Issues and stakeholders in EPR implementation

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Issues and stakeholders in EPR implementation

A multi-perspective research on the interaction of issues and

stakeholders in a healthcare setting

University of Groningen, Faculty of Economics and Business

MSc. Business Administration, Change Management

24-07-2013

J. van den Bos

Oosterhavenstraat 13

9711SB Groningen

j.van.den.bos.6@student.rug.nl

Student number: 2222558

First supervisor university: dr. J.F.J. Vos

Second supervisor university: dr. ir. M.C. Achterkamp

Supervisors at the field of study: dr. I. Lesman & drs. C. van Well

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Issues and stakeholders in EPR implementation

A multi-perspective research on the interaction of issues and

stakeholders in a healthcare setting

ABSTRACT

Earlier research suggests that for better results in EPR implementation, implementers must incorporate a wide range of factors, closely involve stakeholders, pay attention to social factors, and integrate better change management practices. This paper takes an issues management approach to IS implementation, with a strong emphasis on stakeholders. Issues and stakeholders are examined in the pre-implementation phase of an Electronic Patient Record (EPR). Based on an embedded, multilevel case study in a healthcare institution, the interaction between issues and stakeholders and their influence are addressed. Issues and stakeholders are analyzed from two perspectives: a single issue perspective which consist of a stakeholder identification and analysis based on a single issue, and a multiple issue perspective which consist of an issue identification and classification amongst potential user groups of an EPR. Stakeholder identification based on a single issue is a proper method to use when dealing with the implementation of a complex information system such as EPR. The proposed issue identification offers a complete view of the complexity of issues of potential users towards an EPR technology. Assessing issues helps to focus on key problems and provides a framework for the classification of issues in an EPR project. The pre-implementation phase in the implementation proved to be highly dynamic and influenced by many issues and stakeholders. This paper concludes that issues are complex and this research tries to reduce this complexity to enable individual healthcare institutions to establish benchmarking for EPR implementation issues.

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INTRODUCTION

The importance of healthcare to individuals and governments and its growing costs makes healthcare an important area of research for academics in business and other disciplines. Information systems (IS) have much to offer regarding healthcare costs and the improvement of the quality of care (Fichman et al., 2011). In many healthcare institutions, the focus is on a specific IS project, namely an Electronic Patient Record (EPR). EPR is a software application which contains and saves patient data in a digital form. The purpose of an EPR is usually to support the current or future patient care process. Expectations regarding an EPR are high, and the benefits from the use of technology can be considerable. Healthcare institutions invest massively in EPR, but despite these investments, it is an IS that is common to fail to some extent (Avison & Young, 2007; Jensen & Aanestad, 2007). Some projects fail due to technical problems or because the system could not meet business-specific needs. However, Legris & Collerette (2006) argue that many fail due to weak implementation, notably due to problems related to stakeholders. Implementing an EPR requires significant technical, as well as organizational changes. Yet, the individuals that manage the implementation of an IS, the implementers, often fail to address important organizational aspects such as the expectations and concerns of those who have a stake in the project, causing problems for integration of the technology (Langenwalter, 2000; Greenhalgh et al., 2009; Payton, 2011).

Those who have a stake in the project are called stakeholders. Freeman (1984: 46), the pioneer of stakeholder theory, defines a stakeholder as: “any group or individual who can affect or is affected

by the achievement of the organization’s objectives”. Harris & Weistroffer (2009) argue that the

involvement of stakeholders is not only important, but absolutely essential to the success of an IS implementation. Notably how stakeholders influence and perceive an IS during the implementation is an important aspect, as little is known about the projects’ activities and project execution; uncertainty is high in this stage. During the implementation stage, stakeholders are a primary source of uncertainty, because the implementation affects many stakeholders with varying perspectives, interests, and with different degrees of autonomy and expertise who are all involved in the implementation of an EPR (Boonstra & Govers, 2009). According to Ward & Chapman (2008), this source of uncertainty can be understood by identifying who the relevant stakeholders are, what are the issues that stakeholders are interested in, and how they can influence a project.

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preliminary the issue that is the focus of all the activities of the stakeholder, instead of the focal organization. Therefore, it is useful to also take an issues management approach rather than only an organization management approach when dealing with stakeholders in an IS implementation.

Issues management is the process of identifying and analyzing issues, followed by actions to bring harmony between implementers and stakeholders (Heath, 2002). Crable & Vibbert (1985: 5) argue that “issues are not simply questions that exist; an issue is created when a stakeholder attaches

significance to a situation or perceived concern”. Issues are events that stakeholders point out which

may have a significant effect on the functioning or performance of an organization (Lientz & Larssen, 2006; Regester & Larkin, 2002). If an issue remains unresolved, implementers risk creating unnecessary conflicts, delays, or even failure of an implementation of IS. Roloff (2008) states that addressing the various issues that emerge, and thus practicing issues management, allows implementers to meet the challenges of the implementation process of an IS. The importance of using issues management especially in the pre-implementation stage of a project is high. By having an early awareness of issues, implementers have more time to deal with the issues and are more able to successfully implement an IS project. While there has been many research focusing on the implementation process and its critical issues (Bingi et al., 1999; Hong & Kim, 2002; Umble et al., 2003), much of the research has focused on issues with very limited or no regard to stakeholder perspective (Finney & Corbett, 2007). Little is known about the role of issues and stakeholders during IS implementation in healthcare and in similar sectors (Boonstra & Govers, 2009). More research can help clarify the importance of an issues management approach regarding stakeholders during IS implementation in healthcare.

To contribute to existing theory, this research takes an issues management approach regarding stakeholders to analyze the interaction between stakeholders and issues in an EPR pre-implementation phase in a healthcare setting. The goal of this study is to provide a new interpretation of how healthcare can deal with stakeholders and issues. Furthermore, it tries to broaden our current understanding of the complexity of issues in relation to stakeholders. Therefore, the following research question will be used for this research: How do stakeholders and issues interact during the

pre-implementation of an EPR? This question can be answered by addressing the interaction between

stakeholders and issues from two different perspectives: a single issue perspective to gain an in depth perspective, and a multiple issue perspective to gain a broader perspective. The first sub question addresses the stakeholders-issues interaction from a single issue perspective: (1) How can stakeholders

be identified based on a single issue during the pre-implementation of an EPR? A single issue

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complexity of issues. An answer on the second sub question can take away this limited view by addressing the stakeholders-issues interaction from a multiple issue perspective: (2) What are the

issues perceived by stakeholders during the pre-implementation of an EPR and in what way do the perceived issues affect the support of stakeholders regarding an EPR implementation? By taking a

multiple issue perspective, issues can be identified that stakeholders perceive during the implementation process of an IS and how these issues affect stakeholder support. Langenwalter (2000) states that various stakeholders have their own expectations whether they are aware of it or not, whether they admit it or not, and whether it makes a big difference or not. Therefore, during the implementation phase of an IS many issues may emerge perceived by stakeholders. All these emerging issues make it difficult for implementers to resolve the issues that can threaten to fail the project. Assessing stakeholders and issues from these perspectives may help implementers to understand how issues evolve and why stakeholders and issues are important aspects for implementers to address.

The structure of the paper is as follows, in the next section the underlying assumptions of issues and stakeholders are being described in a literature review. The section concludes with a conceptual model for this research. In the third section the research methodology is given, describing the research design, case context, data collection and data analysis. Thereafter, in the fourth section, the results of the research are presented. Eventually, discussion and conclusions of the findings of this research are presented in the final section of this paper.

ISSUES AND STAKEHOLDERS

To gain an understanding of how literature, regarding issues and stakeholders in IS implementation, has progressed, a thorough review of literature is necessary. It is important to first create an understanding of the concepts issues management and stakeholder theory before addressing specific aspects regarding the interaction between issues and stakeholders in IS implementation. This section concludes in two conceptual models in which all variables of interest are presented.

Issues Management

In the late 1970s and early 1980s, scholars were trying to develop management theories to help explain management problems that involved high levels of uncertainty and change. Howard Chase is seen as the pioneer of issues management and created the concept as a response strategy and warning tool for management in 1977 (Jaques, 2005). By the mid-80s issues management was well rooted but still under development. Since then, many alternative models concerning issues management have been developed by scholars from various disciplines. Coates et al. (1986, p. 9), for instance, define issues management as: “the organized activity of identifying emerging trends, concerns or issues likely

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organizational responses toward the future”. Nowadays, issues management is about building,

maintaining, and repairing relationships with stakeholders and stakeseekers. Heath (2002) states that the objective of issues management is to make a smart, proactive and more respected organization. Such an organization is one that understands and responds to its stakeholders. Many scholars take an organizational perspective on issues management rather than a stakeholder perspective (Heath, 2002; Jaques, 2006). Taking a stakeholder perspective on issues management is under researched, although when taking this perspective, by identifying stakeholders based on issues and addressing issues that stakeholders perceive, could potentially influence the outcome of an IS implementation.

While issues could have a positive effect on the outcome and success of an IS, the absence of addressing issues could give rise to difficulties during the implementation (Soja, 2006). To make an IS successful and to achieve improvement, implementers have to be able to successfully cope with and address a wide variety of issues by using issues management (Gaunt & Ollenburger, 1995). Issues management is often confused with crisis management; while they are linked, they are not the same. An important aspect of issues management is “the future”, it is concerned with forecasting. It involves looking forward to identify potential events that may influence the organization, while crisis management is a more reactive approach focusing on the situation after a crisis has occurred (Jaques, 2007). According to Roloff (2008), it is important that issues management, instead of crisis management, is used in a project for better cooperation between implementers and stakeholders and to gain mutual understanding of issues to have a proper implementation.

Gaining mutual understanding can be difficult as issues may vary; some issues may be best served by carrying the project forward, others by stopping or weakening it. In issues management similar issues are shared, but differences are also addressed to understand conflicting interests and needs. An issues management approach on stakeholders brings discipline to the work of gathering knowledge about issues and the interests of stakeholders and may add to a successful outcome of a project. Boutilier (2011: 4) argues that issues management is useless without relating them to stakeholders: “trying to manage issues without building relations with stakeholders is like trying to

direct a movie and change the script without ever talking to the actors or crew”. Thus, to enable

issues management to be useful, also stakeholder theory has to be taken into consideration.

Stakeholder Theory

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2010). Laplume et al. (2008), for instance, argue that because organizations can gain a lot from having a beneficial relationship with its stakeholders, scholars have been giving significant attention to stakeholder theory. In order to obtain benefits from stakeholders in IS implementation, organizations need to try to manage the stakeholders. Stakeholders can be either internal, such as senior management or employees, or external, such as society or government. Organizations not only have stakeholders on the organizational level, they also have various stakeholders in projects which all have different interests.

When implementers of a project want to proactively manage stakeholders, they need to understand stakeholder interests and behavior and attempt to manage these interests. Many scholars argue that it is important that implementers take the time to identify, understand, involve, and manage project stakeholders (Schwalbe, 2009; Parmar et al., 2010; Laplume et al., 2008). Thus, a project such as the implementation of an IS also deals with various stakeholders which need to be addressed. In case of an IS implementation, implementers can gain a lot from having a beneficial relationship with its stakeholders. Therefore is the importance of addressing stakeholders during implementation significant.

Addressing stakeholders is easier said than done, managing stakeholders has become a systematic approach to organize the relationship between the organization and society. Roloff (2008) states that nowadays, organizations tend to interact with more and more heterogeneous stakeholders. As a result, organizations find it increasingly difficult to adapt to the numerous and often contradictory expectations of stakeholders. In case of an IS implementation, when using an organization-focused stakeholder management, implementers are unable to anticipate on changing expectations and to identify issues when they are not yet threatening for the project. When only an organization-focused stakeholder management is used, an optimal beneficial relationship between implementers and stakeholders will not be obtained. This because achieving a beneficial relationship between implementers and stakeholders depends on the issue at hand.

Issues and Stakeholder Identification

Scholars, such as Hajer & Wagenaar (2003) and Roloff (2008), state that stakeholders are issue-driven, it is not an organization that is the focus of discussion, but an issue relevant to several stakeholders. Successful issue-focused stakeholder management has the potential to predict changing expectations and therefore to come up with proper solutions when dealing with stakeholders. By changing the focus from organization stakeholder management to issue stakeholder management, it might result in better understanding between implementer and stakeholder. Roloff (2008) also argues that it is important to use issues management in an early stage of a project for better cooperation between implementers and stakeholder.

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involved with different issues. Kolltveit & Gronhaug (2004) argue that the potential influence of stakeholders is high in the early phase of the project. Failure to gather necessary information from stakeholders in early phase of the implementation significantly delays later phases (Lahiri & Seidmann, 2012). The early phase of the implementation process, also called the pre-implementation phase, involves activities as planning for the technology introduction, deciding roles, in-house resources, managing the introduction, and planning the logistics of the change (Herold et al., 1995). Markus & Tanis (2000) state that the pre-implementation phase has proved to be a critical stage, and not addressing issues in the early phase of the implementation process has significant impact on the total success of an IS. Failures in this phase may escalate in later phases and throughout the project, and the organization might end up with a non-suitable or non-usable technology.

It is also important to focus on issue stakeholder management in the pre-implementation phase, and to identify stakeholders based on issues as, according to Payton et al. (2011), stakeholders help accentuate the desirable changes and offer their knowledge and skills which are necessary to execute the change. Furthermore, studies have reported evidence of the importance of identifying and involving stakeholders and their issues regarding an IS and actively managing the people aspects throughout the implementation phase (Mourier & Smith, 2001; cf. Achterkamp & Vos, 2008). Achterkamp & Vos (2007) argue that stakeholders and issues are interconnected, but how they are interconnected is unknown. It is therefore valuable to identify stakeholders based on issues to gain insight in what role stakeholders play in relation to a specific issue and who to involve when dealing with an issue. When dealing with an IS implementation, a stakeholder identification enables implementers to have a better understanding of stakeholders involved in the project and therefore enables more informed decisions regarding the adoption of an IS (Mantzana et al., 2007).

In the stakeholder literature, stakeholder identification is seen as a classification problem. Many classification models are available, although the salience model of Mitchel et al. (1997) is considered to be the main classification model in stakeholder literature (Scholl, 2004). Mitchell et al. (1997) propose a first step in managing stakeholders by assessing stakeholders on their level of salience. Stakeholder salience can be defined as “the degree to which managers give priority to

competing stakeholder claims” (Mitchell et al., 1997: 854). The level of salience helps to determine to

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Figure 1. Stakeholder typology Mitchell et al. (1997: 874)

The salience model may help implementers of an IS in the early phase of the implementation to classify stakeholders according to their salience. Salience can be used in stakeholder identification in an IS implementation to estimate the influence possibilities of the parties involved regarding an specific issue. Managers often end up addressing the claims of powerful and vocal stakeholders who affect the firm, such as definitive stakeholders, rather than the vulnerable stakeholders who only are affected. This is simply because this is the most pragmatic way to ensure the effectiveness of the organization on a short term perspective (Roloff, 2008). However, when concerning an IS implementation, implementers should not overemphasize the demand of powerful stakeholders and should include vulnerable stakeholder groups. A long term perspective is needed for successful IS implementation.

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maker is the stakeholder that sets requirements and evaluates whether these are met, and a designer contributes expertise and is responsible for the deliverables. Finally, a representative is a person who acts on behalf of the passively involved (Vos & Achterkamp, 2006; 2007). Identifying stakeholders in a project as IS implementation in combination with classifying these stakeholders based on their salience level and roles in the project may enable implementers to have a better understanding of stakeholders in the light of an issue. However, only a better understanding of stakeholders in the light of an issue does not lead to successful IS implementation. The issues, that stakeholders themselves perceive, should also be taken into account when dealing with an IS implementation.

Stakeholders and Issues Identification

Burchell & Cook (2006) state that issues that stakeholders consider as important often do not surface, or are not taken into account during formal decision-making of the change project, because implementers may not see issues stakeholders perceive as important. However, the neglect of issues at stake and only focusing on crises, may lead to unnecessary conflicts, delays or even failure of a change project. While many scholars researched the IS implementation process and its critical issues, much of the research has very limited or no regard to the perspective of stakeholders. Little research has been done that encompasses all significant issues and their characteristics (Finney & Corbett, 2007). Jensen & Aanestad (2007), for instance, argue that attention has been paid to the interaction between IS and the organization, although only few researchers address how stakeholders, and especially users, perceive and make sense of the implementation of an IS. According to many scholars in IS implementation it is necessary to take a stakeholder-oriented perspective and involve the stakeholders to obtain full potential from the technology (Jensen & Aanestad, 2007; Berg, 1999; Tan & Hunter, 2002).

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implementation of an IS can be considered successful, when the technology meets more than 90% of the perceived needs of the potential users. Thus, the issues that stakeholders have, and then especially the users of the technology, are important to consider in an early phase of the implementation process of a project to meet their needs.

Issues Classifications

While agreeing that identifying stakeholder issues are crucially important in the pre-implementation phase of an EPR, it is important to also understand the characteristics of these issues. Scholars often only focused on a specific aspect of the implementation process or a specific issue instead of the multiple classifications of the issues (Tarafdar & Roy, 2003; Robey et al., 2002; Grant, 2003). Issues should be analyzed in order to gain a thorough understanding of how stakeholders react and why they react in such ways to the implementation of an EPR. Dutton & Jackson (1987) argue that effectively classifying issues is a precondition for the effective use of issues in contexts of change. Identifying and classifying issues creates the opportunity to understand the various interpretations of stakeholders, which implementers in turn can use to manage stakeholders. In case of IS implementation, implementers may use classifications for assessing the process-oriented and outcome-oriented issues of an implementation process, the impact, and the nature of issues.

Process-oriented and outcome-oriented issues

Many scholars use the classification of process-oriented or outcome-oriented when evaluating important factors (Heppner & Hendricks, 1995; Rauschmeyer et al., 2009; Kumar & Nti, 1998). Also in IS implementation this distinction is used. Bingi et al. (1999) analyzed factors affecting an IS implementation, and suggest that implementation process-oriented issues should be carefully managed to reap the benefits. Also, Jensen and Aanestad (2007) analyzed issues after the implementation regarding the implementation process and the outcomes of an EPR.

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functions of an IS technology, while the changes in work tasks of users of the technology might be seen as an outcome-oriented consequence. When dealing with EPR implementation, a classification can be made whether the issues are process or outcome-oriented.

Issue impact

To determine the impact of the issues, another dimension can be added than only the process-oriented and the outcome-oriented issues. Jensen & Aanestad (2007) suggest key differences between process and outcome-oriented issues, but also make a distinction between the impact of the issues based on two themes. They provided an analysis of how nurses and doctors make sense of and talk about an EPR after implementation. The first theme is related to healthcare professionals’ conceptions of technology. During the implementation of an EPR, each potential user selects certain aspects of the system as important. The second theme concerns how the technology relates to the healthcare professionals themselves. Each user group may have a different understanding or idea of how EPR is to be used in their work practice. Ludwick & Doucette (2009) argue that professionals will become more occupied with the computer and less oriented toward the patient. It is therefore possible that EPR could lead to less personalized and more routinized care, and less interaction with patients, leading to negative clinical outcomes such as dissatisfaction with care.

Also, Lapointe and Rivard (2005) recognize that when an IS is introduced, stakeholders will first assess the impact of an IS in terms of the interplay between the features of the system, and individual and/or organizational level initial conditions. Thus, according to scholars, an issue may have an impact on different levels such as on the technology itself, on the individual or on the organization.

Nature of issues

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historical reasons behind the choices made or the distinct features in the organizational culture. Differences between various disciplines, functions, or viewpoints can lead to permanent disputes. Classifications

The classifications provide the possibility to emphasize how different stakeholders perceive the issues through different lenses. The various classifications may help in the understanding of issues that stakeholders perceive in pre-implementation more thoroughly. But do issues also gain insight in the level of stakeholder support in an IS implementation?

Issues and Stakeholder Support

The issues that stakeholders attach to an IS, affects their behavior, namely whether the stakeholders resist or support the technology. While agreeing that stakeholder issues are crucially important in IS implementation, Abdinnour-Helm et al. (2013) argue that stakeholder support is another aspect important for the successful outcome of a project as EPR implementation. It does not matter how well developed an IS may be, it will not have a great impact on the organization unless stakeholders are heard, and when stakeholders support the technology. Coetsee (1999) states that support is the first form of acceptance and occurs when stakeholders demonstrate support for the intended change, and is characterized by a positive attitude towards the change. Support implies that one is in favor of the change, and is associated with more positive perceptions, attitudes and behaviors from stakeholders towards the change (Chiaburu & Harrison, 2008). Active support of stakeholders is important (Kelley, 1992) in promoting movement (Knowles & Linn, 2004) towards the use of an IS such as EPR. Meeting stakeholder interests of an EPR is challenging, because stakeholders can have a lot of power:

“those advocating a new IS need to ensure that enough influential stakeholders support the project because they believe it will serve their interest” (Boonstra et al., 2008: 108). Furthermore, Judson

(1991) argues that support is important to achieve maximum benefits of the change. Different levels of support to an IS may exist due to the different views of various stakeholders regarding the importance of such systems (Ifinedo & Nahar, 2007). Therefore, in the case of EPR implementation, implementers need to take into account the different views of stakeholders when dealing with support.

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technology than stakeholders with a lower number of issues. Therefore it can be suggested that stakeholder issues and support intend to be interlinked.

Conceptual Model

The literature review shows that the interaction of issues and stakeholders is complex. The proposed interactions of the variables as are derived from the literature discussed above, are displayed in the two conceptual models in figure 2 and 3.

Figure 2. Conceptual model 1

Figure 3. Conceptual model 2

Stakeholders Issues Process-oriented and outcome-Impact Nature Issues The number of issues

Stakeholders Potential user groups

Stakeholder Support Potential user

groups

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METHOD

This research expands literature on issues management and stakeholders, as it tries to show the interaction between issues and stakeholders during the pre-implementation phase of an EPR. As the literature analysis showed, the interaction between issues and stakeholders is complex. To address this complexity, and to broaden the understanding of the interaction between the two aspects, this research was split up into two studies. These were separate studies, with their own data, but within the same healthcare institution. However, the two studies were connected as they both addressed issues and stakeholders. The first study addressed a stakeholder identification and analysis based on a single issue, to gain an in depth understanding of a single issue. The second study took a multiple issue perspective and identified issues based on stakeholders to gain a broad perspective of issues. In this section, after discussing the research design, the two studies are addressed separately.

Research Design

In this research, an embedded multilevel case study (Yin, 2003) in a healthcare institution was used. This can provide rich data and is valuable since it provides the opportunity to describe the events of a specific case in an in-depth manner. An embedded multilevel case study approach fits this perspective well, as it permits an in-depth investigation of the evolving stakeholder and issue analysis and their outcomes (Gerring, 2004; Yin, 2003; Dubé & Paré, 2003). Eisenhardt (1989) states that a case study can be used as a research strategy focusing on the understanding of the dynamics that are present within single settings, which particularly suits the research conducted in this paper. The healthcare case study concerned the implementation of an EPR project. Greenhalgh et al. (2009) state that a case study approach in a EPR research show how contextual factors shape, enable, and constrain the newly implemented technology in a healthcare institution.

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Data collection

To answer the first sub question of this research; how can stakeholders be identified based on a single

issue during the pre-implementation of an EPR, qualitative data was collected. The data was gathered

through the analysis of a stakeholder identification session. An identification session was held with six members of the implementation project group of the EPR. The participants, three male and three female, were selected for their knowledge regarding the EPR, on their different backgrounds, tasks in the project, and functions in the healthcare institution, so they could provide insight into stakeholders during EPR implementation.

The identification method used was based upon the model presented by Achterkamp & Vos (2007) (Appendix 1). In this case, the identification and analysis was conducted in three steps. The first step consisted of the identification of issues regarding the EPR. To identify EPR related issues, support questions were used, which are presented in table 1. Furthermore, the technique of coding was used to identify and classify the issues. How these issues were coded is explained and presented in the data collection section of study 2, because the technique of coding is a great part in that study. After the identification of the issues by the participants, one issue was chosen to identify stakeholders, their roles, and their salience regarding the EPR.

Table 1. Support questions for issue identification  What is an actual and crucial EPR-issue?

 Whereby are many stakeholders involved?  What are the different views?

 About what is knowledge from stakeholders needed?

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Table 2. Attributes of salience

Power - This stakeholder has the influence, knowledge and / or skills to impose its will on the issue. (Totally disagree to totally agree)

Legitimacy - It is deserved that this stakeholders brings forth any concerns regarding the issue. (Totally disagree to totally agree)

Urgency - When this stakeholder brings forward any concern regarding the issue, there should rapidly be sought for a solution. (Totally disagree to totally agree)

Data analysis

The issues that arose in the first step of the identification session were coded and analyzed based on the issues classifications that were also used in study 2. The data analysis of study 2 explains the issues classifications thoroughly (see table 7). In the second step, stakeholders were identified based on the most pressing issue. The stakeholders were grouped together according to their role, namely client, decision maker, designer and / or (representative of) passively involved. After this, in the third step, the level of salience of each identified party was analyzed. The degree of salience was scored after the determination of salience according to the three attributes, power, legitimacy, and urgency. Each attribute combination had a code, which determined the degree of salience. The scale of Mitchell et al. (1997) was used to classify stakeholders according to their level of priority and level of attention the implementers gave to a specific stakeholder regarding the researched issue (see table 3). In total, salience was determined for 30 of the parties involved in the issue.

Table 3. Salience scales

1 = Dormant stakeholder (Power) (low on salience) 2 = Discretionary stakeholder (Legitimacy)

3 = Demanding stakeholder (Urgency)

4 = Dominant stakeholder (Power, Legitimacy) 5 = Dangerous stakeholder (Power, Urgency) 6 = Dependent stakeholder (Legitimacy, Urgency) 7 = Definitive stakeholder (Power, Legitimacy, Urgency) (highly salient)

Study Two – Multiple Issue Perspective Data collection

The second study entailed an identification of EPR related issues perceived by stakeholders in the pre-implementation phase. To answer the second sub question; what issues do stakeholders perceive in the

pre-implementation of an EPR and in what way do the perceived issues affect the support of stakeholders regarding an EPR implementation, qualitative and quantitative data was collected by

means of a survey.

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participants received an e-mail (Appendix 2) to fill in the survey. Before the survey was conducted, it was tested in two pilots to ensure that the survey was clear and unambiguous. The check for clarity of the statements was especially important as the meaning intended by the statements may not be the meaning as respondents apprehend (Converse & Presser, 1986). Based on the pilots adjustments were made for the final survey that was send to the participants. All management staff of the three stakeholder groups were approached to participate. Furthermore, all employees of the departments ophthalmology, orthopedics, geriatrics, and the oncological branch of obstetrics and gynecology were selected to participate. Also, a random sample was drawn from the remaining employees of the remaining three stakeholder groups, namely doctors, nurses, and paramedics. This came down to a total number of 1,579 participants who were asked to participate. The survey was part of a large scale research regarding the EPR implementation in the healthcare institution. This research did not make use of the entire survey as not all questions were relevant for this study; data was gathered from certain components of the survey.

Qualitative data collection

To capture the first part of the sub question, what issues stakeholder perceive, respondents were asked to answer the open-ended question: what are, according to you, the key issues regarding EPR? Due to the large data set, the technique of coding, which refers to linking previously or ad hoc developed categories and concepts to text fragments (Bauer & Gaskell, 2000), is used to categorize the stakeholder issues. In this research, the code development involved both inductive and deductive strategies. Codes are derived from topics addressed in the literature review and may be considered as deductive codes. Besides this deductive coding method, attention was given to issues raised by participants, to not impose derived codes on data on which they do not apply, and allowed relevant specific concepts to come forward (Hennink et al., 2011). Inductive coding allowed the data to ‘speak for itself’, and came directly from the data and were developed by directly reading the data. Table 4 summarizes the key steps in the coding process used in this research.

Table 4. Key steps in coding process Step Coding process / description

1 Issues were read by one independent coder several times for familiarization 2 The researcher coded the texts inductively and deductively for issue groups,

process-oriented and outcome-oriented issues, issue impact, and nature of issues 3 Coding schema is finalized with descriptions and examples

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Quantitative data collection

To capture the support of stakeholders regarding EPR implementation, respondents were asked to answer questions about support regarding the EPR implementation. Respondents were asked to what degree they agreed with each statement on a 5 point likert scale, 1 represented totally disagree and 5 represented totally agree. An inapplicable/no opinion option was added to exclude respondents checking the neutral box if they had no opinion about a statement. Appendix 3 shows which statements preliminary belonged to the factor support. An exploratory factor analysis was performed using a principal component analysis (PCA) with varimax rotation to see whether the statements regarding support loaded on the same factors as expected. Items were excluded from next analyses when they did not load well on a factor, when the reliability of the factor increased when the item was removes, and when the item did not match on theoretical basis. The rotated component matrix (Appendix 4) showed that the statements differ from the statements that were prior expected to load on the factor support (see table 5). The factor support was reliable, as the factor had a Cronbach’s Alpha higher than .70. An inverted variable was used for the second item in table 5 as it loaded negatively on the factor support. This means that the interpretation of this statement is also inverted. For the factor support, a multi-item scale was created by summing up the items comprising the factor and dividing them by the number of statements. By doing this, the data is made quasi interval, allowing different parametric statistics to be used. A histogram (Appendix 4) showed that the factor support is normally distributed.

Table 5. Support scale items and reliability measure Active support to the implementation of EPR (alpha = .789)

I actively contribute to a successful implementation of the EPR. (Totally disagree

to totally agree)

I do not interfere with the implementation of the EPR. (Totally disagree to totally

agree)

I can influence the design of the EPR. (Totally disagree to totally agree) Data analysis

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Table 6. Descriptive statistics Respondents

characteristics Respondents (n = 479) Sample (n = 1,597)

Gender (%) Male 37 32

Female 63 68

User group (%) Doctors 34 32,5

Nurses 34,7 33,2

Paramedics 24,4 30,3

Management 6,9 4

Age (mean ± SD) Doctors 43±11 41±11

Nurses 43±12 43±12

Paramedics 45±11 43±12

Management 49±9 49±7

Issue identification qualitative analysis

To capture the first part of the sub question, what issues stakeholder perceive, issues were coded and analyzed based on a start-list of codes from theory, namely the issues classifications. Process-oriented and outcome-oriented issues by, for instance, Rauschmeyer et al. (2009) and Jensen & Aanestad (2007), issue impact by Lapointe & Rivard (2005) and Jensen & Aanestad (2007), and the nature of issues by Forsell et al. (2010) formed the main categories and their specific antecedents formed the concepts. Table 7 shows an example of the results of the coding process used for the analysis. All data were read several times to gain familiarity with the information to ensure that all relevant codes were correct. Next to the three original categories, a fourth category was detected by means of open coding (Bauwer & Gaskell, 2000). Open or inductive coding was used to relate each issue to a specific issue group to determine 21 issues categories (for complete coding schema, see Appendix 6). In this research the concept outcome-related issues were coded as expected outcome issues, because the project found itself in the pre-implementation phase and was therefore not yet implemented. Furthermore, while exploring the data, a context specific fourth concept was added in the classification issue impact, namely patient related issues.

Table 7. Example coded categories and concepts for issue identification Category Concepts (codes) +

References

Type Description Example from data Process and

outcome issue

Process (Bingi et al., 1999; Jensen & Aanestad, 2007; Rauschmeyer et al., 2009)

Deductive Issues related to the features of the process itself

“Proper guidance / and explanation on the departments when

implementing and using the EPR” Expected outcome (Forsell et al., 2010; Jensen & Aanestad, 2007; Rauschmeyer et al., 2009)

Deductive Issues related to the outcomes of the

implementation process

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23 Issue impact Self-related

(Lapointe & Rivard, 2005; Jensen & Aanestad, 2007)

Deductive Issues related to work practices of healthcare professionals

“No major changes will happen regarding my current job when working with EPR. However, if it will have major changes for my job I expected a provision of information from my

manager”

Organisation related (Lapointe and Rivard, 2005)

Deductive Issues related to the organisation as a whole concerning EPR implementation

“More concrete information about what the changes mean and a representative of each department should indicate what specific requirements to do our work right. Maybe this is already the case, but then this is not clear for many people

System related (Lapointe and Rivard, 2005; Jensen & Aanestad, 2007)

Deductive Issues related to the technology (EPR) itself

“The system should be reliable and files should always be available”

Patient related Inductive Issues related to the patients

“Patient data should be well protected for those who have nothing to do with them”

Nature of issues

First order (Star & Ruhleder, 1996; Forsell et al. 2010)

Deductive Issues related to everyday situations

“It has to work fast, should be easy to use and needs to have the possibility to switch between patients”

Second order (Star & Ruhleder, 1996; Forsell et al. 2010) Deductive Unexpected issues, which occur mainly after implementation. Often a collision or combination of two or more first order issues

“It should be easy to work with and should not mean another increase of additional administrative work that will result in a lot of time that will be lost due to the use of EPR. This will then again be at the expense of the time for patient care, and this will cause

frustration for the person who has to work with the EPR”

Third order (Star & Ruhleder, 1996; Finney & Corbett, 2007)

Deductive Issues that are political or social in nature

“Too many people (in my opinion too many external people) are appointed for the supervision of the project. We must include

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Issue identification quantitative analysis

Based on the assumptions of scholars such as Weick (1995) and Mitroff (1983) there is reason to infer that the respondents had different understanding of the EPR, as they found themselves in different professions in the organization and were interested in different aspects regarding the EPR implementation. To determine the influence of the stakeholder group one is in on the issues one perceived, quantitative analysis was used. The codes of the qualitative analysis were used for the quantitative analysis. The combination of qualitative with quantitative methods allowed for a focus on the complex web of issues. The quantitative analysis gives a better understanding of the qualitative data. Each category and the concepts within were coded to make them nominal data for quantitative analysis. First, a one-way ANOVA was used to see whether or not the number of issues significantly differs per stakeholder. A one-way ANOVA test was performed of stakeholder group on the number of issues. Second, another ANOVA was performed to see whether or not the process-oriented and outcome-oriented issues significantly differs per stakeholder. Pearson’s chi-square tests were performed to see if one’s profession, thus the stakeholder group one is in, is related to the impact of their issues and to the nature of their issues.

Issues and stakeholder support analysis

To capture the second part of the sub question, in which way issues affect stakeholder support regarding EPR implementation, the issues and questions about support regarding the EPR implementation were analyzed quantitatively. A Pearson’s correlation coefficient was used to determine whether there is a positive association between stakeholders and the number of issues they perceive. This determined whether there is evidence of a positive linear relationship between issues perceived by stakeholders and their active support. Thus, whether stakeholders who perceive a higher number of issues, were more supportive regarding the EPR implementation. To determine whether there was a positive linear relationship, a linear regression analysis was carried out. Furthermore, linear regression analysis was conducted to see if there was a significant regression within each user group and their support. The number of issues per stakeholder and the multi-item scale of the factor support were used to perform the regression analyses. Age and gender were used as control variables in all tests.

RESULTS

The results of the first sub question, how can stakeholders be identified based on a single issue during

the pre-implementation of an EPR, are presented in study one – single issue perspective. Study two –

multiple issue perspective firstly presents the results of first part the second sub question, what issues

do stakeholders perceive in the pre-implementation of an EPR? This was answered by addressing the

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in what way do the perceived issues affect the support of stakeholders regarding an EPR implementation, was answered by presenting the relationship between issues and stakeholder support

in the pre-implementation phase of the EPR.

Study One – Single Issue Perspective

Step 1: Issue identification. In table 8 the results of the issue identification are presented. These issues

were identified by the six participants of the identification session who are all part of the project group that is implementing the EPR. After the identification, the issues were classified according to the issues classifications. When looking at the issues and their classifications it can be stated that only six participants already perceive issues that differ a great deal from each other. The participants which all are part of the project group, mainly focus on issues regarding the organization and on third order issues. Various issues arose during the session, and all participants named multiple issues. For the stakeholder identification, the first issue presented in table 8 was chosen for the stakeholder identification. All participants believed that the issue ‘uniformity versus freedom’ was the fundamental issue regarding EPR implementation and therefore worthy of further investigation.

Table 8. Issue identification  Uniformity versus freedom (outcome, self, third order)

 Role of clinical pathways in EPR (outcome, system, first order)  Working together in EPR (outcome, organization, third order)  Role of the patient (process , patient, third order)

 How to deal with teething troubles (process, organization, third order)

 Cooperation between doctors/physicians and nursing staff (outcome, organization, third order)  Involvement in implementation process (process, organization, second order)

Step 2: Stakeholder identification based on ‘uniformity versus freedom’. The core of the

method used was the actual identification of the parties involved, and designating roles to all parties. In using the method, a total of 34 stakeholders were identified regarding the issue ‘uniformity versus

freedom’ (table 9). These stakeholders were classified on roles, which is based on activities within the

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Step 3: Stakeholder salience. Table 9 also shows how the identified stakeholders are related to

Mitchell et al.’s (1997) typology. The stakeholders were classified by the participants of the stakeholder identification session. As the table shows, participants only determined the salience of three roles, namely clients, decision makers, and designers. The majority of the identified stakeholders are definitive stakeholders, they contain all three attributes, namely power, legitimacy, and urgency. Solely a single issue as ‘uniformity versus freedom’ already has 15 definitive stakeholders, which means that implementers give high priority of the claims of these stakeholders regarding this specific issue.

Table 9. Stakeholder identification and perceived stakeholder salience.

Clients Decision maker

Stakeholder Attributes Salience Stakeholder Attributes Salience Management reporting P, L, U 7

Medical chiefs

specialists P, L, U 7

Business managers P, L, U 7 Board of directors P, L, U 7

Software designers P, L, U 7 Project group P, L, U 7

Staff departments P, L, U 7 Supplier P, L, U 7

Healthcare professionals

(doctors) P, L, U 7 Insurance companies P, L 4

Medical chiefs P, L, U 7 Politics P, L 4

Healthcare professionals

(nurses&paramedics) L, U 6 Staff convent - -

Researchers P, L 4

Sub chiefs of

departments - -

Insurers P, L 4

Patient P, L 4

Staff group - provision of

information L 2 Directors (group) L 2 Medicine students L 2 Designer (Representative of) passively involved

Stakeholder Attributes Salience Attributes Salience

Project leaders P, L, U 7

Patient associations

(family etc.) P, L 4

Project team P, L, U 7 Individual patients - -

Medical information

technologists P, L, U 7 GPs, nursing homes - -

IT experts P, L, U 7 Care administration - -

Supplier and implementation

consultant P, L, U 7 Coders - -

Experts of different hospitals

(experience exp) L, U 6 - -

NICTIZ L 2

Various communities - -

Notes. Stakeholder attributes: P = Power, U =Urgency L = Legitimacy,

Scale salience:1=Dormant stakeholder, 2=Discretionary stakeholder,3=Demanding stakeholder,

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The findings from the identification session shows that already a single issue is very complex. First, the participants already identified many different issues. Second, many stakeholders were already identified based on a single issue ‘uniformity versus freedom’ in the pre-implementation phase of the EPR technology by solely six participants. It is plausible that a single issue perspective is a very limited view of the complexity of issues and stakeholders. The results of the second study provide a more encompassing picture of issues.

Study Two – Multiple Issue Perspective

The results of the analysis of issues that arose among various stakeholders in the pre-implementation of EPR are presented. First, the qualitative results of the identified issues are presented. These qualitative results regard the coded issues groups and the issues classifications. After this, the findings of the quantitative analysis of the identified issues are shown. Finally, the results of the relationship between issues and support are presented.

Issue identification qualitative results

This section provides the results of the qualitative analysis of the issues that arose during the pre-implementation phase of the EPR within the four stakeholder groups. A total of 479 stakeholders gave 775 issues regarding the EPR in the pre-implementation phase. Figure 4 shows which issues stakeholders perceived as most important in the pre-implementation stage of EPR. It presents an overview of the top 5 issues of each stakeholder.

Doctors (n=163) gave 337 issues concerning the EPR technology. In the pre-implementation phase most issues that arose from doctors are regarding new features and expectations of the EPR technology and user friendliness of the technology. The technology should contain specific features which are important to perform their profession. Furthermore, the technology should be easy to use. Doctor: “The system should be able to easily generate letters and it should be able to dictate with

voice recognition” (expected outcome, system related, first order). Nurses also gave many issues

concerning the EPR technology. From the 166 nurses 255 issues arose. Most issues that arose from the nurses in the pre-implementation phase were regarding user friendliness and new features and expectations of the technology. The EPR technology should be easy to use and contain features which are important for their profession. Nurse: “Checklists should be integrated in EPR: what and when

things have to be changed and/or swapped” (expected outcome, system related, first order).

Noteworthy is that in comparison with the other stakeholders, paramedics did not offer many issues concerning the EPR technology. Paramedics (n = 117) gave 115 issues concerning the EPR technology. In the pre-implementation phase most issues that paramedics saw were regarding the new features and expectations and the provision of information regarding the EPR technology. Paramedic:

“In the EPR, the lab results should be displayed properly” (expected outcome, system related, first

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28 32% 15% 9% 9% 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% Doctors 24% 18% 12% 7% _6% 0% 5% 10% 15% 20% 25% 30% 35% 40% Management

Most issues that management see are, just as the other three groups, concerning the new features and expectations of the EPR technology. Furthermore, just as the paramedics, they regard the provision of information and the implementation process itself as an important issue to address. Management: “We

must be able to log in quickly, the system should work fast, and system breakdown should not occur”

(expected outcome, system-related, first order).

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Issues classifications

The stakeholders perceived various issues which were being classified based on the issue classifications, namely process and outcome issues by, for instance, Rauschmeyer et al. (2009) and Jensen & Aanestad (2007), issue impact by, for instance, Lapointe & Rivard (2005) and Jensen & Aanestad (2007), and the nature of issues by Forsell et al. (2010) Table 10 summarizes the descriptive statistics of the issues classifications among the four stakeholders.

Table 10. Descriptive statistics of issues classification Issues classification (n = 775) Concepts Doctors (n = 337) Nurses (n = 255) Paramedics (n = 115) Management (n = 68) Process-oriented and expected outcome-oriented issue (%) Process Expected outcome 27 73 31 69 37 63 49 51

Issue impact (%) Self 31 32 30 7

Organization 17 18 15 47

System 47 39 38 44

Patient 5 11 17 3

Nature of issues (%) First order 78 68 71 81

Second order 9 13 4 4

Third order 13 19 25 15

Process and expected outcome issues

The majority of issues that arose in the stakeholder group doctors, are issues concerning the expected outcomes of EPR, namely 73%. Of these expected outcome issues, 63% were system related, they concerned the EPR-system itself (see figure 5). Another 24% of issues concerning expected outcomes of the technology were self-related, the issues concern the daily work practices of the stakeholder. The 27% of issues that were process oriented were mainly concerned with the provision of information during the implementation process of the EPR technology. These issues were for 49% self-related, doctors want to know what the EPR technology will mean for their profession. Doctor: “I actually

don’t know anything about what the EPR will be and how it will influence our jobs, and to what extent we have to adjust our work process, and if we get information about this before the EPR actually is implemented” (process, self-related, first order). Another 45% of the process-oriented issues were

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Figure 5. Doctors - Process and outcome issues and their impact

The majority of issues that were brought up by nurses, 69%, were issues concerning the expected outcomes of EPR. Of these expected outcomes issues, 53% were system related, they concerned the EPR itself (see figure 6). Another 26% of the expected outcomes issues were self-related, and 15% patient related. The 31% of process related issues were mainly regarding the provision of information during the implementation process of the EPR technology. These issues were for 45% organization related, and 44% self-related. On the one hand, nurses brought up the issue that the whole organization should be well informed and trained. Nurse: “There should be regular

meetings to inform employees about EPR” (process, organization, first order). On the other hand, the

nurses wanted to know, similar to the doctors, what EPR means for their own work processes. Figure 6. Nurses - Process and outcome issues and their impact

The majority of issues that arose in the stakeholder group paramedics, are issues concerning the expected outcomes of EPR. Of the expected outcomes issues of the EPR, 53% were system related (see figure 7). Another 25% of expected outcomes issues are self-related, and 16% are patient related. Patient related issues concern the privacy of patient data. Noteworthy is that many paramedics could not think of any issue concerning EPR, as they believed that the technology will not have any influence on their work. Paramedic: “My profession does not have any connection with the EPR, and

therefore I do not have an issue at the moment” (expected outcome, self-related, first order). Of the

49% 45% 3% 2% 24% 7% 63% 6% 0% 20% 40% 60% 80% 100%

Self Organization System Patient

Process Outcome 44% 45% 9% 3% 26% 6% 53% 15% 0% 20% 40% 60% 80% 100%

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issues that were identified, 37% were process related issues and mainly concern the provision of information during the implementation process of the EPR technology. 33% are organization related, and 36% are self-related.

Figure 7. Paramedics - Process and outcome issues and their impact

In the management group, 51% of the issues that arose were concerning the expected outcomes of EPR (see figure 8). Of these issues, 74% have an impact on the system itself. 17% of expected outcomes issues are organization related and focus on redistribution of work resources. Management: “there should be enough computers for everyone to work on” (expected outcome, organization, first order). Of the issues identified by paramedics, 12% were self-related, a small percentage in comparison with the other stakeholders. 49% were process related, and mainly impact the organization as a whole and are focused on the provision of information during the implementation process of the EPR technology. In the user group management the focus lies on the provision of information for the whole organization and the implementation process. Manager: “We need a clear

course of action, we have the feeling that we are running in circles, doing the same thing over again”

(process, organization, first order).

Figure 8. Management - Process and outcome issues and their impact

Thus, Issues concerning the expected outcomes of the EPR technology were dominant in the pre-implementation phase. Except in the stakeholder group management where the expected outcomes oriented and process oriented issues were almost equally distributed.

38% 33% 12% 17% 25% 5% 53% 16% 0% 20% 40% 60% 80% 100%

Process Outcome 12% 76% 12% 3% 17% 74% 6% 0% 20% 40% 60% 80% 100%

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Issue impact

Many issues that doctors identified had an impact on the EPR system itself, namely 47%. Another 31% of the issues were self-related, the issues concern the daily work practices. Doctors conceived that their work practice and their role will change when the EPR technology is implemented. Doctors perceived that the EPR will be a constraining tool when it comes to supporting their practice, they assumed that the use of EPR will be too time-consuming, and that it will increase administrative work, which tends to take away the focus on patients. Doctor: “I am afraid that this is yet another step in the

wrong direction in terms of efficient work, there is (again) an increase of administrative duties and responsibilities for doctors. This hinders (even more) the time for our core task, namely patient care”

(expected outcome, self-related, second order).

Nurses, similar to the doctors, identified issues that mainly had an impact on the EPR system, namely 39%. These issues often related to the expectations concerning the EPR system. Nurse: “All

data should be placed in one single area, so it can quickly be found” (Expected outcome, system

related, first order). Furthermore, 32% of the issues had an impact on the nurses themselves. The self-related issues concerned the daily work practices. Nurses conceived that their work would become easier when the EPR technology actually is implemented. Nurse: “It seems to be an easy system.

Prescriptions of doctors will be easier to read, which reduces the chances of mistakes” (expected

outcome, self-related, first order). However, nurses were also concerned that the use of computers will increase and that not everyone is able to work digitally. These issues had an impact on all the potential users of the system in the whole organization. Nurse: “I think that the EPR will be a problem for

people who are not familiar with a computer. Some colleagues cannot even work with our current system” (expected outcome, organization related, second order). Also, 11% of the issues had an

impact on the patient. These issues mainly concerned the privacy of patient data.

The majority of issues that arose in the stakeholder group paramedics had an impact on the EPR system itself, namely 38%. Of the remaining issues, 30% had an impact on the paramedics themselves. The self-related issues concerned amongst others the effect of EPR on the work processes. Paramedic: “I expect that the EPR will be too extensive and not friendly to use (many clicks, too much

information) to remain a good overview”(expected outcome, self-related, first order). Also, 15% had

an impact on the organization as a whole. On the one hand, paramedics stated that the whole organization should be well informed. Paramedic: “Clear information and explanation what the EPR

is and what is means for employees would have been in place” (process, organization related, first

order). On the other hand, paramedics saw that it was unclear how the EPR would affect their profession. Paramedic: “As an analyst on the laboratory, it is unclear for me to what extent we have to

work with the EPR” (expected outcome, self-related, first order). Furthermore, the nurses had the

Issues and stakeholders in EPR implementation

Issues and stakeholders in EPR implementation

A multi-perspective research on the interaction of issues and

stakeholders in a healthcare setting

University of Groningen, Faculty of Economics and Business

MSc. Business Administration, Change Management

24-07-2013

J. van den Bos

Oosterhavenstraat 13

9711SB Groningen

j.van.den.bos.6@student.rug.nl

Student number: 2222558

First supervisor university: dr. J.F.J. Vos

Second supervisor university: dr. ir. M.C. Achterkamp

Supervisors at the field of study: dr. I. Lesman & drs. C. van Well

Issues and stakeholders in EPR implementation

A multi-perspective research on the interaction of issues and

stakeholders in a healthcare setting

ABSTRACT

TABLE OF CONTENTS

INTRODUCTION

ISSUES AND STAKEHOLDERS

METHOD

RESULTS