions and market structures may provide a sense of false security since new technology or other changes can bring about industry transformation.

Risk is that by the time the need for change has been identified it may be too late for existing players to react

Fast changing environments where it appears that existing players can continue to dominate through applying proven – for responses. Risk of being caught out by this approach example, IBM with the shift to networks and decline of mainframes, and the ‘Big 3’ US car makers in the face of Japanese competition.

New response needed

Old response appropriate

High uncertainty

Figure 2.5: Urgency of innovation for organizations Source: Tidd, 2003, p. 18

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With this figure, Ettlie (2006: 8) makes clear that the higher the change of technological innovation is, the higher the necessity is for organizational innovation. If the organizational innovation does not take place after technological innovation, the potential benefit of the innovation will not be captured. This is also important for the introduction of [PRODUCT X] for hospitals. If [COMPANY X] as supplier of EHR-system introduces a high amount of technological innovation, without the focus for organizational innovation for hospitals, the introduction of [PRODUCT X] will be a potential failure.

§ 2.3 Diffusion of innovations

In the context of this study, it is important to know what factors influence the diffusion of an innovation (like the introduction of [PRODUCT X] on the hospital market). Rogers (1995 in Tidd, Bessant and Pavitt (2005: 185)) mention 5 characteristics of an innovation that affect its diffusion:

• Relative advantage

This is the extent to which an innovation is perceived as better than the previous product (in financial terms as well as non-economic terms)

• Compatibility

The extent to which an innovation is consistent with existing skills, experiences and procedures

• Complexity

The extent to which an innovation is seen as difficult to either understand or use

• Trialability

The extent to which it is possible to experiment with the innovation, before one comes to depend on it

• Observability

The extent to which the results of an innovation are visible for others

These factors are important characteristics that influence the diffusion of an innovation. In this study, the relative advantage, compatibility and the complexity are covered.

For the diffusion of innovations, the stakeholders approach is also relevant. Paul et al (1999: 110-112) state that within and outside organizations, a number of parties exist, that have

Potential Failures Potential Failures Technological innovation O rg an iz at io na l i nn ov at io n

Figure 2.6: Successful management of newly adopted technology Source: Ettlie (2006: 8)

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their own goals. Many different parties in- and outside the hospital, have different interests in the implementation of an EHR-system. The respective parties have their own ways to put pressure on the people responsible for the choice of an EHR-system. Some stakeholders might not see the importance of the introduction of an EHR-system, while others will find it highly important. Paul et al (1999: 110-112) emphasize that it is important to be aware of the stakeholders and their interests. Then it is possible to know how the implementation of an EHR-system can be managed and what tensions might be expected.

A stakeholder analysis of EHR-system implementations, can be performed on several levels of aggregation. Without any problem a long list of stakeholders can be thought of (e.g. patients, physicians, nurses, medical administrative assistants, care managers, paramedics, other hospital personnel, the Ministry of Health, Welfare and Sport, NICTIZ. In the Dutch healthcare, many stakeholders can be distinguished (internal and external to the hospital organization). In the context of this study, only the most important stakeholders are listed that have direct interest in the implementation of an EHR-system in a hospital. For NICTIZ (the organization responsible for the nation-wide network of EHR-systems),

van der Hoorn and van den Dool (2005) wrote an article in which a reference architecture for healthcare is presented in order to be able to connect to the nation-wide network. According to Van der Hoorn and van den Dool (2005) the following stakeholders are the most important stakeholders when one thinks about the implementation of EHR-systems.

Stakeholder Interest

Patients • Receive an effective treatment

• Low cost

• Little chance for medical errors

• Usage of ‘best practices’

• High privacy of medial information

• Transparent documentation of treatments and results Care deliverers • Reduce (avoidable) medical errors

• Reduce liability for medical errors

• Efficiency

• Quick access to relevant patient information

Care managers • Efficiency (within and outside the organization) to keep costs low

• Patient safety (also for liability reasons) Information managers • Good information architecture

• Optimal systems to store the medical information Developers of systems • Good usage of technology (On the on hand, the usage

of new technology is interesting, in order to have the newest functionalities, but on the other hand this may mean higher risks than existing work methods) Table 2.1: Stakeholders in hospitals concerning EHR-system implementation

The interests of the listed stakeholders at first sight are not much conflicting. If however an EHR-system will be implemented, every stakeholder(group) may follow its own interest. If an EHR-system is implemented, for instance some care deliverers may think that their interests are served, and others disagree. This may means that this stakeholder is not content with the EHR-system, and might reject the system.

Moore (2002) describes how disruptive products can be sold to mainstream markets. He distinguishes between 5 groups of buyers:

• Innovators (technological enthusiasts)

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• Early adopters (visionaries)

Like to use new technology early, to realize a competitive advantage for their organization

• Early majority (pragmatists)

People who buy new technology when there are good references of the technology, to avoid buying in technology that will become a failure.

• Late majority (conservatives)

People who want to buy new technology after there is a proven advantage when the product is used.

• Laggards (sceptics)

People who preferably avoid the usage of new technology The division of these ‘groups’ is as displayed in the following figure:

According to Moore, the introduction of new technology goes from left to right in the life cycle. When an organization wants to sell high tech products to mainstream markets, it is important to know the characteristics of the different buying groups. Moore states that it is relatively easy to sell to innovators and early adopters, but that it is difficult to then make the step to the early (and late) majority. The risk for organizations is to be so caught up in early successes (of innovators and early adopters) that the real challenge is not acknowledged. This challenge is to bring the product to the mainstream market (early majority and late majority). Moore speaks of a chasm that has to be crossed when organizations want to sell to the early (and the late) majority. The chasm is the white area between the early adopters and the early majority in figure 2.7. The chasm exists because the early majority buyers, require good references before buying the product. Early adopters don’t make the good references. This is a chasm that has to be crossed.

To cross the chasm, Moore advises to take four steps, which he calls the D-Day strategy (this refers to the invasion of the Allied Forces in Normandy in World War II). The steps are: 1. Target the point of attack

In this step it is important to define the target-market, and define the market segments. For each segment it is important to know the potential customer’s ‘compelling reason to buy’ (or: must-have value proposition). Based on this information, the point of attack can be planned

Figure 2.7: The revised Technology Adoption Life Cycle Source: Moore (2002)

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2. Assemble the invasion force

In this step it is important to have a so called “whole-product”, which is a product that delivers everything a customer wants. Innovators and early adopters are willing to find out how the product works on themselves, but for the early majority it is important to have a complete product, including supporting services, additional software, standards and procedures etcetera.

3. Define the battle

In this step, according to Moore, competition must be ‘created’. The product must be positioned against the existing alternatives this product will replace.

4. Launch the invasion

Here it is important to find a distribution channel that attracts the pragmatist buyer. The aim is to become market leader. The pricing of the product should reflect this.

The idea of these four steps is that first the company must focus on one single beachhead (like Normandy in World War II). When this beachhead is dominated, this is a springboard to the extended markets. For [COMPANY X] this theory is important. They also have to cross the chasm defined by Moore. Therefore [COMPANY X] first should spend much resources to win over the beachhead, and then take next steps to realize a high market share.

Network externalities and Lock-in

An important item in the technology adoption literature, it the existence of network externalities. According to Katz and Shapiro (1986: 822), network externalities can be described as the situation in which the benefits consumers derive from the use of a product or service, depend on the number of other consumers that purchase a compatible product or service. Chakravarty et al (2005: 748) mention that computer markets provide the strongest examples of network effects. As an example, Microsoft is discussed, who according to Chakravarty et al (2005:748) has become market leader by writing application software that is compatible with the Windows operating system. They also point on the possibility of the lock-in effect that can occur, which means that an inferior product may become the market standard even though superior market alternatives may be available.

For hospitals that work with [PRODUCT X], network externalities are also likely to become relevant. The more hospitals use an EHR-system that can communicate with [PRODUCT X], the more value a hospital with [PRODUCT X] derives from this EHR-system. It is unclear to what extent lock-in will occur, because standards for interoperation and for the connection to the nation-wide network are pre-defined by NICTIZ and the Ministry of Health, Welfare and Sport. The network effects will be stronger as the hospital that uses [PRODUCT X] can interoperate with more care delivery organizations that use compatible systems. In other words: the more hospitals that use [PRODUCT X] (or other compatible systems), the more benefit can be derived from [PRODUCT X] due to the network externalities.

Acceptance of technology

When we look at the diffusion of technological innovations, the Technology Acceptance Model is also useful. This theory tries to explain why organizations do or do not accept technology. The theory states that two fundamental beliefs determine whether a system is or is not accepted by end-users. These variables are Perceived Usefulness (PU) and Perceived Ease of Use (PEOU).

Davis, Bagozzi and Warschaw (1989: 985) define perceived usefulness and perceived ease of use as follows:

Perceived usefulness (PU):

The prospective user’s subjective probability that using a specific application system will increase his or her job performance within an organizational context

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The degree to which the prospective user expects the target system to be free of effort.

According to the Technology Acceptance Model, the PU (perceived Usefulness) is an important determinant of the Behavioural Intention, and thereby for the real use of the system.

For the study, it is important to know that these two variables are very important in the acceptance of technology. This means that [COMPANY X] should offer [PRODUCT X] in a way that hospitals perceive this product as useful and as a product with ease of use. It is important to notice that the theory is about the perceived ease of use and the perceived usefulness. This underlines the importance of communication about [COMPANY X]’s system to customers, to influence their perception e.g. by focusing on appropriate trainings and clear product specifications.

The two main variables of the Technology Acceptance Model (Perceived Usefulness and perceived Ease of Use) are important for [COMPANY X]. The question if hospitals will choose [PRODUCT X], depends on the extent to which [COMPANY X] is able to communicate the Perceived Usefulness en de Perceived Ease of Use to hospitals.

This model also underlines the importance of early implementations. On the market, mostly systems are found with limited functionalities. When hospitals choose for a new EHR-system, it is likely that they will make inquiries about the experiences of other hospitals. If however end-users reject the technology, an expensive system is bought by the organization, but it is useless, and a waste of investments.

§ 2.4 Definition of EHR-systems

In the Netherlands, there is no hospital where a complete EHR-system like [PRODUCT X] is implemented. Therefore, I looked for studies in international literature, to see what sorts of EHR-systems exist, and to know what the place of the EHR-system [PRODUCT X] is. The purpose of the EHR-system definition is to define what kind of system [PRODUCT X] is. If we have a definition of the systems, it is better possible to understand what kind of EHR-systems are found in hospitals and what kind of EHR-system [PRODUCT X] is.

Four levels of EHR concepts

Although we mentioned the term Electronic Health Record a few times, there are different definitions for that term. Therefore I distinguish four levels of EHR concepts to avoid confusion of tongues. The four concepts start very high, and end at a very detailed level. These four levels of EHR-concepts are also used by [COMPANY X] in presentations for customers. The same definitions are used, and explained in greater detail.

Figure 2.8: Technology Acceptance Model

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1. Nation wide EHR-system:

The Ministry of Health, Welfare and Sport, and NICTIZ, the National IT institute for Healthcare use a very general definition of EHR-systems. The government stimulate and coordinate the building of a nationwide infrastructure for EHR-systems8_{. Their goal is to}

make possible a nation wide EHR-system to make it possible that all hospitals can exchange patient records digitally. All hospitals must be connected to the so called ‘Landelijk Schakelpunt’, which is a central ICT-facility that facilitates the exchange of digital patient records between care providers (hospitals) digitally. Every care delivery organization has to meet a set of standards to be allowed to connect to this service. In the future, the (digital) medical record of patients can very well be stored in more than one hospital. Via the ‘Landelijk Schakelpunt’ every connected hospital will be able to see all the treatments a patient had in all Dutch hospitals.

2. Regional EHR-system:

The step from a mainly paper-based hospital to a hospital with full possibilities to

exchange medical information nation-wide, is a big step. In some regions, the first steps towards a smaller, regional cooperation can be found. An example is the region ‘Zuid-Holland Noord’9_{. This RCG (Regional Commission on Healthcare) is a platform of care}

delivery organizations, insurers, municipalities in the region to stimulate cooperation among these parties. On the website it can be read that in the year 2004 they simulated a system that is already operational in Israel for 3,8 billion citizens. The EHR-system there worked as a ‘virtual medical record’, where hospitals are responsible for the digital storage of their medical records, and the cooperating care delivery organizations can view the relevant parts of the medical record. The intention of the RCG was to study the possibilities for this region. Now the plan is to build a regional EHR-system, which can be connected to the nation wide EHR-system in the Netherlands, whenever this is made possible. Here EHR-system means an infrastructure to exchange Electronic Health Records between care delivery organizations in the region (e.g. hospitals, pharmacy and the family doctor).

3. Institutional EHR-system:

At a lower level, one can find care delivery organizations, like hospitals, using EHR-systems (at what I call the institutional level). Before a nation-wide EHR-system can be functional, it is necessary that all hospitals in the Netherlands, digitalize their medical records that are now stored in paper-based archives. Additional to this digitalization process, physicians should work digitally. An institutional EHR-system is a hospital-wide system in which the medical records are stored digitally. This replaces the need to keep paper-based medical records. This might not appear to be a big transition, but the opposite is true. The paper-based medical record must be digitalized, physicians have to work digital and there must be an (preferably one) EHR-system that is suitable for the digital storage of the former paper-based records.

4. Individual EHR-system

At the lowest level, one can find EHR defined as a specific Electronic Health Record for one patient. In this definition, an EHR is a file in which electronic information can be found of one specific patient. This EHR might have to be retrieved from a number of the larger systems described above (institutional, regional paper-based record most

hospitals still use at the moment.

In this study, our focus is on the institutional definition of an EHR-system, and more specific, on an EHR-system used in hospitals. Hospitals are free to work together (read: to establish

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regional EHR-systems), and when hospitals want to realize this, [PRODUCT X] can be used for this, but the starting point for [COMPANY X] is that this is an EHR-system for a hospital. The term EHR-systems for hospitals still is not self-explanatory. Relative simple systems, with only abilities to view some test results digitally, are called EHR-systems as well as more advanced systems, with possibilities to work paperless. Ernst & Young (2003) performed a study on the status of EHR-systems in the Netherlands (2003). In this study, a distinction is made between three types of EHR-systems:

• Informative

• Registrative

• Multidisciplinary EHR-systems

A conclusion of this study was that less than 10% of the hospitals at that moment had realized an EHR implementation with only limited registrative possibilities. This study was conducted circa 3 years ago.

Gartner’s definition of an EHR-system

At [COMPANY X], the definition of the Gartner Group is used often, to define the EHR-system [PRODUCT X], and to be able to explain the differences of this EHR-EHR-system and the systems that are operational currently in hospitals. The Gartner Group is a large organization based in the United States that gives technological advice to their customers. For EHR-systems, the Gartner Group have developed a framework, with the purpose to have a clear definition of EHR-systems. With this article, he tried to tackle the market confusion about EHR definitions, and to provide a model for organizations to be able to evaluate EHR-systems (Gartner, 2004: 5).

Gartner’s definition of an EHR-systems (in Gartner’s terms: Computerized patient Records (CPR)) is:

“A CPR system contains patient-centric, electronically maintained information about an

individual’s health status and care, focuses on tasks and events directly related to patient care and is optimized for use by clinicians. The CPR system provides support for all of the activities and processes involved in the delivery of clinical care”. (Gartner, 2004: 1)

The Gartner group uses a general definition of an EHR-system. The system does not only store medical information, but it also supports the required activities and processes to deliver care. The Gartner group distinguishes 5 generations of EHR-systems, based on nine

capabilities. Every next generation in Gartner’s definition must meet higher standards at the nine capabilities.

The nine capabilities the Gartner group distinguishes: 1. Clinical data repository (CDR)

Storage of medical information. 2. Interoperation

Extent to which the system can communicate with other systems within and outside the hospital.

3. Support for privacy

Medical data must be treated confidentially and EHR-systems must guarantee that the medical information stored in the EHR will only be visible to the actors that are allowed to see this.

4. CMV (Controlled Medical Vocabulary)

Sometimes there are more names for one disease. For the government and for insurers, the DBC codes are relevant. For physicians, international standards for diagnoses (International Classification of Diseases (ICD-9 and ICD-10)) are relevant. A vocabulary

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server (VOSER) is required to standardize the medical concepts, and to make sure that EHR-systems use a common vocabulary for all systems.

5. Clinical WF

Clinical Workflow capabilities allow the EHR-system to support processes needed to provide care

6. CDS (Clinical Decision Support)

An advanced capability to include rules and decisions in the EHR-system to support clinical work-processes

7. Document and data capture

All relevant data must be gathered by the EHR-system. Results must be imported from external systems (located in the hospital or from systems outside the hospital).

8. Clinical display

Presentation of medical information. 9. Order management

Digital ways to order tests and therapies, which replaces the need to have orders written on papers by the physician.

(Gartner, 2004: 6).

In an article of the Gartner group (2004), the requirements of the 5 generations he distinguished, are explained in great detail. Below, I summarized the most important characteristics of each generation.

Generation 1 – The Documentor

The first generation EHR-system only provides a site specific solution to access medical information. Uploaded and scanned texts are available, and there are (minimal and simple) ways to display medical information. This information (in the EHR-system) is often

incomplete. The name, ‘the documentor’ is because the purpose of these EHR-systems is to document all relevant medical data.

Generation 2 – The Collector

The second generation is a uniform system to organize and manipulate clinical information and summary text. Nurses and physicians can add patient information to the EHR-system. Access to data is ‘role-based’. Users can easily acquire information from the EHR-system. Simple database-driven graphical representations can be generated and simple patient-list dashboards are available that can highlight abnormal results. Generation 2 systems have limited decision support and limited workflow capabilities. The name ‘The collector’ is

because this generation of EHR-systems, collect all relevant data that normally is stored only in the paper-based medical record.

Generation 3 – The Helper

The third generation EHR-system must meet documentation needs of ambulatory and select acute-care settings. Data storage must meet high standards (e.g. HL-710_{, XML). The system}

must give pro-active alerts to the physician. The system must also have notification options (paging, email) to have others viewed results. Data-results displays must be updated as soon as new information is available. All types of orders (e.g. requests for tests) can be entered by the physician as well as nurses. Representation of data is flexible and configurable by the user. Limited links with systems outside hospitals must be possible (e.g. exchange of

prescriptions with the pharmacy). Workflows can be defined and used with the EHR-system. Dictated notes can be automatically be incorporated in the appropriate context. Several input methodologies like handwriting or speech recognition must be supported. The EHR-system must provide functionalities to perform trend-analysises in many ways. The name, ‘the Helper’ is because this system does not only collect and document medical information, but