We collected data through interviews with 66 users and other hospital staff, carried out 38.5 hours of observations, collected 13 hospital-specific documents, and conducted interviews with 14 stakeholders outside the immediate hospital environment. A summary of data collected in each case study site is provided in Table . This also shows a breakdown of the number of different participating professions.
Summary of data collected at each hospital
As a result of our inductive analysis, we were able to identify a number of important factors relating to the integration of Lorenzo with user work practices. These are outlined in detail in Table and included the following main categories:
Emerging themes from our study
• Software characteristics and associated consequences
• Coping strategies employed by software users in different contexts
• Direct and indirect knock-on effects.
We elaborate on these themes below with supporting illustrative data (further data are available on request from the corresponding author).
Software characteristics and associated consequences
The software in question was nationally procured, which meant that organisations, although to some extent free to choose which 'releases' (i.e. versions) they wished to implement, were presented with a fixed set of core releases that allowed limited customisability at either an organisational or group/individual user level. This reflected the then government's central desire to see interoperability. This was seen to be particularly important in the context of a state-run national health service. However, the focus on interoperability resulted in poor alignment between local work processes and software specifications. Users thus frequently expressed concern that the software lacked fitness for purpose and/or usability.
"Two fundamental criticisms remain that the system is not, and what you see on the screen is not intuitive, in other words if you haven't been taught, haven't used it regularly enough to remember what all the sequences are, so if you're only dipping into it occasionally it is actually very, very difficult because it is, you cannot sort of automatically think well this is what I want to do next and look at it and say that's what I do ... the other criticism of it is the speed of the system that you don't, when you expect to move from one field to another it is not instant and that is a big concern in a system where one feels instinctively that it ought to be." (Interview, Consultant, Time 2)
The limited ability to customise the software meant that it was difficult to adapt to suit local needs, which often resulted in significant increases in users' workloads.
"Somebody rang me, 5-10 minutes on the phone, and it takes you, one time it took me over 50 minutes to do it all because it's a phone call, going downstairs to get the file cause you still have to have the file, finding the file, bringing that up then logging on, waiting, cause I just did this one thing and then putting it all on, trying to print it and it took 50 minutes and that was just a parent had rang me to say that they needed to cancel the session (laughs)." (Interview, Therapist, Time 2)
The nature of Lorenzo also meant that it had to be implemented in phased releases as increasing functionality became available. Consequently, paper and electronic systems had to be run in parallel initially in order to compensate for the limited functionality of the early releases. Acknowledging that this temporary arrangement may have increased workload for end-users yet further, local implementation teams suggested possible workarounds for users to cope with these parallel systems. These, for example, included the:
"...printing of Lorenzo notes and attaching these to paper files, creating written notes if there are issues with electronic notes (i.e. paper used as fallback)". (Source: local Deployment Verification Report)
Coping strategies employed by software users in different contexts
We in addition observed a number of more unintended workarounds and coping strategies employed by users struggling to accommodate software that was perceived to be of poor usability. Some users, particularly those with more autonomy such as senior consultants, resisted use altogether by insisting on using paper records.
"... medical staff sort of dig their heels in and then don't do it, do they and if they can get out of doing it they'll do it on paper..." (Interview, Administrative Staff, Time 2).
Others, notably those who could not avoid using the system, devised various ways to compensate for the increasing demands on their time and concerns about the shortcomings of the technology. The most commonly employed techniques here included using other systems to compensate (e.g. typing letters in Microsoft Word as the spell-check was perceived to be much faster than that embedded in the software and/or reverting to paper systems); partially using the system (e.g. not recording certain activities if they were not viewed as important); and using the system in ways other than intended by management (e.g. getting around compulsory boxes by cross-referencing).
"So you end up, because you can't cut and paste so you can't say look OK this is the same let's cut and paste it into here, you end up having to write it multiple, multiple times or you end up having to cross-reference and I actually think it is safer for the [patient] to have all the risk stuff clearly and concisely written in one place. The nature of the form means that one place isn't the form so I actually write it very clearly in the progress note or the assessment form and I always in the boxes that open up I just put 'please refer to [name of form]', which then increases the amount that the risk indicator is a tick box exercise." (Interview, Nurse, Time 2)
Over time, some of these difficulties of integrating Lorenzo within users' everyday work practices attenuated to some extent as they became more familiar with the system. This was particularly true in smaller-scale deployments in sites that had invested significant time and resources to adapt the software to fit with their everyday practices. In addition to more effective integration with work practices as a consequence of increased familiarity, stakeholders reported at follow-up interviews that, as they received system upgrades, technical performance had improved significantly, particularly in relation to speed.
"I think the speed difference is massive from when we first started to now, you hardly wait at all... A lot has changed... I know the steps to take to find stuff so it's not a problem to find stuff." (Interview, Allied Healthcare Professional, Time 2)
In addition, some of the interim workarounds, such as printing forms completed on Lorenzo and attaching these to paper files, attenuated when the whole service used Lorenzo. Over time, paper appeared to progressively lose its significance, increasingly being used as a "back-up system", with users employing compensating techniques such as, for example, performing another activity whilst waiting for the system (such as switching on the computer and making a cup of coffee); inputting less descriptive data as this helped to speed up data entry; or allocating extra time at the end of consultations for correcting spelling mistakes made whilst typing.
Direct and indirect knock-on effects
Coping strategies employed by users had several direct and indirect knock-on effects. These are considered below in relation to collaborative working, patients, paper records, managerial outputs and recording activity.
Collaborative working-hierarchical structures and communication
The new technology impacted on the ways in which the healthcare team interacted. This was in some instances seen as a positive consequence, but in other situations as a negative development. In relation to the former, some users felt that using the system helped to make communication more effective over longer distances.
"Yeah it is [more effective] because now we know that definitely everybody has access so things like, so last week we had a really urgent nail surgery on the Wednesday and I could actually book her in to have it on the Thursday knowing safely that her assessment was all there and I didn't have to rush off a set of notes and everything else it was all done. And that's only minor benefits for us but everyday where we use it more and more now we're paper free we just think of more things." (Interview, Allied Healthcare Professional, Time 2)
On the other hand, users also reported that the system changed the way the healthcare team interacted in negative ways. This was mainly expressed in relation to changing professional roles and responsibilities with an increased emphasis on administrative tasks. It was seen as particularly problematic by clinical staff who expressed concern that the resulting displacement of administrative duties on to their shoulders was detracting from their more pressing clinical responsibilities.
"It takes you much, much, much, much, much longer; it doesn't really help us at the moment. This version is absolutely useless to be honest and yeah, it's a waste of time, you're sitting in front of a computer and you should see basically patients and doing something and so instead of this you're typing in something, and you're kind of frustrated when you wait for something that took half a minute as a chest X-ray, it takes now at least 10 minutes..." (Interview, Junior Doctor, Time 1).
Similarly, the system tended to change professional responsibilities, often making existing hierarchies more visible. For example, it only allowed nurses who had special training to order X-rays. Other nurses had to ask the doctors to order these if necessary. In such cases, doctors then had to complete the form, which created more (unwelcome) work for them. Conversely, nurses felt that some of their professional autonomy had been eroded (although it has to be noted that officially most nurses were not allowed to order X-rays-they were doing it informally by completing the cards on behalf of a doctor).
"... for example you get a load of new doctors on the ward and you get a patient in with a specific condition you know automatically before the consultant even comes round what investigations that patient is to have, because there's a protocol so you know what they're going to have or you know, because you've experienced what they're going to have so you could in effect order them and we did do, you know, if someone came in with renal colic I would order, you would just do it because that's what you knew the patient was going to have." (Interview, Nurse, Time 1)
Time with patients
The introduction of the new system was perceived to reduce the time healthcare professionals could spend with patients, leaving clinical staff frustrated, as direct patient care was seen as more central to their role and professional identity. The increased time spent in front of the computer thus adversely impacted on job satisfaction.
"I mean the fact that there's no jobs in the NHS at the moment is the only reason why people would have stayed and morale has been, people are just not feeling job satisfaction because as I say when you should be seeing patients you're actually sitting at a screen that is going interminably slow." (Interview, Therapist, Time 2)
In some instances, the technology also reduced the perceived quality of the interaction with patients. Using computers whilst consulting was, for example, felt to impact on communication flow, rendering the consultation more formal and less engaging.
"It means that it's almost like a barrier to communication because you're having to take your eyes off that patient and break that communication to look down at a laptop or a computer and I don't think that's terribly professional..." (Interview, Allied Healthcare Professional, Time 1).
Other systems such as paper
It also became apparent that the introduction of the new system not only impacted on individuals, but also had an effect on paper records (which were, as mentioned above, still used in parallel). Here, paper was often found to be more distributed across geographical locations within healthcare settings. For example, different users would take paper files to their desks at different times to file the electronic print-outs whereas before the introduction of the system all paper records were held centrally in the reception area.
The paper comes out of a printer in his office but he [Therapist] explains that this printer is also shared, he signs the paper and explains that he "now have to find the paper file to put the paper copy into it", he says that sometimes he cannot find the paper file as other clinicians might have it... (Researcher Notes, Observation).
As a result, other users needed increasingly to "chase" paper records.
"Oh yes, I mean I've had one where I've said "I'm sure someone has seen this case" and of course it's just not on the file cause it's still with other people. And when it's things like medication and things like that, sometimes I'll just come in and I've not been in for a week and I just need to pick up the file and there is nothing there and I know she's seen them but it's not typed in which never happens with notes cause they just sit there and write it while the client is there. So it's very time consuming." (Interview, Therapist, Time 2)
The medical record itself
Similarly, data entry itself was impacted upon, this in the main manifesting as delays in transcribing the record with the introduction of the new system. This was due to the software being perceived as slow and as impacting on the communication flow with the patient. Notes were therefore often typed up at the end of the day or, in some instances, days after the consultation had taken place. Paper notes were used in the meantime as reminders.
"Well at the moment because we've sort of piloted it on the [name] wards we have tried to make an effort to use [name of system] as much as possible. I mean we were asked to try and request investigations live on the ward rounds using a portable computer but unfortunately as I said because of constraints of time it wasn't possible to use it that way, it just took too long because we, you know, we have a fair number of patients to see in a short space of time. And so the junior staff are making notes of who needs which investigation and then they're requesting them via [name of system] at the end of the ward round." (Interview, Consultant, Time 1)
As a result of this delayed data entry, the new computer system was found to be less up to-date than systems that were previously in place.
He [nurse] then puts the Smartcard [an electronic card used for user identification] into the keyboard and picks up a folder of patient notes on his desk, on top of the folder is a small notepad page with some scribbles on it, he then looks at his paper diary (like a book and full of scribbles) and looks up when he saw the patient, "ah 2 pm on Friday" (it's Monday today), he says that he jots down notes on paper "to jog my memory", it is a girl with an eating disorder... (Researcher Notes, Observation).
Managerial outputs were also affected by the introduction of the new electronic system. When staff employed workarounds, this would in some cases result in inaccurate reports being generated by the system further down the line, impacting on managers' ability to track activity levels.
"... so you're getting a certain amount of well I'll just try anything that makes it look like its worked and then you get problems with back-end data because there's a diversification of the numbers of processes that people are using cause they are just desperate to try and get from A to B in a day and they'll try any route to get there that looks like it's working to them." (Interview, Manager, Time 2)
An interesting example given in this context was that users in outpatients would book appointments on the system using a route that was less laborious, but which meant that, although these appointments would show on their screens as booked, they would not show on the rest of the system as booked. As a result, managerial outputs became so unpredictable that they in a number of instances no longer reflected the reality of what actually happened.
Conceptualising overall consequences for work practices
ANT helped us to conceptualise changes in constellations between various network components including humans, paper and the technology. This is illustrated in Figure , which depicts existing work practices before the introduction of Lorenzo, planned changes in work practices with the introduction of Lorenzo, and actual changes in work practices resulting from the introduction of Lorenzo.
An ANT-based diagrammatic presentation of the changed networks.