international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 journal homepage: www.ijmijournal.com Healthcare professionals’ organisational barriers to health information technologies—A literature review Maria Lluch a,b,∗ a LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK b Institute for Prospective Technological Studies (IPTS), Joint Research Centre - European Commission, Edificio Expo - Calle Inca Garcilaso, s/n. 41092 Seville, Spain a r t i c l e i n f o Article history: Received 13 January 2011 Received in revised form 19 September 2011 Accepted 20 September 2011 Keywords: ICT adoption in healthcare HIT adoption Barriers for adoption Medical informatics Health information technology Hospital information systems Computerised medical records systems Healthcare organisations Organisational models Socio-technical Systematic literature review Electronic medical record Structure of healthcare organisations Tasks People policies Incentives Information and decision processes a b s t r a c t Objectives: This literature review identifies and categorises, from an organisational management perspective, barriers to the use of HIT or ICT for health. Based on the review, it offers policy interventions. Methods: This systematic literature review was carried out during December 2009 and January 2010. Additional on-going reviews of updates through automated system alerts took place up until this paper was submitted. A total of thirty-one sources were searched including nine software platforms/databases, fifteen specialised websites/targeted databases, Google Scholar, ISI Science Citation Index and five journals hand-searched. Results: The study covers seventy-nine articles on organisational barriers to ICT adoption by healthcare professionals. These are categorised under five main headings – (I) Structure of healthcare organisations; (II) Tasks; (III) People policies; (IV) Incentives; and (V) Information and decision processes. A total of ten subcategories are also identified. By adopting an organisational management approach, some recommendations to remove organisational management barriers are made. Conclusions: Despite their apparent promise, health information technologies (HIT) have proved difficult to implement. This systematic review reveals the implementation barriers associated to organisational management and their interrelations. Several important future directions in the field are also suggested: (1) there is a need for further research providing evidence of HIT cost-effectiveness as well as the development of optimal HIT applications; (2) more information is needed regarding organisational change, incentives, liability issues, end-users HIT competences and skills, structure and work process issues involved in realising the benefits from HIT. Future policy interventions should consider the five dimensions identified when addressing the impact of HIT in healthcare organisational systems, and how the impact of an intervention aimed at a particular dimension would interrelate with others. © 2011 Elsevier Ireland Ltd. All rights reserved. ∗ Correspondence address: LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK. E-mail address: [email protected] 1386-5056/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2011.09.005850 international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 1. Introduction Healthcare systems are at risk due to increasing demand, spiralling costs, inconsistent and poor quality of care, and inefficient, poorly coordinated care processes. In response, governments are developing various strategies, one of which consists of heavy investments in information and communication technologies (ICT) for health or health information technologies (HIT) [1,2]. For example, the recent health reform in the USA includes plans to spend $18.9 billion to promote HIT and provide incentives for information technology (IT) adoption [3] by healthcare organisational systems. Europe has allocated D500 million of EC funding to research in this field since the early 1990s [2], put in place the eHealth Action Plan [4] and made public statements in support of HIT applications in healthcare organisational systems [5]. At EU Member State level, there is wide diversity in the implementation of HIT and in particular the development of Electronic Health Records (EHR) which is considered a central component of an integrated HIT [6]. For instance, Finland implemented EHR in 2008 [7]; Slovenia launched its eHIT project in 2008 [8]; Italy has recently budgeted D1.3 billion as part of its eGov 2012 Plan [3]; England launched the National Programme for IT (NPfIT) in 2002 [9] with an estimated budget of £12.7 billion though its completion deadline has been extended until 2014–2015 [10]. Today the range of possible applications of HIT in healthcare organisational systems is enormous. The technology has progressed significantly and HIT implementation is expected to result in higher quality and safer care that is more responsive to patients’ needs and, at the same time, more efficient (appropriate, available, and less wasteful) [11]. Examples of HIT are electronic health records (EHR), e-prescriptions, computerised provider order entry (CPOE), picture archiving and communication systems (PACS), access to medical journals and databases on the internet, videoconferencing for doctor appointments, or feedback via the Internet to doctors so they can improve the care they provide. For instance, advocates point to the potential reduction in prescription errors as a critical advantage [12]. Out of the broad spectrum of HIT applications in healthcare organisational systems, the adoption and use of EHR has received a lot of attention in recent policy discussions [13]. Despite their promise, HIT have proved difficult to implement [14]. More than a decade of efforts provide a picture of significant public and private investments, notable successes and some highly publicised and costly delays and failures [15]. This has been accompanied by a failure to achieve widespread understanding of the benefits of electronic record keeping and information exchange [11]. Even though computers are increasingly being used in hospitals and practices, not all healthcare professionals use HIT [16] and little is known about the organisational changes, costs, and time required for healthcare centres to successfully implement systems. Software vendors are often held responsible for the slow uptake due to their inability to effectively deliver reliable products [17–19], by for instance offering off-the-shelf products with little room for customisation. Quantifying the extent of HIT failures explained by technology problems has proven a challenging and controversial undertaking. Some authors report that technical factors explain 5% of HIT failures [20], some estimate them at 20% [18] whilst others report that the problems are not likely to be related to the technology itself but to the lack-of socio-technical consideration [21]. Notwithstanding the fact that technical problems definitely explain failures in HIT implementation, the introduction of HIT should not be viewed as a problem in technology exclusively but rather as a problem in organisational change [22]. For the above reasons, many different strategies, beyond procurement, are being used to try and promote the use of HIT. These include training groups of healthcare professionals to use a specific HIT, teaching someone one-on-one to use an HIT, or simply providing training materials. However, HIT remain underused by healthcare professionals [23] who still struggle to integrate them into their practice. At the same time, because HIT are transforming the overall healthcare system, scholars have identified a need to use holistic approaches when studying HIT in healthcare and to include organisational management models and knowledge from other disciplines [24–26]. If HIT systems are to deliver their promise, it is of paramount relevance to ease its adoption by obtaining evidence in support of the cost-effectiveness claims when constructing business cases. Currently, such evidence is insufficient [6]. Furthermore, socio-technical factors are given insufficient attention and addressing them properly is expected to enhance HIT adoption [22,27]. The socio-technical approach relies in our capacity to model systems and predict the impact of new technologies within existing social systems [27]. The literature related to socio-technical systems is often approached from two different perspectives. Studies where the focus is related to lack of customisation of the technology – i.e.: how suboptimal IT solutions or poorly designed systems – and results in low use or unintended workarounds [28–32], given the weak intrinsic utility of the software. On the other hand, there is a full body of socio-technical literature focusing on organisational issues that arise when introducing IT within clinical practice. The objective of this systematic literature review is to identify the barriers to HIT adoption from an organisational management perspective and categorise them using the fivestar model developed and refined by Galbraith [33–35]. Once identified, the barriers are analysed and their interrelations are discussed using an organisational management perspective and applying it to healthcare organisational systems. Whilst authors often raise the need for a strategic fit and organisational or cultural changes [25,36–39], most of them fail to address the impact of these on a variety of organisational factors. For instance, the Agency for Health Care Research and Quality (AHRQ) [39] conclude that current practice in clinical medicine may have to undergo major structural and ideological reorganisation in order to integrate itself with, and benefit from, HIT. These approaches would provide an understanding of the impact of HIT in healthcare organisational systems and resulting policies would aim to strategically align and fit them together, taking into account how they interact. For the purposes of this review, given the different terms in use for HIT, the terms “Health ICT”, “eHealth” and “Health Information Systems” (HIS) and their variations wereinternational journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 851 considered as equivalents. Similarly, the terms Electronic Health Record (EHR), Electronic Medical Record (EMR), Electronic Patient Records (EPR), Summary Health Record (SHR) or Personal Health Record (PHR) were also considered as equivalents. Notwithstanding the fact that these terms are not actually equivalents, differences in their definition and use have been widely reported [40,41] and it is recently that consensus about what each of them means has been achieved. Thus, it was considered that treating them as equivalents would ensure inclusion of the relevant literature and help in summarising the findings. In addition, it is relevant to point out that currently the term most commonly used is EHR and the most accepted definition is that provided by HIMSS [42]. 2. Methods 2.1. Search strategy The search was carried out during December 2009 and January 2010. Additional on-going reviews of updates through automated system alerts took place up until the submission of this paper. A search was carried out of software platforms which include databases from the following disciplines: Management, Business, Health, Information Systems and Social Policy. An assessment of publications in these disciplines and their availability in software platforms revealed that it was appropriate to search in CSA ILLUMINA, EBSCOHOST, JSTOR Multiple Collections, ACM Digital Library, Proquest, Emerald Journals, Ingenta, PubMed and ScienceDirect. Google Scholar was also used, as a general search engine for literature, in an attempt to track grey literature. Additionally, specialised and targeted databases of systematic literature reviews, government sources and think tanks were also used: Cochrane Collaboration, EPPI Centre, the Campbell Collaboration, the York Centre for Reviews and Dissemination (CDR), RAND Corporation, Joanna Briggs Institute in Australia, National Institute for Health and Clinical Excellence (NICE), Social Care Institute for Excellence, the Commonwealth Fund, Canadian Health Services Research Foundation, Kings Fund, UK Telemedicine and E-health Information Service (TEIS) – University of Portsmouth, DG INSFO at the EC, WHO Global Observatory for eHealth and the OECD. Due to differences between the search options of the databases selected, search strategies were adapted for each of them with a view to finding a balance between consistency in the terms used and the unique features of each (Appendix 1 provides an overview of the search strategy in each case. See supplementary material). Based on the results obtained, selected journals (The Lancet, New England Journal of Medicine, Health Affairs, International Journal of Medical Informatics, and Health Management Technology) were hand searched. Additionally, the ISI Science Citation Index was searched for relevant authors. To sum up, the search sources included nine software platforms, fifteen specialised websites, Google Scholar, ISI Science Citation and five hand-searched journals. 2.2. Selection criteria The aim of this review is to identify organisational management barriers for HIT adoption. A focus on socio-technical aspects of HIT implementation or post-implementation in healthcare settings was tacitly included within this objective [43,44]. In particular, publications which emphasise the organisational consequences of technical systems and provide an understanding of how people and healthcare organisational systems interact or react to technologies were considered for inclusion as opposite to those focusing on the software intrinsic utility. Additionally, various other factors were taken into account when deciding which studies to include. The type of study was not considered restrictive and a wide range of information sources were consulted: scientific articles, commentaries, editorials or other short reports; research reports, public organisation reports, government reports describing the development, use, or comparison of strategies on health information systems; systematic reviews on the topic; conference documents, presentations and conference publications; and media articles. The time frame was limited to 1995 onwards in all cases except for hand-searched journals. The year 1995 was selected because this was the year when the NASDAQ composite index started its unforeseen rise, marking the beginning of the so-called technology boom. Scholars in the field also use this year as a cut-off date for literature searches [45]. The study setting was narrowed to publications in English from the OECD countries and EFTA countries. Once the above criteria were set, a first screening of all titles and abstracts was carried out. Next, full text copies of all potentially relevant studies were retrieved and screened. Finally, journals to be hand searched were identified. The time frame for hand-searched journals was limited to 2007 onwards only given that the aim was to complete findings with recent developments in the field. 2.3. Data collection and analysis One reviewer was dedicated to this task. In order to ensure validity of the assessment, 100 references out of the results obtained from the first screening were randomly selected for screening by a second reviewer. Any difference between the assessments of the two reviewers was arbitrated by a third. There was lack of consensus in only one of the cases and after a brief discussion agreement was reached. As a result, the assessment criterion was considered valid for the one researcher to carry out all further screenings. 3. Results 3.1. Overview of results A total of 31 sources were searched. The searches originally returned a total of 4035 references and additional automated updates. Two types of repetition were identified: titles repeated within the same source (internal repetition) and titles repeated when combining sources (external repetition). Following a manual exercise, a total of 372 duplicate references were identified.852 international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 One learning point is that relying on EndNote to identify duplicates can result in inaccuracy and the author recommends ratifying duplications manually. Regarding hand-searched journals, those providing the highest unique results were the International Journal of Medical Informatics and Health Affairs. In the case of Health Affairs this is due to the presence of two special issues on the topic involving web-only articles. Although the database search had provided a hint of the presence of two special issues on the topic, some articles had not originally been identified. Systematic application of the inclusion and exclusion criteria to titles and abstracts screening – specified in the earlier section – produced 803 articles to be read (details are provided in Fig. 1. Unique results in each source are detailed in brackets). After reading the articles, seventy-nine unique studies met the inclusion criteria. Seven of the studies were systematic literature reviews [13,16,46–50], all of which had conducted searches in healthcare and social science databases. However, none of them had searched management or business databases. This is surprising as many authors claim that HIT are transforming the overall healthcare organisational system, and that hence there is the need to use holistic approaches when studying the impact of HIT on them and to include organisational management models [25,26,38,51–53]. These have been screened against the rest of the literature results and the sections highlighted in their discussions and conclusions have been used where appropriate, avoiding double counting at all times. Forty studies used a qualitative approach often using the case study method in combination with literature reviews [11,18,21,25,26,41,43,52–83]. Twelve publications applied quantitative approaches including survey results, descriptive statistics [84–91] and modelling approaches [19,51,92,93]. Finally, twenty of them used mixed methods, including quantitative and/or qualitative approaches [14,36,38–40,94–108]. Out of these, only two – covered in three different publications [14,39,94] – were cost-effectiveness studies on HIT implementations, healthcare professionals’ motivations and incentives for HIT adoption. These two studies used both qualitative and quantitative methods. When looking at type of application, EHR, ePrescription and on-line bookings were the most widely covered in primary care, whilst EHR, CPOE, PACS and tele-applications were the target in specialised and hospital care. 3.2. Categorisation of factors under study and types of barrier When looking at types of barrier for HIT adoption, the same lessons were extracted from widely differing care settings and HIT application systems on many occasions. Indeed, most of the studies aimed to identify all relevant barriers and did not set out to focus on a specific barrier. Organisational management barriers have been grouped into five main categories (I–V) following the Galbraith model [35,109,110]: (I) Structure of healthcare organisations; (II) Tasks; (III) People policies; (IV) Incentives; and (V) Information and decision processes. It was possible to fit all the barriers identified in the studies into the taxonomy developed under the Galbraith model. Thus, applying this model never represented a criterion for exclusion from an organisational management perspective. Each individual category, along with its subcategories, is discussed below. 3.2.1. Structure of healthcare organisational systems The structure of an organisation represents the way different team members or different tiers of care are organised and how they coordinate and work together. 3.2.1.1. Hierarchy. Often healthcare organisational systems, specifically those in hospitals, follow a hierarchical model, seniority is often based on clinical experience. Yee et al. [21] argue that when analysing HIT system failures in detail, it is often the case that the problem is not related to the technology itself, but to the lack of socio-technical consideration. They argue that generation Y (born after 1978) professionals may be the change agents for HIT implementation in health. They claim, however, that healthcare organisational systems with strong hierarchical traditions, such as those in hospital settings, are likely to expect generation Y to conform to the culture rather than embrace new changes. As a result, there is a strong need to re-engineer the healthcare hierarchical system in order to best leverage the potential of generation Y workers. Though the work by Ash et al. [111] aims to identify “unintended consequences” rather than barriers, it also points to a series of shifts in the power structure through forced work redistribution and mandated safety pursuits and also shifts in control with a perceived loss of clinician control and autonomy. Both these shifts result from the implementation of CPOE in different healthcare settings. 3.2.1.2. Team work and cooperation. A substantial additional number of publications also identified the current structure of healthcare organisational systems as a barrier [13,55,69,71–73,94] and argue that the current structure does not encourage teamwork involving different tiers of the healthcare organisational system (i.e. primary care with hospitals). They state that cooperation and teamwork, which can be supported by HIT, are required for proper chronic disease management [105]. Indeed, Mostashari et al. [55] when looking at two EHR implementations in New York and Massachusetts, pointed out that team-based care strategies were needed for successful implementations and that this was the only way forward for care coordination supported by EHRs. Al-Qirim [72] also identifies structural aspects within healthcare organisational systems as an area for further research, given the clear separation between the different tiers of care: primary, secondary, tertiary, and community care providers which are functionally interdependent in providing an integrated health and disability support service to individuals. Effective ways of coordinating these different tiers need to be found. The report developed by Aas [71] focuses on the collaboration between providers required by today’s healthcare organisational systems and how HIT are developing new virtual structures as the main organisational change to beinternational journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 853 Original Search Yields Total = 2,868+669+105+103 = 3,745 references Software Platform search: CSA ILLUMINA 691 (640) EBSCOHOST 124 (100) JSTOR Multiple collections 339 (335) ACM Digital Library 22 (22) ProQuest 24 (24) Emerald Journals 13 (13) IngentaConnect 144 (135) PubMed 467 (408) ScienceDirect 1,044 (1,009) Total 2,868 results (2,686) Google scholar search Total 669 results (594) Targeted sources results Cochrane collaboration; EPPI Centre; Campbell Collaboration; CDR; RAND; Joanna Briggs Institute; NICE; SCIE; Common Wealth Fund; CSHRF; Kings Fund; TEIS DG INSFO; WHO eHealth, OECD Total 105 (64) results Hand Search results New England Journal of Medicine (2); Health Affairs (18); The Lancet (8); International Journal of Medical Informatics (20); Health Management Technology (1). Total 103 (54) results Title and abstract screening 4,035 Reference Lists 290 (265) (Web of Science; identified by author contact) Full text screening 803 79 articles Quality Reviewed and included in the Study 3,232 rejected - 372 duplicate publication - 3 unable to find translator - 2 not found - 2,855 not meeting inclusion criteria (relevance to research question, socio-technical approach, timeframe, OECD or EFTA country) 726 rejected Not meeting inclusion criteria (relevance to research question, socio-technical approach, timeframe, OECD or EFTA country) 2 articles from automated updates meeting inclusion criteria Note: numbers in brackets represent unique results Fig. 1 – Details of literature review sources and screening process. Note: Numbers in brackets represent unique results.854 international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 addressed. The RAND study [94] claims that HIT support moreintegrated healthcare, hence current healthcare structures should be redesigned accordingly. Along the same lines, Ahern et al. [73] also identify the need for further research on coordinated care and healthcare structures for the efficacious use of technology amongst others. Winthereik and Vikkelsø [69] address this field, arguing that the current inefficiency in the cooperation between healthcare organisational units within the system has become more severe through the use of HIT. They studied the use of the ‘discharge letter’ from the hospital to the GP’s practice and concluded that this letter often causes problems due to the increasing pressure to demonstrate accountability. The authors call for more research into the relation between articulation and accountability in order to understand how HIT applications systems can be designed to support both aspects. 3.2.1.3. Autonomy. Levenson et al. [74] in their study on “Understanding doctors” identify major cultural barriers and autonomy issues, which have arisen due to current patient consumerism patterns and HIT. Indeed, cooperation with other healthcare professionals needs to be organised adequately so that it does not conflict with the autonomy that most healthcare professionals (primary care being the most prominent example of autonomy) are used to. The study by Ash and colleagues, mentioned above, also identifies threats to autonomy as an unintended consequence of HIT implementation. 3.2.2. Tasks Tasks represent the way in which the work is organised. Up until now healthcare organisational systems have been taskfocused and centred on the provider or facility rather than on the patient. More recently, however, process-focused care, which centres on the patient, is being attempted. It coordinates the work of many care team members (including patients, physicians, nurses, mid level providers, lay caregivers, clinical educators, pharmacists, case managers, and call-centre personnel) to provide each patient with highquality, efficient care across time and across all care venues. The transition to HIT that supports value-added, patientcentred care tasks has profound implications for workload (often raised as lack of time), workflows and work processes. 3.2.2.1. Changes in work processes and routines. Coiera and co-workers [18,43,98], starting from the need to develop socio-technical systems, argue that technologies profoundly transform healthcare. They emphasise the importance of roles, tasks and workflow and how technologies should be designed to adapt to these. Furthermore, the authors address the relevance of communication in HIT rather than just focusing on IT aspects, suggesting further research on communication amongst providers and the use of Remote Patient Monitoring and Treatment (RMT) applications that HIT bring. Finally the authors claim there is a need for a multidisciplinary holistic design framework and for the deployment of methods to evaluate HIT. Forland [75] describes the transition in a primary care practice from paper-based to EHR. She studies how practitioners interact with the HIT system and the resulting changes in their routines. She concludes that organisational management issues must be assessed if HIT implementations are to succeed. A needs assessment carried out by Harrop [38] in hospital and primary care settings reaches similar conclusions. Brokel et al. [76] highlight the need to change work tasks from a process-oriented approach (i.e. ordering a blood test) to a patient-oriented process (i.e. healthcare episode). 3.2.2.2. Face-to-face interaction versus new ways of working. Healthcare delivery has traditionally been associated with face-to-face interaction between the patient and the healthcare professionals. Shortliffe [99] highlights the fact that clinicians have expressed fears that the increasing use of HIT solutions will lead to the depersonalization of healthcare hence the need for cultural change. Finch et al. [77] in their study on the development of teledermatology in the UK, concluded that the routine provision of this service remains limited, mainly due to the new ways of working it imposes. 3.2.3. People policies People policies also vary in terms of how accountable each individual is made to be for his/her actions; whether the individual can be penalised and how or in terms of career development policies and training (whether they are offered or not, voluntary or mandatory), amongst others. For instance, clinicians will require specific training according to their specialities. When it comes to HIT skills, the lack of training and IT/HIT literacy may represent a barrier. Because people policies also have an impact on the institution’s centre of gravity and the autonomy given to practitioners, they should be in line with the overall strategy. 3.2.3.1. Training, IT/HIT skills. Some authors identified the training and competences of healthcare professionals as the end-users operating a specific application as key factors in HIT adoption [39,49,50,54,79,85,87,89,92]. These include Ludwick and Doucette [13] and the Cochrane collaboration [16] during their discussion in their literature reviews. Flynn et al. [78] also see training as having a positive effect and add that financial incentives would help, given the time invested to acquire the right skills and to operate the HIT application. On the other hand, their study focuses on information exchange and they found that healthcare professionals were concerned that HIT could change their relationships with patients. The study by Hayward-Rowse and Whittle [79] shows that lack of training to operate a specific applications is a barrier that also affects the nursing community, not only physicians. Meade et al. [87], in their study in Ireland, identify “poor training” and “absence of computer skills” as the second main barrier after “lack of time”, with the latter linked to workflow factors. Similar conclusions were reached by Granlien et al. [85] in their study of an HIT implementation in a Danish hospital where healthcare professionals felt the need for training to operate the HIT as end-users. MacFarlane et al. [80], in their study also in Ireland start by developing a portfolio of HIT applications. They then select a few of them for further analysis and conclude that focusing on training and skills development, implementing changes ininternational journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 855 workflow, and appointing an HIT champion may lead to successful implementation. The authors extend their discussion on the need for training to support, as covered in the next section. 3.2.3.2. Support. Support has been identified as a catalyser for HIT uptake and lack of it as a barrier. When MacFarlane et al. [80] discuss it, it is addressed from different angles. One of them is the need for technical support, which when it fails, results in frustration and low use of technologies. This point has also been revealed by other authors [38]. Support from management and from colleagues in integrating HIT in healthcare professionals’ daily practice, their professional role and service delivery is another relevant aspect identified in the literature [36,37,80]. As outlined by MacFarlane and his team [80], healthcare professionals can find this support not only from management and clinical champions but also from colleagues and professional networks. Finally, support at policy-making level is required for widespread HIT adoption beyond pilot stages [80,98]. 3.2.3.3. Trust and liability. Friedman and Iakovidis [107] highlight the need for cultural and organisational changes, emphasising that communities of users and healthcare professionals must be established and that trust is required if communication and exchange are to be achieved. Trust has been identified as a challenge in the literature from different perspectives. Rosen et al. [65], when studying the use of an on-line referral system for GPs in the UK, identified significant distrust of data produced by NHS organisations about their own services and facilities (i.e.: waiting times or star ratings of health service organisations). Recognition of the methodological problems associated with clinical outcomes data also influenced GPs’ views about using such data as a basis for actively advising patients, hence their preference for informal sources and traditional referral processes when referring patients, resulting in low uptake of the on-line application. The work by Winthereik and Vikkelsø [69] provides insights on how the discharge letter is meant to represent an overview of the patient case for clinical purposes, whilst at the same time giving an account that reflects organisational liability of the hospital stay in a specific context. This double nature of the document represents a challenge for GPs who are meant to take over responsibility that belongs to the hospital. At the same time, they are expected to distil the clinical interpretation, make sense of the information and determine whether what has been done at the hospital was clinically responsible or not. Often this reality results in distrust in the discharge letter and unnecessary work undertaken by GPs to double check informally with the hospital or to repeat some of the tests. The work carried out by Callen et al. [36] actually identifies how trust in the healthcare organisational system has an impact on the rights that each healthcare professional holds on a new CPOE system. In particular, they describe a hospital where nurses are given rights to order tests on the new CPOE system and how as a result, nurses felt they were being trusted which promoted their acceptance of the system. Ross et al. [66] describe an HIT implementation which involved both big and small practices operating with the same health plan. The authors highlight the fact that practices already engaged in a network of professional and social ties are more ready to adopt HIT. In addition, their study also presents the opposite case where a major barrier arose when defining the members of the HIT implementation governance body. In particular, the wish to have small practices represented equally in the governance body was the major issue mainly due to the lack of trust in health plans. This also reflects the conflicts that often take place between purchasers and providers. Furthermore, when Pagliari et al. [96] address trust issues, they actually refer to (lack of) trust in e-communications and failure of HIT to meet clinicians’ expectations. Hackl et al. [83], interviewed 8 physicians in Austria and concluded that, although changes in workflow constituted a relevant barrier, physicians were seriously concerned that EHR data could be used punitively against them. Furthermore, EHRs could fail due to their lack of cooperation. Burton et al. [106] when studying the use of EHR, acknowledge that EHR leads to healthcare cooperation but point out that the legal liability of physicians who rely on data from other providers has not been established. For example, they raise the issue of the uncertainty about whether an e-mail message from a patient constitutes part of a medical record for which the physician may be liable. Hence they identify liability issues as a barrier to teamwork. 3.2.3.4. Lack of legal framework. This area is closely related to the earlier theme on trust and liability. As described, lack of trust can be rooted in liability issues, for instance when producing a medical report. In addition, Sands et al. [91] argue that the main concerns for data sharing arise from current legal frameworks. They claim that the lack of a legal framework for liability issues on email communication results in physicians’ concerns that they will be held responsible for patients who misuse email for time-sensitive matters and who are unaware of the asynchronous nature of email communication. 3.2.3.5. Accountability to their employer and to policy makers. Rigby et al. [81], start instead from the premise that integrated care requires healthcare professionals to work as a team and to share information. As a result, they foresee that most team members will suffer a three-way split between their autonomous professional commitment to their patient, their loyalty to the team, and their formal accountability to their employer. They conclude that shared care brings further complexity, as it is normally between a hospital consultant and a general practitioner. In contrast, as earlier described, Ross et al. [66] insist that solidarity and trust can act as facilitators for the adoption of EHR and EHR systems. Ford et al. [93] using data from previous publications, argue that physicians are concerned that policymakers, insurers and administrators will use EHRs as a proxy mechanism to influence, restrict, or dictate how medicine is practiced. Thus, for these authors, the main issue is that this threat to physicians’ autonomy results in lack of information sharing.856 international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 3.2.3.6. Centre of gravity and autonomy. Centre of gravity is a prime determinant of organisational structure, systems and processes. The policies designed and the allocation of resources are likely to reflect where the centre of gravity sits. Overall, the centre of gravity serves as an additional determinant of the reward and career systems within organisations. A shift downstream requires a corresponding shift in the power base of the organisation, away from the dominance by the top and middle-management. It could be argued that the centre of gravity of the healthcare organisational system has remained with GPs in countries where their role as gatekeepers is strong, as is the case in England. Here, current policy developments aim to provide higher commissioning and budget responsibilities to GP consortia. Against this background, implementing a centralised NPfIT represents a shift away from the traditional centre of gravity and could be perceived by GPs as a threat to their autonomy [36]. It would therefore be a serious barrier to HIT adoption. The NPfIT in England has been criticised for using a top-down approach by a variety of authors including Cresswell and colleagues and also Coiera [47,98]. Along the same lines, Pagliari et al. [100] urge clinicians and policy makers to establish a dialogue rather than a war, if they wish the NPfIT to be successful. Even in cases where the approach is not centralised, as in Canada, clinicians are concerned about sharing their waiting list information and exposing the private operations of their practices. They fear they could be penalised as a result and lose their autonomy [108] 3.2.4. Incentives Reward systems of an organisation should be aimed at focusing and influencing individual behaviour. Reward systems must be viewed as broadly composed of direct monetary compensation, benefit packages and associated perquisites, bonus incentive plans, promotion and career development opportunities, managerial praise and recognition, as well as intrinsic rewards emanating from job satisfaction. Several scholars have associated the resistance of healthcare professionals with lack of incentives, arguing that adequate funding and a review of current payment systems would result in faster adoption [11,25,26,38,46,48,51,53,82,84,95,97,101] and potentially in data sharing [14]. Issues around incentives are very prominent in the literature review by Chaudhry et al. [46], where modifying physicians’ reimbursement is identified as a key topic in policy discussions. The literature by Boonstra and Broekhuis [48] also highlights start-up costs as a barrier. This issue, however, has been disregarded in this study as it is being tackled by current policies in most OECD and EFTA countries. The objective of this study is to identify those barriers that are not being dealt with properly. On the other hand, although start-up costs are being addressed by most governments, the effectiveness of these interventions remains to be seen. Tufano [52] finds that HIT have a negative impact on the balance between the work and personal lives of physicians. This author concludes that adequate incentives for HIT adoption should help to regain an equilibrium, for instance through telework. In one of the studies, Ford et al. [19] modelled EHR adoption in the USA and claimed that in the current situation it is unlikely that the 2015 target for a fully integrated EHR would be achieved. They argue that interventions such as pay-for-performance (P4P)1 programmes would stimulate EHR use. Bates [102] offers a similar angle and concludes that a P4P programme and quality incentives along the lines of the current system of payment to GPs in the UK would help overcome existing barriers to EHR adoption. When, Mehrotra et al. [95] tested the association between P4P incentives and the use of quality improvement initiatives, HIT use was used as an indicator of quality improvement. Therefore, this study uses as an indicator what for most authors is an assumption. In contrast, an interview with the (at the time) national coordinator of HIT in the USA [103] suggests that pay-foruse2 may be a good strategy and also concludes that patients should be the owners of heath information. Halamka et al. [82] identify increases in workload as a barrier to the adoption of an ePrescription system by healthcare professionals. However, they conclude that if incentives are aligned, this barrier can be overcome. Taylor et al. [14] propose that governments and/or insurers apply pay-for-use incentives to offset some of the costs of adoption or conversion. Once implemented, these could be followed by pay-for-performance incentives given that these are designed to share the value of HIT-enabled quality and efficiency improvements with the providers producing that value. Rosenfield et al. [101] reach similar conclusions when they discuss different payment systems to incentivise HIT adoption. They find that the complexities associated with HIT implementation, such as the impact on workflow, will continue to be a major barrier, and any truly effective organisational management solution should also address incentives. Following Rosenfield’s [101] approach, another group of scholars insist that incentive policies to promote HIT adoption are not enough and that changes in workflow and processes are of paramount relevance [40,43,66,79,85,87,99,101,104]. In particular, Ross et al. [66], after mapping health information workflows in healthcare organisational systems and interviewing professionals, found that achieving uniformity in processes, and standardising routines and information flows using HIT (as addressed in Category II) was a critical factor, whilst financial incentives were secondary to technical and workflow issues. 1 Pay-for-performance (P4P) is a payment scheme that rewards physicians for meeting a payer’s predefined clinical or patient satisfaction benchmarks. P4P programmes typically base their incentives on a mix of preventive care and chronic disease management benchmarks. Measures of clinical quality or other measures such as the use of diagnostic imaging or the use of preferred medications are used as indicators in P4P programmes. 2 Pay-for-use would represent a variable payment every time HIT are used; i.e. pay per email interaction, or pay per each EHR that is updated and available to other stakeholders.international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 857 3.2.5. Information and decision processes For healthcare professionals to cooperate and work as a team, information needs to be shared amongst them, an issue that has become an unforeseen challenge. Introducing HIT implies modifying information and decision processes as a whole and has an impact and lack of alignment with the dimensions earlier defined. Chronaki et al. [90] found that changes in flow and processes translated into a heavier workload for healthcare professionals, hence their resistance to these innovations. Similar conclusions were found in other studies and settings [39,56,67,68,78,87]. Heavier workload is associated with the early stages when information in paper format has to be digitalised. Once the technology is in use, clinicians complain about the system being slow or taking longer to enter data [65,70]. Kittler et al. [86] and also Yee et al. [21] found that fears of heavy workload were also held by patients consulting their medical records and by physicians who were concerned that patients would overwhelm them with electronic communication. Therefore workload concerns are due to both technical problems (thus, outside the scope of organisational management) and the process of transforming clinical data in paper format into digital format as well as new forms of communication processes and channels resulting from HIT implementations (i.e.: email). In addition, the introduction of HIT embeds data sharing. Even in countries where the use of EHR – one of the central components of an integrated HIT – was high (i.e. Denmark [57–60], Sweden [41], some regions in Spain [61], the Netherlands [62] or the UK [63,64,88]), sharing of EHR was the area of focus. As EHRs seemed to be accessible only from clinicians’ or GPs’ computers, they formed silos and were unavailable to other healthcare professionals or stakeholders. Interestingly, Iakovidis [105] had already established a distinction between an EHR and an EHR system: “a distinction between the EHR and the EHR system which operates on EHR in order to manage the information and provide information to qualified users in a user-friendly manner. Good EHR systems help the users to retrieve the information in a fast and user friendly manner (interfaces), communicate easily with others, and make user’s work more effective. (. . .) From this definition we can immediately differentiate EHR systems from stand-alone systems”. As a result of lack of information sharing, it can be stated that no country, including those that have succeeded in reaching a high penetration of EHR amongst GPs, has yet achieved a full and complete EHR system. A set of barriers related to information sharing have been identified in the literature and these have been mainly categorised under people policies (category III). Indeed, by introducing HIT systems, information flow is the aspect that is being modified and the above categories are the ones that would need to be adjusted in line with this change. 4. Discussion The scope of this literature review is broader than those previously carried out in the field [13,16,46–50,112], given that it includes searches in management databases. In addition, the taxonomy used follows an organisational management approach, as the literature identified a need for this. When assessing the types of drivers and barriers identified, the literature identified socio-technical, cultural and organisational issues associated with resistance to HIT. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a healthcare work environment. These concepts contend that there is a relationship between the tools that facilitate the healthcare processes and the interpersonal interactions needed to carry out the day-to-day clinical tasks of a care facility. New implementations require healthcare organisational systems to build an understanding of their processes so that it is understood how a new system will fit in. Such efforts often uncover process inefficiencies, amongst others. On the other hand, it is evident from the literature that none of these dimensions are stand-alone issues; rather they interact with each other. This has been raised and re-phrased as the need for strategic fit, or alignment, or the lack of holistic approaches when studying HIT, including the inclusion of management organisational models and knowledge from other disciplines. To date, there has been consensus in most of the literature of the need for further research to better understand barriers for HIT adoption, how different factors and actors interact and are interrelated as well as potential ways to overcome them. In this study, barriers were categorised using an organisational management model developed by Galbraith which incorporates information systems [35,109,110]. Often the studies reviewed targeted more than one type of barrier, which represented quite a challenge for this exercise. In these cases, the barrier that was emphasised over the others was the one used for categorisation purposes. The barriers identified were categorised under five headings: (I) Structure of healthcare organisations; (II) Tasks; (III) People policies; (IV) Incentives; and (V) Information and decision processes. The results reviewed showed that barriers within different categories and subcategories are interrelated. For instance, by implementing HIT systems, we are actually modifying information and decision processes. However, it also has an impact on the concerns about liability of healthcare professionals, often rooted in lack of a legal framework (related to people policies) and to autonomy issues. Autonomy issues are related to both people policies and structure of the healthcare organisational system. In addition, the current structure is a barrier which often hampers coordination and team-work, even by virtual teams, and incentives for “virtual” cooperation are not in place in most healthcare organisational systems. Trust is an essential requirement for healthcare cooperation supported by HIT systems. By trust, it is meant trust in the quality of the data upon which decisions are being made. Therefore, it implies trust in the quality of the data that another healthcare professional has introduced in the system, trust in the system retrieving and portraying the data in the appropriate form as well as trust in the overall delivery organisation, as described in the results. As seen, although trust and liability may come across as very different issues, often lack of trust in data entered by another healthcare professional is caused by liability issues.858 international journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 Not only are incentives not in place but current frameworks and people policies actually represent a disincentive for coordinated care supported by HIT. Indeed, liability and accountability concerns have not yet been addressed in most healthcare systems. Current policy developments in the area emphasise security issues mainly related to patients’ data protection [48] which is definitely a relevant issue, but a clear legal framework should also be developed if healthcare professionals are to feel comfortable using HIT. Overcoming the barriers to the acceptance of HIT by physicians will be a long and challenging process. The industry can definitely contribute by delivering systems that are easier to integrate into healthcare professional practice. In addition, if we are to change people policies, incentives, structures and current tasks and processes and ensure all of the dimensions are aligned, time for adjustment is required and it is advisable not to be impatient. From this perspective, there are some interesting examples that we can learn from. For instance, providing training and offering support have been identified as enhancing HIT uptake. It is likely that the more user-friendly, flexible and intuitive the technology is, the less training is required. However, training is also understood as a means to promote user engagement as well as user involvement during system design. A shared vision and support at different levels (policy level, management, colleagues and technical support) is likely to result in lower barriers for uptake. In England, though achieving a proper EHR system and information sharing nationwide is proving challenging, the penetration of EHR in GP practices is amongst the highest internationally [64]. The authors agree that this high penetration has been induced by the Quality and Outcomes Framework (QOF) payment system [25,64,102]. Hence, although the top-down approach used in England may act as a barrier to the NPfIT [98], accompanying policies may enhance its uptake and the QOF payment system may be one of them. Another interesting example is that of Denmark. In fact, primary care physicians and specialists in Denmark are now being paid a fee for email communications with their patients. This fee is double that paid for a phone consultation [57–59]. In Denmark, GPs were already paid to take calls from their patients from 8 to 9 a.m. every day and with wider use of HIT, primary care physicians and specialists were also paid a fee for email communications with their patients. The fee for each email consultation and/or email with other physicians (i.e. about lab results) was twice that for telephone calls. In 2008, some 50,000 emails a month were exchanged between physicians and their patients. Use of email technology by physicians became mandatory from the end of the same year. 5. Limitations This study has attempted to combine a large amount of diverse literature into a unifying organisational management model applied to healthcare organisational systems. The methods used were systematic – explicit, rigorous and transparent – and independently verifiable. However, the literature was vast and complex, the approach in this review was emergent and somewhat unconventional, and many subjective judgments were inevitably made. A different group of researchers with the same objective would be likely to get different results. This is arguably an inherent characteristic of any systematic review that addresses complex interventions and seeks to unpack the nuances of their implementations in different social, organisational or environmental contexts. The findings presented here do not aim to be prescriptive, but rather to shed light on the problem and suggest areas for consideration. Second, limitations also arise from the sources used. For instance, the hand search was restricted to five journals only. It is very likely that hand searching other journals such as JAMIA or the BMJ would have enriched the results. Moreover, two publications which were not found may have revealed relevant findings. Third, out of the publications included in the results, some of them did not involve primary data collection. However, these references contained interesting findings which although they originally seemed reasonable, they may require to be tested. This may represent a bias in the findings of this study. Fourth, although the taxonomy proposed in this study covers all the barriers previously identified, other taxonomies and categorisations could have been proposed to analyse and group the barriers. This literature review has focused on the organisational aspect within the socio-technical approach given these studies provide deeper insights on organisational aspects. Thus, constraints arise from this approach and results are limited to organisational factors. Furthermore, a full body of literature addressing cost-effectiveness and issues related to software design and software utility within socio-technical research has not been included. This may introduce a source of bias in the findings, given that attitudes and behaviours may be the result of technical features and specifications. Indeed, by not including this literature, it is assumed that even if the IT industry were to deliver perfectly suitable solutions and their cost-effectiveness would be irrefutable, the barriers identified in this review would still be encountered. If HIT are to make an impact in healthcare delivery and improve patient outcomes, policy-makers, insurers, software developers, healthcare managers and techno-enthusiasts need to take into consideration the need for evidence on their cost-effectiveness as well as socio-technical aspects of implementation from all angles. 6. Conclusions The advantages of HIT over paper records are readily discernible to techno-enthusiasts: i.e. digital environments allow reliable and efficient storage, gathering and exchange of data, thus improving performance and quality of care, especially for patients with multiple chronic conditions. They also reduce costs. However, without better information, stakeholders interested in promoting or considering adoption of health information technology may not be able to determine what benefits to expect, in particular for chronic disease management and coordinated care, how best to implement the system in order to maximize the return on their investment, or how tointernational journal of medical informatics 8 0 ( 2 0 1 1 ) 849–862 859 direct policy at improving the quality and efficiency delivered by the healthcare sector as a whole. Despite their promise, implementing HIT systems has proved to be difficult. In this article, based on a systematic review of seventy-nine articles, barriers to HIT adoption have been identified and categorised using an organisational management approach under five headings: (I) Structure of healthcare organisations; (II) Tasks; (III) People policies; (IV) Incentives; and (V) Information and decision processes. This paper analyses each of these categories and their subcategories and also their interrelations. This study suggests several important future directions in the field: (1) additional studies need to assess future areas of HIT deployment and data sharing that would lead to HIT systems; (2) there is a need for further research providing evidence of HIT cost-effectiveness as well as the development of optimal HIT applications; and (3) more information is needed regarding organisational change, incentives, liability issues, end-users HIT competences and skills, structure and work process issues involved in realising the benefits from HIT. Future policy interventions should consider the five dimensions identified and the impact that modifying one of them will have on the others as they all interrelate and should be aligned. In addition, evidence on cost-effectiveness of HIT and efforts to deliver optimal HIT systems should also be a priority. Author’s contributions ML has developed the concept underpinning the paper and the subsequent search strategy. She also interpreted and analysed the data and developed the taxonomy based on the management literature. She has read and approved the final manuscript. Competing interests The views expressed in this article are the author’s and do not necessarily reflect those of the European Commission. The author declares that she has no competing interests. Acknowledgments The author is grateful to David McDaid, Adam J. Oliver and Josep Valderas at the LSE for their support to this work and comments on earlier drafts of this paper. In particular, DM gave the author one-on-one coaching on managing software databases and references. DM was also the second reviewer of the 100 references screened and AJO was the arbitrator. The author is also grateful to Patricia Farrer at IPTS for her contribution in English editing this study. Last but not least, the author would also like to acknowledge the journal’s editor and reviewers for their comments that contributed much to the final paper. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijmedinf.2011.09.005. Summary points What was already known on the topic? • HIT adoption by healthcare professionals has shown to be a challenging endeavour due to a variety of barriers. • Barriers are of different nature and there is a need to address the organisational changes that HIT represent in healthcare. What this study add to our knowledge • Multidisciplinary approaches can enlighten and assist in HIT implementation. • Some of the barriers to successful HIT implementations can be approached from an organisational management perspective. • Organisational issues are interdependent and there is a need to identify the impact in each organisational aspect and address them adequately when implementing HIT in healthcare delivery. r e f e r e n c e s [1] Accelerating the Development of the eHealth Market in Europe, in: eHealth Taskforce Report 2007 – Composed in Preparation for the Lead Market Initiative, European Commission, Information Society and Media DG, Luxembourg, 2007, Available at: http://ec.europa.eu/ information society/activities/health/docs/publications/ lmi-report-final-2007dec.pdf. 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