Dealing with existing data in legacy systems when transitioning between Electronic Health Records in three Swedish counties. Author: Mina Makar

Transcription

1 Master's Programme in Health Informatics Spring Semester 2014 Degree thesis, 30 Credits Dealing with existing data in legacy systems when transitioning between Electronic Health Records in three Swedish counties Author: Mina Makar Author: Mina Makar Main supervisor: Professor, Gunnar Klein, Informatics, Örebro University Co-supervisor: Dr. Maria Hägglund, Health Informatics APPENDIX Centre, Karolinska Institutet Examiner: Associate Professor, Nabil Zary,Center for Learning and Knowledge, Karolinska Institutet

2 Master's Programme in Health Informatics Spring Semester 2014 Degree thesis, 30 Credits Affirmation I hereby affirm that this Master thesis was composed by myself, that the work contained herein is my own except where explicitly stated otherwise in the text. This work has not been submitted for any other degree or professional qualification except as specified; nor has it been published. Stockholm, 16 th of May 2014 Mina Makar ii

3 Master's Programme in Health Informatics Spring Semester 2014 Degree thesis, 30 Credits Dealing with existing data in legacy systems when transitioning between Electronic Health Records in three Swedish counties Abstract Background: Transitioning from one Electronic Health Record system (EHR) to another has become a necessity for many healthcare organizations. Compared to transitioning from paper-based systems to EHRs, very little has been published about transitioning between two EHRs. Objective: To understand more about the different approaches used for managing the data in the legacy systems when transitions took place and to investigate the opinions of the users regarding this. Methods: Interviewing both decision makers from the Swedish county councils where the study took place who either led or took part in the transitions and from the corresponding vendors who took part in the transitions (total of 7 interviews). A questionnaire targeting three user categories (specialist doctors, resident doctors and nurses) was administered and 53 responses were received. Results: Using the legacy systems and the new ones under a certain period, accessing the information in the legacy systems via a link (to a database) that connects the new system with the data exported from the legacy system and manually entering the data to the new system were the three main identified approaches that had been used. Automatic data transfer is currently infeasible given the architectural differences between the systems. Although relatively long time has passed since the transitions took place, 75% of the users who responded to the questionnaire are still dependent on the information from the legacy systems and 60% of the users expressed having no or very slight influences on the decisions made regarding the legacy information. Conclusion: Until automatic data transfer becomes feasible, the currently existing approaches and new ones to deal with the legacy information are in need to be developed. Users of the EHRs should be actively and continuously included in the transitioning-related decisions. Keywords: Transition, Legacy Systems, Medical Records Systems, Electronic Health Records, Qualitative Research, Sweden iii

4 Acknowledgements The author would like to express deep gratitude to: Professor Gunnar Klein: You ve been a huge source of knowledge, inspiration and support. I learned and I m still learning much from you! Professor Sabine Koch: Thank you for all your help and support! Dr. Maria Hägglund: A great teacher and a wonderful person! All the wonderful people I interviewed: You ve contributed immensely to my knowledge. This study would have been infeasible without your valuable contribution. The respondents to the questionnaire: Thank you for allocating some of your precious time to answer. Finally, a big thanks for my family and friends for being there whenever needed! iv

5 Table of Contents Glossary/List of abbreviations.vi List of figures...vi List of tables. VII 1. Introduction Electronic Health Records Healthcare system in Sweden Stockholm County Uppsala County Östergötland County EHRs in Sweden Transition in Stockholm, Uppsala and Östergötland Current state of the knowledge about EHR transitions Study aims and objectives Methods Research Methodology Research Approach Study Setting Data Collection Tools Semi-structured Interviews Questionnaire Data Analysis Semi-structured interviews Questionnaire Ethical Considerations Results Approaches to information handling in transitions between EHRs Decision makers Types of Decisions/Approaches...33 v

6 No Automated Data Transfer Why automated transfers are difficult Users experiences and opinions of the transition strategies Respondents characteristics Respondents experiences with the legacy and the new systems Usage of the legacy system Respondents opinions regarding how the information in the legacy systems should be dealt with upon transition to new ones Influence on the already done transitions Discussion Strategies to deal with the legacy data EHR users perspectives Conclusion References Appendices..a Appendix A Letters, Interview Questions & Questionnaire.a Appendix B Illustrative Images....g Appendix C Tables....j Appendix D Graphs..v vi

7 List of Abbreviations: 1. CDSS Clinical Decision Support System 2. CGM CompuGroup Medical 3. CPOE Computerized Physician Order Entry 4. EBP Evidence Based Practice 5. EHR Electronic Health Record 6. ICT Information and Communications Technology 7. LIO Östergötland County Council 8. LUL Uppsala County Council 9. SALAR Swedish Association of Local Authorities and Regions 10. SCB Statistiska Centralbyrån (Statistics Sweden) 11. SLL Stockholm County Council List of Figures: Figure 1: Some benefits of EHRs in healthcare...2 Figure 2: Stockholm, Uppsala and Östergötland Counties....4 Figure 3: Percentage of users of the available EHRs in Sweden, Figure 4: COSMIC in Swedish County Councils..7 Figure 5: Takecare in Swedish County Councils... 8 Figure 6: The prepared interview questions.16 Figure 7: Number of daily responses...32 Figure 8: Number of respondents from each professional group...33 Figure 9: Female to Male respondents..33 Figure 10: Respondents using/not using the legacy systems 36 Figure 11: Checked information categories by the respondents..37 Figure 12: Chosen information types in contrast with each other 39 Figure 13: Influence of respondents on the performed transitions vii

8 List of Tables: Table 1: The 4 dominant EHRs in Sweden in 2012 & Table 2: Official Swedish authorities names and websites..13 Table 3: List of interviewees, their roles and their current positions Table 4: User-information blanks and the respective provided choices Table 5: Constructed questionnaire translated to English.. 21 Table 6: List of recipients of the questionnaire.. 25 Table 7: Respondents age groups. 34 Table 8: Amount of users with respect to experience with the legacy system..34 Table 9: Amount of users with respect to experience with the new system..35 Table 10: Periodicity of usage of the legacy systems by the respondents.35 Table 11: Information that is searched for using the legacy systems Table 12: Choices from the proposed solutions.37 Table 13: Choices of the types of information that should be transferred.39 Table 14: Respondents influence on the already done transitions 40 viii

9 1. Introduction 1.1. Electronic Health Records Electronic Health Records (EHRs) can be defined as Repository of patient data in digital form, stored and exchanged securely, and accessible by multiple authorized users. [1]. The benefits of EHRs in modern healthcare extend way beyond just effectively storing and retrieving patient data [10]. EHRs enhance communication between different healthcare professionals [2-4] in addition to enhancing communication between patients and healthcare professionals via portals that are connected to the EHRs [5,6]. Studies have shown that medical errors are decreased owing to the usage of EHRs that have integrated Clinical Decision Support Systems (CDSS) and Computerized Physician Order Entry systems (CPOE) [7-9,12,13]. Using EHRs with CDSS also has a positive impact on patient safety not only because of the decrease in drug-related prescription errors, but also due to the support of Evidence Based Practice (EBP) [11]. Reducing costs and better support for conducting research using the electronically stored data are also other aspects that successful implementation and usage of EHRs can result in. [3,4]. Improving previously mentioned aspects leads consequently to improving the quality of the provided health care service. [4,15] 1

10 Figure 1: Some benefits of EHRs in healthcare 1.2. Healthcare system in Sweden Sweden is a country that is administratively divided into 21 counties which contain 290 municipalities kommuner [15,16]. A county council landsting is responsible for collective functions within the respective county e.g. public transport. Healthcare administration is also decentralized and is one of the responsibilities of the county council [17,18]. County councils are responsible for both hospitals and primary care. According to the report ehealth in Swedish County Councils published in 2012 by the Center for ehealth Center för ehälsa, private hospitals are not common in Sweden which makes the county councils responsible for around 95% of the existing hospitals. Primary care is more privatized and around 40% of the primary care is delegated to private entities that are tied by contracts with the county councils [19]. On the other hand, municipalities are responsible for local functions e.g. schools. Child, elderly and disabled care are the responsibilities of the local municipalities [17,19]. 2

11 1.2.1 Stockholm County According to Stockholm County Council s website (available in Swedish) Stockholm County is composed of 26 municipalities kommuner [21]. The population of Stockholm County as estimated by Statistics Sweden Statstiska Centralbyrån (SCB) in 2013 as 2,163,042 which represents approximately 22.42% of the population in Sweden making Stockholm County the most populous in Sweden. Stockholm municipality has the highest population with 897,700 followed by Huddinge municipality with 102,557 [22]. The amount of primary care centers vårdcentraler in Stockholm County is 235 centers according to the search done using the national healthcare guide ( [23]. Stockholm County Council s website states that there are 7 emergency hospitals in the county which are: Danderyd hospital, Karolinska university hospital, Norrtälje hospital, Sankt Erik eye hospital, Sankt Göran hospital, Södersjukhuset (Stockholm South General Hospital) and Södertälje hospital [24,25] Uppsala County The Swedish Association of Local Authorities and Regions (SALAR) states that Uppsala County is composed of 8 municipalities (available only in Swedish) [26]. According to SCB, the population of Uppsala County is 345,481 which represents 3.58% of the population in Sweden. Uppsala municipality has the highest population (205,199) followed by Enköping municipality (40,656) [22]. Upssala County Council s website (LUL), states that there are 26 (The number represents both private primary care centers and county council owned ones) primary care centers all over the county in addition to 2 hospitals which are Akademiska university hospital in Uppsala municipality and Lasarettet hospital in Enköping municipality (only in Swedish) [27,28]. 3

12 1.2.3 Östergötland County Östergötland County is composed of 13 municipalities (only in Swedish) [29]. The population of the whole county is 437,848 representing 4.53% of the population in Sweden. Linköping has the highest population with 150,202 followed by Norrköping with 133,749 [22]. Searching for primary care centers in Östergötland using ( resulted in 44 primary care centers in the County [30]. Östergötland County Council s website (LIO) states that there are 3 hospitals in the county which are: Linköping university hospital, Vrinnevis hospital in Norrköping and Lasarettet hospital in Motala [31]. Figure 2: Stockholm, Uppsala and Östergötland Counties 4

13 1.2.4 EHRs in Sweden The adoption of EHRs in primary care dates back to the early 1990 s [19]. Although the adoption of EHRs in primary care started that early, it wasn t until the early 2000 s that hospitals driven by county councils began to use EHRs. According to the report National ehealth - the strategy for accessible and secure information in health and social care prepared and published in 2010 by the Center for ehealth Center för ehälsa and the Swedish Ministry of Health and Social Affairs, the National ehealth Strategy was developed in 2005 and adopted in 2006 [20]. The 2013 Ehealth in the County Councils yearly report by Lars Jerlvall and Thomas Pehrsson designates 4 main EHRs that dominate the Swedish market which are [31] (available in Swedish): COSMIC (By Cambio Healthcare Systems) Melior (by Siemens) TakeCare (By CompuGroup Medical, CGM) System Cross (By Evry) The same report also demonstrates the amount of users of each of these systems with respect to the amount of users (in primary care and hospitals) of EHRs all over the country (estimated at 223,548 users) which is as follows (highest to lowest) : 1. COSMIC: 26.7% (approx.60,000 users) 2. Melior: 25.9% (approx. 55,000 users) 3. TakeCare: 20.6% (approx. 45,000 users) 4. System Cross: 10.6% (approx. 25,000 users) 5

14 Figure 3: Percentage of users of the available EHRs in Sweden, 2013 (Adapted from the report Ehealth in county councils [31]) Comparing the Ehealth in the County Coucils report from 2012 [19] with the one from 2013 [31] regarding the percentage of users of the 4 dominant systems in the Swedish market we notice the following changes: Table 1: Comparison between the 4 dominant EHRs in Sweden in 2012 and 2013 Amount of users in 2012 (total Amount of users in 2013 (total 217,361 users) 223,548 users) 1. Melior: (27.6% or approx. 60, COSMIC: (26.7% or approx.60,000 users) users) 2. COSMIC: (25.8% or approx. 2. Melior: (25.9% or approx. 55,000 55,000 users) users) 3. TakeCare: (19.4% or approx. 40,000 users) 4. System Cross: (11.0% or approx. 25,000 users) 3. TakeCare: (20.6% or approx. 45,000 users) 4. System Cross: (10.6% or approx. 25,000 users) 6

15 The amount of users increased by 6,187 users from 2012 to 2013 (approx. 3% increase). The changes also show that Melior lost approx. 2% of its market share and at the same time both COSMIC and TakeCare gained 2% of the market share (approx. 1% increase in market share to each system) making COSMIC the system with the highest market share in Sweden. Cambio Healthcare Systems global website ( lists down the county councils in Sweden that use COSMIC as follows [32]: Jönköping County Council Uppsala County Council 1 Kronoberg County Council Västmanland County Council Värmland County Council Kalmar County Council Östergötland County Council 2 Jämtland County Council Figure 4: COSMIC (green) in Swedish County Councils Whilst COSMIC seems to be more widely spread in different counties, as of 2013, TakeCare has only 2 counties as customers which are [31]: 1 Included county in the study 2 Included county in the study 7

16 Stockholm County Council 3 Dalarna County Council Knowing the size, population and the amount of healthcare centers in Stockholm County though would easily clarify why TakeCare has the 3 rd position among the most dominant systems in Sweden. Figure 5: Takecare (yellow) in Swedish County Councils History of transitioning of EHRs in Stockholm, Uppsala and Östergötland A. Stockholm: There s no central decision from the County Council regarding TakeCare states the report (only in Swedish) prepared by the County council s auditors landstingsrevisorerna published by SLL in What the report mentions is that TakeCare gained ground gradually in Stockholm based on the feedback provided by the users which led organizations like Karolinska University Hospital 3 Included county in the study 8

17 to decide in July 2004 that TakeCare will replace all the other documentation applications that existed by then [33]. B. Uppsala The introduction of COSMIC in Uppsala County dates back to 2003 [34] when the LUL decided to introduce COSMIC in the whole County. By the time the decision was taken, some primary care centers had already been using EHRs, while Akademiska University Hospital had been using a paper-based documentation system (only in Swedish) [35]. C. Östergötland Since 2008, COSMIC has been the used system in both primary care and hospitals in the County [36]. The transition included primary care centers which had been using other EHRs and Linköping University Hospital which had paper-based documentation system (only in Swedish). [37] 1.3 Current state of the knowledge about EHR transitions There are many reasons for transitioning from legacy systems to new ones. Interoperability is one the most important ones that led many county councils to the decision of transitioning in order to facilitate sharing of information within the county [38]. Other possible reasons might be outdated systems, inability to support certain features by the legacy systems or even merging or separation of healthcare organizations. 9

18 The challenges related to transitioning to EHRs are not new. Healthcare organizations faced such challenges when transitioning from paper based systems to electronic based ones. Economic barriers in the form of high costs of purchasing vendor-supplied EHRs was regarded as one the major obstacles that adoption of EHRs was facing [47]. Attitudes towards EHRs among the users have always been a huge concern for decision makers when they decide to adopt EHRs. Studies have been conducted to investigate the reasons for the negative and resisting attitudes towards EHRs among healthcare professionals showed that reluctance to using pre-defined clinical guidelines (or what is referred to sometimes as cookbook medicine ), fear of new technologies and worries about patient-clinician relationship are among the reasons for the restating attitudes. The impact on workflow is one of the aspects that both decision makers and healthcare professionals expressed their concerns about when transitioning from paper-based to electronic-based record systems took place. Consequently, studies agreed that successfully managing the changes in workflow related to transitioning to EHRs would result in a successful implementation [48-50]. On the other hand, one of the factors leading to an unsuccessful implementation of an EHR in a healthcare setting were a paper-based system had been used is failure to digitalize the data in the paper health records. Described as a both time consuming and resource demanding process, digitalizing the legacy paper-based data either through manually entering them to the new EHR or through scanning the records (or parts of them) and making them accessible via the new system is a crucial process to avoid being dependent on paper documents after transitioning from paper records to EHRs takes place [47]. Although transitioning from legacy EHRs to newer ones in the previously mentioned counties and even other counties is not new, searching for studies that were done either during the transition itself or studying the effects afterwards 10

19 showed that such studies were lacking. Moreover, very few amount of studies worldwide which address transitioning from one legacy EHR to another exist compared to the amount of studies addressing transitioning from paper-based documentation systems to electronic-based ones [39-43]. This leaves many unexplored aspects that are related to transitioning between two EHRs. One of the explored aspects was safety. Performed between 2008 and 2009 in an ambulatory clinic with 17 participants (physicians), the study highlights that transitioning between two EHRs may result in some safety threats and recommends further studying and understanding of such threats [40]. Very similar results were shown by another study conducted in 2009 and included 19 physicians in an ambulatory clinic that tried to study the physicians experiences not only regarding safety issues, but also their attitude towards the new EHR. In addition to expressing that the new EHR didn t improve the safety, the participants showed somewhat negative attitudes towards the new EHR due to its complexity [39]. Trying to investigate the satisfaction among users on a wider scale (at 6 ambulatory clinics with 197 participants) after transitioning between two EHRs, there was a slight degree of satisfaction with the transition mostly owed to the satisfaction with the new features that the new EHR offers compared to the old one. The same study shows that there was also a considerable degree of dissatisfaction which the study owed to being dissatisfied with certain features and inability to complete certain tasks using the new EHR [42] As noticed, the previously mentioned studies concentrate only on ambulatory settings. This makes up for even fewer studies that have hospitals in scope. In an attempt to investigate the expectations of hospital staff when transitioning from a CPOE (not a full EHR) to a new EHR, the attitudes and expectations of the 11

20 hospital staff were generally positive (with the exception of nurses who showed less positive attitude) [44]. Moving on to an even wider scope, decision makers were included in another study that aimed at describing the plans and decisions made while transitioning from a legacy system to a new one which showed that there are many challenges related to transferring the data from the legacy EHR to the new one due to the differences in how both systems are structured [41]. The previously mentioned studies concentrated on the aspects of one group only at a time (either decision makers or users). A study that combines the aspects of both groups was not found. Vendors were also not present in the previously mentioned studies as participants which leaves the perspectives of an important group that is involved in the transitioning processes unexplored. 1.4 Study aims and objectives The aim of this study is to highlight the different approaches by which the information in the legacy systems are dealt with when transitioning from legacy EHRs to newer ones, opening up the doors for more in-depth studies of the effects of using such approaches and even studies about the transitioning process itself. There are many aspects to be studied in this newly explored field. Therefore the existing patient information in the legacy systems was chosen as the main aspect of this study as there s a little that s known about this very important aspect. To be able to fulfill the aim of this study, the following objectives have been addressed: Investigating whether the existing data in the legacy EHRs are transferred to the new ones or not. Understanding the different plans by decision makers to handle the data in the legacy systems 12

21 Investigating the users opinions regarding how the data in the legacy systems were and should be dealt with Based on the aims and objectives of this study, the main research question is How were the existing patient information in the legacy systems dealt with when transitioning to new EHRs? Two sub questions are also to be addressed in order to meet the study aim and objectives which are What were the strategies that the 3 counties adopted regarding the legacy data? What are the users opinions regarding those strategies and their vision of an ideal one? 2 Method 2.1. Research Methodology Exploratory research was chosen for this study due to the following factors: Few studies addressing the same topic have been conducted Ability to test different hypotheses Exploratory research provides a better understanding of the problem(s) rather than offering a solution/solutions which suits the fact that this is a newly explored field The following goals were set as the ultimate benefit of deploying exploratory research in this study 13

22 Gaining background knowledge about the field of transitioning between two EHRs Providing a better insight on the feasibility of similar or related future studies Highlighting the importance of further studies in the field When planning for this study took place, several hypotheses regarding the strategies (or solutions) that the selected counties used in order to deal with the legacy data were discussed. Using exploratory research allowed the author to test those hypotheses and even develop new ones throughout the course of the study. As the study continued, more refining of the objectives of the study were obtained resulting in more concrete research question(s) that were to be answered. The amount of participants in the study wasn t high, but in alignment with the study aims and objectives would help to test the feasibility of similar future studies and open the doors to new ones in this field. The research methodology can be defined as The way to systematically solve the research problem. This could be also interpreted as the different steps that are followed in order to understand and solve the research problem(s) [45]. Based on the aims and objectives of the study, the steps that were followed are: Ground information In this step, scientific databases, particularly PubMed and SpringerLink, and in very rare cases Google Scholars were used in order to: Obtain more information about EHRs (usage, implementation and effects on various aspects of healthcare) 14

23 Find similar or related studies that directly or indirectly handle the topic of transitioning from one EHR to another Since the study is done in 3 Swedish counties, official Swedish authorities databases (illustrated in the table below) and healthcare portals were searched in order to obtain documents and information about: Administrative divisions in Sweden Swedish counties in the scope of the study Healthcare system in Sweden Primary care centers and hospitals in the counties in scope Vendor-supplied EHRs in the Swedish market and their distribution History of the transition of EHRs in the counties in scope Table 2: Official Swedish authorities names and websites Acronym Authority s Name Website SLL LUL LIO SALAR (English Abbreviatio n) SCB 1177.se Stockholm County Council Stockholms Län Landsting (Swedish) Uppsala County Council Landstinget i Uppsala Län (Swedish) Östergötland County Council Landstinget i Östergötland (Swedish) Swedish Association of Local Authorities and Regions Abbreviated to SKL (Sveriges Kommuner och Landsting) (Swedish) Statistics Sweden Statistiska Centralbyrån (Swedish) Care Guide Vårdguiden (Swedish)

24 CeHis (now called Inera) Center for ehealth Center för ehälsa i Samverkan (Swedish) mentarkiv/ Complementary information was also obtained from the respective vendors official gateways about: The market share and distribution of EHRs in Sweden History of the transition of EHRs in the counties in scope Interviews Owing to the facts that this study is not concentrating on one particular healthcare organization (hospital or primary care center) within a particular county but rather having a wider scope (on the level of county councils) and that the chosen topic to address in terms of the transition itself is existing patient information in the old systems as a whole (not one particular module e.g. medication, vaccination, lab results, notes, patients personal information etc.), two categories of people to be interviewed were identified: IT personnel from the county councils sides who led/took part in the whole project of transitioning from the legacy to the currently existing (new by then) EHRs Project/team leaders from the respective vendors sides who led/took part in the transition from the legacy systems to their own products The level on which this study is conducted, nature of the research question (being qualitative than quantitative), desired in-depth information from decision makers and the flexibility that semi-structured interviews provide, all contributed to picking semi-structured interviews for this stage [51] 16

25 Questionnaire To be able to fulfill the objective of investigating users (Although there are different categories of users who use EHRs, for the purpose of this study, users are only limited to doctors (residents and specialists) and nurses (regardless of specialty)) opinions regarding the transition with respect to how the patient information was dealt with, constructing and sending out a questionnaire was chosen as the next step following the interviews. Whilst interviews provide more in-depth information about a certain topic, questionnaires provide answers from a wider scale of respondents that are difficult to cover using interviews given the same period of time Research Approach Provided the aims, objectives and research question(s), qualitative research [52] was chosen as the approach of choice. The main scope of the study is to describe how the information in the legacy systems were dealt with before, during and after transitioning to new ones through describing the different solutions and decisions made by the 3 county councils regarding the patient information that existed in the legacy systems. In addition to that, providing an insight on the defined users groups opinions regarding those solutions and their vision of optimal solution/solutions. This means that the amount of information itself is out of the scope of this study which clarifies why qualitative rather than quantitative research is suitable for this study Study Setting Context Properties A. Stockholm 26 municipalities 2,163,042 inhabitants 235 primary care centers (private and county-owned) 7 county-owned hospitals 17

26 TakeCare is the dominant system in the county Transition to TakeCare started in early 2000 s and ended in 2007 B. Uppsala 8 municipalities 345,481 inhabitants 26 primary care centers (private and county-owned) 2 county owned hospitals COSMIC is the dominant system in the county Transition to COSMIC started in 2003 and ended in 2008 C. Östergötland 13 municipalities 437,848 inhabitants 44 primary care centers (private and county-owned) 3 county owned hospitals COSMIC is the dominant system in the county Transition to COSMIC started in 2005 and ended in Data Collection Tools Semi-structured Interviews Guiding questions A list of guiding questions composed of seven questions were prepared and reviewed prior to conducting any of the interviews. The questions were saved into a Google document and were checked before and during conducting the interviews (same file for both categories). Since the interviews were conducted in a semi-structured fashion, not all the prepared questions were used while 18

27 conducting the interviews and some questions were created and adapted on the spot based on the answers of the interviewees. The questions were prepared in English at first, but were translated to Swedish to be able to use them during the interviews as all the interviews were conducted in Swedish. The questions were reviewed and refined by the author s supervisor before using them. Figure 6: Screenshot taken from Google Docs showing the prepared interview questions Identifying and connecting with the interviewees Convenience sampling was used to be able to identify the people to be interviewed from both categories, s were sent to the respective county councils and the vendors briefly describing the author s background, the study, its aims and objectives and the characteristics of the desired people to be interviewed. A list of names and addresses of the people fulfilling the characteristics of interviewees from both categories was obtained and the identified people were contacted which led to scheduling of the interviews. 19

28 Description of the participants Different county councils have different strategies when it comes to the transitioning process. Whilst in Stockholm the transition was done gradually and on different levels, in both Uppsala and Östergötland it was a central county council decision that lead to the transition which led to the existence of one distinct project in each of Uppsala and Östergötland counties to plan and operate the transition. Consequently, a main project leader for each project existed in those counties. In Stockholm County, more than one project leader existed to work on more specific processes related to the transition. On the other hand, vendors work in teams without assigning one particular project leader for each distinctive transition. These factors led to using the previously mentioned categories as the selection method for the interviewees who are represented in the following table: Table 3: List of interviewees, their roles and their current positions County Organization Role during transition Current position Östergötlan d LIO Project leader Business Area Manager IT Center in Östergötland County Council Uppsala LUL Project leader IT Manager and Strategist in Uppsala County Council Stockholm SLL Project leader IT Management Leader Stockholm County 20

29 Council Administration Stockholm Stockholm Doesn t apply Doesn t apply SLL/Karolinska Hospital Team leader Management Leader Ehealth and strategic IT at Karolinska University Hospital SLL/Karolinska Team leader System Manager Hospital Ehealth and strategic IT at Karolinska University Hospital Cambio Team leader Business Developer at Healthcare Cambio Healthcare Systems Systems, Sweden CGM Team leader Implementations Specialist at CGM, Sweden Conducting the interviews A total number of 7 interviews were conducted with both categories under the period of March and April No particular category was contacted and interviewed during a particular period, but interviews with both categories were done simultaneously under the designated period. All the interviews were conducted in Swedish which makes it easier for the interviewees to speak freely about the projects they were involved in without worrying about the language barrier since they are more used to using Swedish terms and phrases on a professional level rather than English ones. This also contributes to getting more valid and deeper information. 21

30 A total of 6 interviews were conducted face-to-face in the offices of the identified people. One interview was conducted on the phone based on the request of the interviewee. All the seven conducted interviews (either face-to-face ones or the one on the phone) were digitally recorded and stored using a mobile digital recorder and the obtained files were stored locally on the mobile device in addition to sending a copy to the author s computer which was also backed-up using the cloud service Dropbox. The interviewees were orally asked before conducting the interviews themselves for permissions to record the conversations on the conditions of using the recorded files only for the purpose of the study and they all orally agreed to that. The period of each interview varied between 30 minutes and 60 minutes Questionnaire Construction of the questionnaire Early in April 2014, a questionnaire composed of 6 questions was prepared using Google Forms for reviewing. All parts of the questionnaire (description, purpose, questions and guiding hints) were prepared in Swedish and were reviewed by a native Swedish speaker for grammatical and contextual errors. A 7 th question was added later on after receiving supervisor s feedback. The questionnaire starts by giving the respondents a brief description of the study, its aims, objectives and that the received data would be used as part of that study. The description is followed by 4 user-related information blanks which are to be filled by choosing only one of the pre-provided choices. All the four blanks are mandatory to fill out using only the provided choices in order to proceed with the 22

31 rest of the questions and consequently submit the answers. These are illustrated in the following table: Table 4: User-information blanks and the respective provided choices Blank Provided choices Actual Participants County Stockholm Uppsala Östergötland Age Group Under Gender Male Female Profession Specialist (doctor) Resident doctor Nurse The seven questions that follow the user-information blanks were (with the exception of questions number 4 and number 6) mandatory to answer which means that the respondent must pick an answer/answers to each of the 5 questions in order to be able to submit the answers. The questions and the provided choices and hints are illustrated by the following table: Table 5: Constructed questionnaire translated to English Question Type Answers 23

32 1. How long had you been using the legacy EHR? * Hint: Only consider the system you had had exactly before the transition 2. How long have you been using the new EHR? * 3. Do you still use the legacy system (e.g. via a portal) to get information about the patients? * 4. If you answered yes to the previous questions, what is/are the type/types of information that you search for using the legacy EHR? Hint: Check all the categories that apply 5. When transitioning between legacy and new EHRs takes place, how do you Categorical scale Categorical scale Categorical scale Checklist Categorical scale Less than one year 1-2 years 2-5 years 5+ years Less than one year 1-2 years 2-5 years 5+ years No Yes, once a month Yes, once a week Yes, at least once a day Patient personal information Referrals Notes Lab results Medication Warnings Other (activates a blank for the respondent to list down the other category/categories that he/she searches for) Everything must be transferred (from the legacy to the new system) Chosen information 24

33 think the information in the legacy system should be dealt with? * 6. If you picked the choices that is marked with ** in the previous question, can you specify the 3 most important information categories that you would like to be Checklist categories must be transferred ** Somebody should manually write a summary of the most important information in the new system Use both systems (the legacy system to read information and the new one to input new data) at the same time during a defined period of time Get access to the information in the legacy system via a portal that connects it with the new system Nothing is to be transferred and it s better to start with an empty health record Patient personal information Referrals Notes Lab results Medication Warnings Other (activates a blank for the respondent to list down the other category/categories that he/she thinks is/are 25

34 transferred? Hint: Only check 3 boxes! 7. Have you experienced that your workgroup influenced the decision of how the information was dealt with when the transition took place?* Multipoint scale important ) The scale starts from 0 which is tagged No influence up to 5 which is tagged Huge influence Questions marked with (*) mean that they are mandatory Administration of the questionnaire and recruitment of participants After finalizing the questionnaire based on the received feedback, it was ready to be sent out. There were 3 conditions upon which the participants were eligible to take part in the study which are: Being a licensed doctor (resident or specialist) or a registered nurse from any department who works in a healthcare organization (primary care center or a hospital in one of the counties of Stockholm, Uppsala or Östergötland Had used the legacy system for at least a period of less than a year up to more than 5 years Having used the new system for at least a period of less than a year up to more than 5 years 26

35 Obtaining a list of users who fulfill these conditions was extremely difficult owing to the facts that the study doesn t take place at any particular healthcare organization (hospital or primary care center) within the counties in scope, but rather includes the ones which performed the transition from the legacy to the new EHRs and that the situation of some of the private primary care centers was unclear in terms of which EHRs they use/used and whether they performed a transition or not (unlike the ones run by the county councils) The questionnaire was designed to allow only the users who fulfill the previously mentioned conditions to participate in the study through limiting the answers of the questions about profession, duration of the legacy system usage and the duration of the new system usage to definite choices that are identical with the desired participants characteristics and making these questions mandatory to answer in order to submit the responses. To be able to administer the questionnaire, the following steps have been followed: Using the Swedish Care Guide (1177.se) portal in order to obtain some addresses of the primary care centers in Stockholm, Uppsala and Östergötland Using the respective county councils websites which in many cases host homepages of the primary care centers run by the county councils to obtain contact information of the primary care centers Using a provided mailing list that is composed of resident and specialist physicians in General Medicine and Emergency Care Contacting the Swedish Medical Association to help send out the questionnaire These steps resulted in sending out the questionnaire to the recipients described in table 6: 27

36 Table 6: List of recipients of the questionnaire Stockholm Uppsala Östergötland 67 primary care centers (25 private primary care centers and 42 primary care centers run by Stockholm county council) 68 physicians in General Medicine in the Western suburbs of Stockholm 38 physicians in Emergency Care, Söder Hospital (Södersjukhuset) 11 physicians in General Medicine, Danderyd Hospital (Danderyrds sjukhus) 10 private primary care centers 24 General Medicine specialists 4 primary care centers Together with the link leading to the questionnaire, the s sent out to the formerly mentioned organizations/people contained a brief introduction of the author, study, the type of users that the questionnaire is directed to (doctors and nurses who had the used the legacy EHR and have been using the new one) and a request to share the questionnaire with other colleagues that they think fulfill the conditions of participating in the study. (See Appendix A for these documents) The respondents had to answer the questions and enter the required personal information as described before and then press submit. Provided that all the mandatory questions and blanks were filled, the submission would take place and the respondents would receive a confirmation message saying Your response has been submitted. No further information such as results were displayed to the respondents after the submission. 28

37 The identities of the respondents and their contact information ( s, phone numbers etc.) were not recorded or saved to keep the questionnaire anonymous Data Analysis Semi-structured interviews The seven recorded interviews were transcribed. The first 3 interviews were transcribed directly after conducting and recording them while the other 4 were transcribed at a later stage. Transcriptions were written by the author in English directly from the recorded sound files in Swedish. Online translating tools were used in order to get the accurate translations of some of the words that were difficult to translate. The transcriptions were then further analyzed to find patterns that are to be used as material for the results of this study. This means that writing the transcriptions and analyzing the data took place between late March and early May Questionnaire The data obtained from the respondents were exported automatically to an Excel sheet created via Google Spreadsheet which was synced and connected to the questionnaire so that once the respondent submits his/her answers, the answers 29

38 were added to the excel sheet. The author was notified via once any new submissions were done which allowed the author to check and validate the added answers as soon as they were submitted. Response rate was difficult to calculate due to the fact of lacking the amount of eligible users that the questionnaire reached to. As from the 28 th of April 2014 until the 14 th of May 2014, the number of received responses was 53. The obtained data were continuously checked and validated from the time of administration until no more submissions were accepted and analyzed by categorizing the received data using the available tools in Google Spreadsheet which allow the author to view the results (as a whole or selected categories) in graphical representations. (For more information about the used software throughout the different stages of the study, please check Appendix C) 2.6. Ethical Considerations Patient data were not obtained, used or even included in this study. The participants in this study didn t receive and weren t promised any forms of compensation in return for being interviewed or for responding to the questionnaire. Relevant information about the study was presented to the interviewees when they were approached to schedule the interviews and more detailed information was presented orally before conducting the interviews. The questionnaire respondents also received information prior to their participation both in the invitation and in the introduction to the survey. All the participants (either interviewees or questionnaire respondents) were not given any information about the data obtained from one another in order to ensure more neutral and objective obtained information. The study doesn t by any means try to reflect on any differences between the commercially available EHRs in Sweden (either the currently used or the old 30

39 ones). No comparisons between individuals opinions when it comes to the systems themselves were discussed in this study either with the decision makers or the users. The reasons for picking one commercially available system to another are also not a subject of this study. No funding or compensations were received from any organizations in return to including them in the study. The facts that Sweden has a very competitive market and that there are many players in EHR market in Sweden required that some of the obtained data that could be associated to the vendors were not included in the study. The identities and contact information of the seven interviewees were not revealed here, but can be revealed upon a clarified request. The identities of the respondents to the questionnaire were hidden due to the anonymous nature of the questionnaire. Their identities cannot be revealed for any reasons. 3. Results 3.1. Approaches to information handling in transitions between EHRs This section is concerned with the different approaches by which the 3 counties in scope decided to handle the information in the legacy system and the reasons behind the decisions 31

40 To avoid any unnecessary comparisons between the approaches of the 3 county councils and to avoid any system-related associations with the chosen approaches, the results in this section are displayed together without categorizing them based on the county Decision makers The question of how to deal with the information in the legacy systems is brought up early upon making the decision to change the EHR systems. Prior to the implementation of the new system, a decision/decisions regarding how to deal with the patients information that existed in the legacy system is/are made. The decision(s) is/are made by individuals from the respective county council supported by internal (from the county council and/or the healthcare organizations run by the county council) or external consultants. We only provide advice when needed, but it s purely the county council s decision how to deal with the information in the old system said one of the interviewees who works for one of the vendors. This was also confirmed by the other interviewee from the other vendor who also added We work closely with the county councils, but we don t make decisions on their behalf. This implies that vendors comply to the plans made by the county councils regarding how the information in the legacy systems are going to be dealt with before, during and after the implementations of the new systems. There are some major factors that influence the decisions: Economical Time-related Staff-related 32

41 Technical The choice of a certain vendor is not at all a factor that influenced the decisions Types of Decisions/Approaches A. Using the two systems at the same time This was done through extending the license of the legacy system to a certain period, often several years that extends beyond the implementation and start of usage of the new system. That allowed the users of the EHRs to have access to both the legacy and the (by then) new systems on the conditions of using the legacy system to view the information they required and use the new one to input new data. B. Exporting some/all of the data in the legacy system to a database The exported data are accessible through a gateway (link) that connects the database to the new system so that when and if a patient s information existed in the old system, it d be accessible to the user of the EHR in the newly formed and stored record in the new EHR via that link. C. Manual data entry Manual data entry could be regarded as either an approach itself or a consequence of choosing one of the previously mentioned approaches. Manual data entry as an approach itself was applicable when none of the previously mentioned approaches were followed. This meant assigning particular individuals in the healthcare organizations under a definite period of time to 33

42 manually re-enter some of the information that existed in the old system to the (by then) totally empty new system. Upon choosing either A or B approaches, manual data entry is regarded as a consequence or a complementary step to either choices by which the users of the new EHR would copy and manually enter some of the data that were relevant to them from the legacy system or the database to which the data from the legacy system were exported to the respective records in the new system No Automated Data Transfer It is extremely difficult to do an automatic data transfer replied one of the interviewees from the one of the vendors when asked about the possibilities of an automated transfer. The same person owed the difficulty of applying automatic data transfers to the architectural differences between the old and the new systems. To demonstrate the difficulty of doing an automatic transfer, the interviewee said that they were working on performing a transition from an old system to a new one both owned by the same vendor and even with that, an automated transfer was very difficult because of the architectural differences between the two systems. Architectural differences don t allow for automatic transfers confirmed the other interviewee from the other vendor who attributed this as the main obstacle to performing such procedure Why automated data transfers are difficult Investigating whether automatic data transfers are difficult or impossible to perform led to realizing that although architectural differences between the legacy 34

43 and the new systems stand against automatic transfers, there are some other procedures to be done in order to avoid manual data entries. An example of how manual data entries could be avoided was to export all the data from the legacy system to a database and importing the data from that database to the new system. As much as it sounds simple, this is difficult to achieve. Why wasn t/isn t this applied? asked the interviewer It requires a lot of skilled programmers, time and money which are not easy to obtain added the interviewee Users experiences and opinions of the transition strategies A total of 53 responses were received from the beginning of receiving responses on the 28th of April 2014 until no more responses were accepted on the 14th of May The number of daily responses is represented in the following diagram: 35

44 Figure 7: Number of daily responses Respondents characteristics The 53 respondents were divided among 3 groups according to their professions which are: specialists (doctors), resident doctors and nurses. The number of respondents from each group was as following: 16 specialists (30% of the respondents) 15 residents (28% of the respondents) 22 nurses (42% of the respondents) Figure 8: Number of respondents from each professional group 37 of the respondents (70%) were females and 16 (30%) were males 36

45 Figure 9: Female to Male respondents The most dominant age group among the respondents is making up 34% of the respondents followed by 60 + and (23% each). The number of respondents according to the predefined age groups is presented in table 7 (arranged in a descending order): Table 7: Respondents age groups Age group User(s) Percentage % % % % Less than % Respondents experiences with the legacy and the new systems The amount of time which the respondent users (from all the 3 categories) had used the legacy system is presented in table 8 (arranged in a descending order according to the number of users per category): 37

46 Table 8: The amount of users with respect to experience with the legacy system Year(s) User(s) Percentage % % % Less than 1 year 5 9% The amount of time which the respondent users (from all the 3 categories) used/have been using the new system is presented in table 9 (arranged in a descending order according to the number of users per category): Table 9: The amount of users with respect to experience with the new system Year(s) User(s) Percentage % % Less than a year 8 15% % Usage of the legacy system The respondents were asked if they still used the legacy system to get information about the patients and 13 respondents (25%) answered No. The rest of the respondents (75%) answered Yes which means that they still use the legacy 38

47 systems to obtain information about the patients. The respondents were also asked to specify how often they used the legacy systems from 3 given choices which were: once per month, once per week or at least once a day. The periodicity by which users check the legacy systems is presented in table 10: Table 10: Periodicity of usage of the legacy systems by the respondents Answer Number Percentage Once per month 17 32% Once per week 12 23% At least once a day 11 21% Figure 10: Respondents using/not using the legacy systems The respondents (who said that they still use the legacy systems) were also prompted to specify the type(s) of information they try to obtain from the legacy systems. They were given 6 predefined choices in addition to a 7 th choice that allows the respondents to specify other type(s). The respondents were allowed to check one or more of the provided choices. This resulted in: Table 11: Information that is searched for using the legacy systems by the respondents 39

48 Type of information Number of picks Notes Personal Information 14 Referrals 24 Notes 35 Lab Results 24 Medication 30 Warning 15 Other 3 ECG (Electrocardiogram) Figure 11: Checked information categories by the respondents in contrast with each other Respondents opinions regarding how the information in the legacy systems should be dealt with upon transition to new ones The respondents were given 6 choices to pick only 1 from. The choices were based upon the solutions that the county councils already used in addition other relevant solutions. Whilst 0 users picked the choice of Nothing is to be transferred and it s better to start with an empty health record, the proposed 40

49 solutions were picked in the following manner (arranged in descending order according to the amount of users): Table 12: Respondents choices from the proposed solutions Solution Amount of Users Percentage Chosen information categories 16 30% must be transferred Get access to the information in the legacy system via a portal that connects it with the new system 16 30% Use both systems (the legacy system to read information and the new one to input new data) at the same time during a defined period of time 11 21% Everything must be transferred (from the legacy to the new system) 6 11% Somebody should manually write a summary of the most important information in the new system 4 8% The respondents were also asked to specify the 3 most important types of information that they think should be transferred from the legacy systems to the 41

50 new ones (based on selection the choice Chosen information categories must be transferred which was chosen by 30% of the respondents). Medication and warning were the highest picked by 26 % and 23 % of the respondents respectively. Responses arranged in descending order according to the amount of the users picking them were as following: Table 13: Respondents choices of the types of information that should be transferred from the legacy to the new systems Type of information Amount of Percentage Notes users Medication 23 26% Warning 21 23% Notes 14 16% Lab Results 13 14% Personal Information 7 8% Other 5 6% Assessment, ECG, Acute Notes, Epicrisis Figure 12: Chosen information types in contrast with each other 42

51 Influence on the already done transitions A question on how the respondents felt regarding their influence on the transitions that took place in their respective workplaces was asked and the respondents were given a scale ranging from zero (no influence) to 5 (huge influence). Whilst 1 user picked the highest number in the scale (5 huge influence ), a total of 32 users picked the lowest number in the scale (0 no influence ). According to the respondents, their influence was as following: Table 14: Respondents influence on the already done transitions Users Percentage 60% 19% 8% 9% 2% 2% Figure 13: Influence of respondents on the performed transitions 43

52 4. Discussion Planning how the information in the legacy systems is dealt with is an integral part of planning the whole transition. The three included counties had different approaches on how to deal with the information. The reasons for picking different approaches are owed to economical, technical, time-related or staff-related reasons. Whilst legacy data were not ignored or gotten rid of when transitioning took place, some of the legacy data were not transferred to the new EHRs Strategies to deal with the legacy data Three main approaches were found: Using the two systems at the same time during a certain period Exporting some/all of the data in the legacy system to a database Manual data entry With the third option (manual data entry) being also a complementary stage of using the other two approaches in order to re-enter the required missing (but relevant) data in the newly structured records in the new systems, it can represent a burden to some of the users of the EHRs, knowing that they would have to check another resource of information, try to retrieve the data that they require and then input it into a system that is relatively new to them. In this material, essentially no information was transferred automatically other than list of patients and a parallel use for a long period dominates as the solution with very little being manually entered. Automatic data transfer was in this material claimed to be infeasible due to the product related differences of the architectures of the systems [41] and the fact that trying to do automatic transfers using other possible methods as exporting the 44

53 data to a database and importing it to the new system could be difficult and expensive. The product related differences are hard to control by the county councils or even by the vendors themselves because different generations and origins of systems development has led to architecturally diverse systems. However, possibly future systems using standard EHR architectures for the information using archetypes may give some hope that automatic data transfers could be developed and performed EHR users perspectives The respondents to the questionnaire were experienced users who had spent much time using the legacy EHRs (55% of the users had used the legacy systems for more than 5 years and 21% of them had use the legacy systems for 2-5 years), the users who have been using the new systems are also experienced users (40% have been using the new systems for more than 5 years and 43% have been using the new systems for 2-5 years). Also, the transitions in all the 3 counties were not recently performed but several years back so the expressed opinions are quite mature. It is noteworthy that as many as 75% of the respondents still use the legacy systems to obtain information about the patients and that 21% of them do this on daily basis. There is therefore obviously a need for the legacy data that was not transferred. The types of information the participants seek in the legacy systems varied a lot between the respondents with very slight dominance of Notes with 24% followed by Medication with 21% and then Lab Results and Referrals with 17% each. The existence of mixed sought information categories without a highly dominant one can be attributed to the fact that different user categories (nurses, residents and specialists) which responded to the questionnaire might have 45

54 different priorities in terms of the needed information, but it also implies that all the previously mentioned categories of information in the legacy systems are still valuable to the users in contrast to each other. Having been asked about how they think the information in the legacy systems should be dealt with upon performing transitions to new ones, the respondents gave quite mixed answers to the preferred approaches. All the respondents agreed that starting with an empty new EHR isn t at all a preferred approach which was demonstrated by 0 users choosing the option Nothing is to be transferred and it s better to start with an empty health record. Apart from that, there was an equal amount of users (with 30% each) who preferred that chosen information categories should be transferred from the legacy to the new systems or having access to the legacy system using a portal in the new system. 21% of the respondents preferred the option of using both the legacy and the new systems at the same time for a certain period of time. Keeping in mind that the options of either having access to the legacy system via a gateway in the new one or using both systems at the same time for a certain period imply that users prefer having access to the legacy systems while working with the new ones. Only 11% preferred the option of transferring all the data from the legacy to the new systems. This might be attributed to the awareness of the users of the difficulties in performing that and/or the availability of other more feasible choices in the questionnaire or maybe that the users don t want a lot of unnecessary information in the new systems which would make it more complicated to use the new systems. A very limited number of respondents (8%) preferred the choice of summarizing the most important contents in the legacy systems and transferring those summaries to the new ones. Having different priorities in terms of the most important required information, it is understandable that this solution could be regarded as an unpractical for many users. Moreover, doing this during the transition is extremely difficult as suggested by an earlier study [41]. 46

55 Once again, mixed preferences when it comes the 3 most important categories that the respondents who picked the option of chosen information categories should be transferred from the legacy to the new systems is noticed. Medication was regarded as the most important (26%), followed by Warning (23%) while Notes come in the 3 rd place (16%). The rest of the categories received also noticeable amounts of picks which also implies that different user categories have different priorities in terms of relevant information for them. A study showed that there was a slight tendency of satisfaction among the users of the new EHR and attributed that to the new features in the new EHR compared to the old one and highlighted that the users who were dissatisfied had problems completing certain tasks using the new EHR [42]. Including users of the EHRs in the transition process is extremely important not only for the acceptance of the new systems, but also for acceptance of the provided solutions. When asked about the degree of influence they had on how the information was dealt with when the transition took place, 60% of the respondents expressed that they had zero influence on that and only 4% expressed having slightly high or huge influence on it. The mixed opinions regarding how the information should be dealt with according to the users can also confirm that they didn t have much influence on the whole process. Study Limitations Although much information was obtained from the decision makers in the county councils and the relevant personnel working for the vendors, more interviews with people from both categories would have given a richer in-depth insights on the transition processes and how the information was dealt with. 47

56 Guiding questions were used to conduct the interviews, but it was difficult to receive answers to many of them owing to the facts that relatively long time had passed since the transitions had been performed which makes it difficult to remember the exact dates of initiating and executing the transitions and that in Stockholm County in particular, the transitions were done gradually and not in a centralized manner (as in Östergötland and Uppsala). Moreover, some key actors who took part in either planning or executing the transitions particularly from the vendor s sides weren t available as they no longer work for the respective vendors. Investigating the reasons upon which the choices of the selected approaches by each county council were made could have contributed a lot to the study, but that requires a lot of decision makers to be involved in the study which was not feasible given the limited amount of time. Inability to identify the amount of users who used both the legacy and the new systems in all the 3 counties was also another drawback that contributed to diffusely sending out the questionnaire and allowing the recipients to be filtered through the questionnaire itself. If the users had been identified, more answers in general and more specific data (e.g. specialty-related data) would have been obtained. Interviewing the users would have also contributed to identifying more concrete reasons for choosing the preferred approaches. One of the major reasons for choosing 3 different counties which switched to 2 different popular commercial EHRs was the possibility of generalizability of this study. Having received limited amount of interviews and responses to the questionnaire puts this possibility at stake, yet doesn t cancel the fact that the study provides a step forward in terms of exploring the field of transiting between two EHRs. 48

57 Finally, lacking enough time and resources to perform such relatively big study contributed to limitations regarding the used methods. Future Research The results from this study represent a very small step towards exploring different aspects that are related to transitioning between EHRs. A qualitative study that includes the users who used the old systems and are currently using the new ones by which more in-depth information could be obtained through conducting interviews with them to gain more understanding about the information categories that are important for them and their visions of the ideal ways by which patient information should be dealt with when such transitions take place. One of the most interesting methods to be potentially used is Impact Assessment [46] where the transition process itself would be followed while being performed and an assessment before and after the transition would be made regarding one or more aspects such as the users attitudes and the ways the transition and how the information was dealt with affect different aspects related to the provided service (safety, timeliness, quality, efficiency) and even the healthcare providers workflows. The need for studies concentrating on different organizational aspects and change management related to the transition is high and this was experienced during conducting the interviews with the decision makers from the county councils who always tried to highlight the different organizational aspects affected by the transition and how they tried to manage them. 49

58 5. Conclusions This study had the aims of understanding how the data of the legacy EHR systems are dealt with when transitioning from such systems to new ones and to investigate the users opinions regarding the same issue. Decision makers from three Swedish county councils were interviewed together with personnel from the corresponding EHR vendors. User opinions from nurses, resident doctors and specialists were collected using a web based questionnaire. Three different approaches were identified for dealing with the information in the legacy systems with a period of several years of parallel access to the legacy system was the dominating approach with no automatic transfer of data and very limited manual data entry of legacy data. With more clients becoming in need of replacing their old EHRs, clients and vendors need to work together for developing solutions to deal with the data of the legacy systems since a majority of the users actually think there are several important types of data that should be available after transition. Users have mixed and different preferences when it comes to how they see the information in the legacy systems should be dealt with and at the same time feel that they have no or very little influence on the decisions on how to deal with the information. This requires more attention from the decision makers who should include users (not only the IT enthusiasts) when making such decisions. It is definitely clear that more studies in this field are required in order to understand the effects on health care quality and patient safety of such transitions without the legacy data in different types of healthcare services. 50

59 References: 1. Kristiina Häyrinen, Pirkko Nykänen, Saranto K. Definition, structure, content, use and impacts of electronic health records: A review of the research literature Mar 12 [cited 2014 Mar 12]; 77(5):[ pp.]. Available from: 2. Hillestad R., Bigelow J., Bower A., Girosi F., Meili R., Scoville R., et al. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs2005; 25(5):[ pp.]. Available from: 3. Menachemi N., Collum T. Benefits and drawbacks of electronic health record systems2011; 2011(4):[47-55 pp.]. Available from: 4. Menachemi N., Brooks RG. Reviewing the benefits and costs of electronic health records and associated patient safety technologies2006; 30(3):[ pp.]. Available from: 5. Hassol A., Walker JM., Kidder D., Rokita K., Young D., Pierdon S., et al. Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging Aug 6; 11(6):[ pp.]. Available from: 6. Mold F., Ellis B., de Lusignan S., Sheikh A., Wyatt JC., Cavill M., et al. The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol.2012; 20(4):[ pp.]. Available from: /art00009?token=004813a3c3c573d e2f f7c74417c 4e75477e b642738e30. 51

60 7. Bates DW., Teich JM., Lee J., Seger D., Kuperman GJ., Ma'Luf N., et al. The impact of computerized physician order entry on medication error prevention1999; 6(4):[ pp.]. Available from: 8. Walsh KE., Landrigan CP., Adams WG., Vinci RJ., Chessare JB., Cooper MR., et al. Effect of computer order entry on prevention of serious medication errors in hospitalized children2008; 12(3):[421-7 pp.]. Available from: 9. Kaushal R., Shojania KG., Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Archives of Internal Medicine [Internet]. 2003; 163(12):[ pp.]. Available from: Goetz Goldberg D., Kuzel AJ., Feng LB., DeShazo JP., Love LE. EHRs in primary care practices: benefits, challenges, and successful strategies2012; 18(2):[48-54 pp.]. Available from: Bates DW., Kuperman GJ., Wang S., Gandhi T., Kittler A., Volk L., et al. Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality2003; 10(6):[ pp.]. Available from: Cresswell K., Majeed A., Bates DW., Sheikh A. Computerised decision support systems for healthcare professionals: an interpretative review2012; 20(2):[ pp.]. Available from: Bright TJ., Wong A., Dhurjati R. BE, Bastian L., Coeytaux RR., Samsa G., et al. Effect of clinical decision-support systems: a systematic review.2012; 157(1):[29-43 pp.]. Available from: 52

61 14. Chaudhry B., Wang J., Wu S., Maglione M., Mojica W., Roth E., et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care2260; 144(10):[ pp.]. Available from: Institute S. The Swedish System of Government: Sweden.se; 2014 [cited 2014 Mar 26]. Available from: Regions SAoLAa. Municipalities, county councils and regions: Swedish Association of Local Authorities and Regions; 2013 [cited 2014 Mar 26]. Available from: Council SC. About Stockholm County Council: Stockholm's County Council; 2012 [cited 2014 Feb 8]. Available from: Decentralization in Health Care Strategies and outcomes. WHO: Open University Press; Available from: data/assets/pdf_file/0004/98275/e89891.pdf. 19. Lars Jerlvall, Pehrsson T. ehealth in Swedish County Councils Available from: dstingen_slit2012_eng_rapport_ pdf. 20. ehealth Cf. National ehealth - the strategy for accessible and secure information in health and social care 2010 [cited 2014 Mar 26]. Available from: 11_eng_rapport_ pdf. 21. Council SC. About the County 2013 [cited Apr]. Available from: SCB. Population in the country, counties and municipalities by sex and age 31/12/2013 Statstics Sweden2013 [cited Apr]. Available from: 53

62 area/population/population-composition/population-statistics/aktuell- Pong/25795/Yearly-statistics--Municipalities-Counties-and-the-wholecountry/159277/ se. Primary Care Centers in Stockholm 1177.se2014 [cited Apr]. Available from: Council SC. Healthcare: SLL; 2012 [cited Apr]. Available from: Council SC. Our operations SLL2014 [cited Apr]. Available from: SALAR. Uppsala SALAR2013 [cited Apr]. Available from: Council UC. Primary care centers LUL [cited Apr]. Available from: Council UC. Hospitals LUL [cited Apr]. Available from: SALAR. Östergötland SALAR2014 [cited Apr]. Available from: se. Primary Care Centers 1177.se2014 [cited Apr]. Available from: Lars Jerlvall, Pehrsson T. ehealth in Swedish County Councils Available from: _SLIT_2013_ pdf 32. Cambio. Customers: Cambio Healthcare Systems; 2014 [cited Apr]. Available from: 54

63 33. Max Eliasson, Weber A. TakeCare Health Record System in SLL: An indepth review Apr 2014:[1-11 pp.]. Available from: /Landstingsstyrelsen_Bilaga-C3.pdf. 34. Cambio. Uppsala County Council: Cambio Healthcare Systems; [cited Apr]. Available from: Akademiska. Ronden Apr 2014; (3):[1-24 pp.]. Available from: nden/ronden_3_2011_webb.pdf. 36. Cosmic. Östergötland County Council Cosmic Healthcare Systems [cited Apr]. Available from: Ohlson U. Praise and criticism after five years with the Cosmic: Östergötland County Council; 2012 [cited Apr]. Available from: Häggqvist P. Shared Medical Record - opportunities and risks? Apr 2014; (13). Available from: Erika L. Abramson, Vaishali Patel, Sameer Malhotra, Elizabeth R. Pfoh,S. Nena Osorio,Adam Cheriff, Curt L. Cole, Arwen Bunce, Rainu Kaushal, Joan Ash. Physician experiences transitioning between an older versus newer electronic health record for electronic prescribing. International Journal of Medical Informatics [Internet]. 2012; 81(8):[ pp.]. Available from: Erika L. Abramson, Sameer Malhotra, Karen Fischer, Alison Edwards, Elizabeth R. Pfoh, S.Nena Osorio, Adam Cheriff, Rainu Kaushal. Transitioning between electronic health records: effects on ambulatory 55

64 prescribing safety. Journal of General Internal Medicine [Internet] Jan 28; 26(8):[ pp.]. Available from: Gettinger A, Csatari A. Transitioning from a legacy EHR to a commercial, vendor-supplied, EHR: one academic health system's experience. Applied Clinical Informatics [Internet] Jan 28; 3(10):[ pp.]. Available from: Elizabeth R. Pfoh, Erika Abramson, Stephanie Zandieh, Alison Edwards, Rainu Kaushal. Satisfaction after the transition between electronic health record systems at six ambulatory practices. Journal of Evaluation in Clinical Practice [Internet] Jan 28; 18(6). Available from: Stephanie O. Zandieh, Kahyun Yoon-Flannery, Gilad J. Kuperman, Daniel J. Langsam, Daniel Hyman, Rainu Kaushal. Challenges to EHR Implementation in Electronic- Versus Paper-based Office Practices2008; 23(6):[ pp.]. Available from: Kirkendall ES., Goldenhar LM., Simon JL., Wheeler DS., S. AS. Transitioning from a computerized provider order entry and paper documentation system to an electronic health record: expectations and experiences of hospital staff2013 [cited 2014 Apr 14]; 82(11):[ pp.]. Available from: Kothari CR. Research Methodology: Methods and Techniques: New Age International (P) Ltd; Brender J. Handbook of evaluation methods in health informatics: Elsevier Academic Press; Neil B. Mehta, Partin MH. Electronic health records: A primer for practicing physicians2007 [cited Jun]; 74(11):[ pp.]. Available from: Cusack CM. Electronic health records and electronic prescribing: promise and pitfalls. Obstetrics and Gynecology Clinics of North America 56

65 [Internet] [cited Jun]; 35(1):[63-79 pp.]. Available from: Ross S. Results of a survey of an online physician community regarding use of electronic medical records in office practices2009; 24(4):[254-6 pp.]. Available from: Carrie Anna McGinn, Sonya Grenier, Julie Duplantie, Nicola Shaw, Claude Sicotte, Luc Mathieu, et al. Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review2011; 9(46). Available from: Bell J. Doing yourresearch Project A guide for first-time researchers in education, health and social science: Open University Press; Denscombe M. The Good Research Guide for small-scale social research projects: Open University Press;

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67 Appendices Appendix A Example of an invitation letter to the interviewees a

68 Invitation letter to take part in the questionnaire b

69 Guiding interview questions c

70 Questionnaire (in Swedish) d

71 e

72 f

73 Appendix B Some benefits of EHRs in healthcare g

74 Stockholm, Uppsala and Östergötland counties h

75 TakeCare (yellow) and COSMIC (Green) distribution in Sweden i

76 Appendix C Comparison between the 4 dominant EHRs in Sweden in 2012 and 2013 Amount of users in 2012 (total 217,361 users) 1. Melior: (27.6% or approx. 60,000 users) 2. COSMIC: (25.8% or approx. 55,000 users) 3. TakeCare: (19.4% or approx. 40,000 users) 4. System Cross: (11.0% or approx. 25,000 users) Amount of users in 2013 (total 223,548 users) 1. COSMIC: (26.7% or approx.60,000 users) 2. Melior: (25.9% or approx. 55,000 users) 3. TakeCare: (20.6% or approx. 45,000 users) 4. System Cross: (10.6% or approx. 25,000 users) Official Swedish authorities names and websites Acronym Authority s Name Website SLL Stockholm County Council Stockholms Län Landsting (Swedish) LUL Uppsala County Council Landstinget i Uppsala Län (Swedish) LIO Östergötland County Council Landstinget I Östergötland (Swedish) SALAR Swedish Association of Local (English Abbreviatio n) Authorities and Regions Abbreviated to SKL (Sveriges Kommuner och Landsting) (Swedish) SCB Statistics Sweden j

77 1177.se CeHis (now called Inera) Statistiska Centralbyrån (Swedish) Care Guide Vårdguiden (Swedish) Center for ehealth Center för ehälsa i Samverkan (Swedish) mentarkiv/ List of interviewees, their roles and their current positions County Organization Role during transition Current position Östergötlan d LIO Project leader Business Area Manager IT Center in Östergötland County Council Uppsala LUL Project leader IT Manager and Strategist in Uppsala County Council Stockholm SLL Project leader IT Management Leader Stockholm County Council Administration Stockholm SLL/Karolinska Hospital Team leader Management Leader Ehealth and strategic IT at Karolinska University Hospital Stockholm SLL/Karolinska Team leader System Manager k

78 Doesn t apply Doesn t apply Hospital Ehealth and strategic IT at Karolinska University Hospital Cambio Team leader Business Developer at Healthcare Cambio Healthcare Systems Systems, Sweden CGM Team leader Implementations Specialist at CGM, Sweden User-information blanks and the respective provided choices Blank Provided choices County Stockholm Uppsala Östergötland Age Group Under Gender Male Female Profession Specialist (doctor) Resident doctor Nurse l

79 Constructed questionnaire translated to English Question Type Answers 1. How long had you been using the legacy EHR? * Hint: Only consider the Categorical scale Less than one year 1-2 years 2-5 years 5+ years system you had had exactly before the transition 2. How long have you been using the new EHR? * Categorical scale Less than one year 1-2 years 2-5 years 5+ years 3. Do you still use the legacy system (e.g. via a portal) to get information about Categorical scale No Yes, once a month Yes, once a week Yes, at least once a day the patients? * 4. If you answered yes to the previous questions, what is/are the type/types of information that you search for using the legacy EHR? Hint: Check all the Checklist Patient personal information Referrals Notes Lab results Medications Warnings Other (activates a blank for the respondent to list down the other category/categories that he/she searches for) categories that apply 5. When transitioning Categorical Everything must be m

80 between legacy and new EHRs takes place, how do you think the information in the legacy system should be dealt with? * 6. If you picked the choices that is marked with ** in the previous question, can you specify the 3 most important scale Checklist transferred (from the legacy to the new system) Chosen information categories must be transferred ** Somebody should manually write a summary of the most important information in the new system Use both systems (the legacy system to read information and the new one to input new data) at the same time during a defined period of time Get access to the information in the legacy system via a portal that connects it with the new system Nothing is to be transferred and it s better to start with an empty health record Patient personal information Referrals Notes Lab results Medications Warnings Other (activates a blank for n

81 information categories that you would like to be transferred? Hint: Only check 3 boxes! 7. Have you experienced that your workgroup influenced the decision of how the information was dealt with when the transition took place?* Multipoint scale the respondent to list down the other category/categories that he/she thinks is/are important ) The scale starts from 0 which is tagged No influence up to 5 which is tagged Huge influence Questions marked with (*) mean that they are mandatory List of recipients of the questionnaire Stockholm 67 primary care centers (25 private primary care centers and 42 primary care centers run by Stockholm county council) 68 physicians in General Medicine in the Western suburbs of Stockholm 38 physicians in Emergency Care, Söder Hospital (Södersjukhuset) 11 physicians in General Medicine, Danderyd Hospital (Danderyrds sjukhus) o

82 Uppsala Östergötland 10 private primary care centers 24 General Medicine specialists 4 primary care centers Utilized software, their usage and availability Name Description Usage Available at Smart Voice Recorder Free mobile application To digitally record and store the conducted interviews re/apps/details?id=com.and rwq.recorder Google Documents Free webbased word To write down and use the guiding questions ll processor before and while conducting the interviews Google Forms Free webbased formcreating To create and administer the ll software questionnaire sent out to the users Google Spreadsheet Free webbased To store and analyze the received responses ll s Excel like software through the questionnaire Google Drive Free webbased document storing To store and administer the previously described files ll p

83 platform Paint.net Open- To form, digitally edit source and enhance some of software for the provided figures editing of (maps, screenshots and digital illustrative figures) photos Dropbox Free (but To back up all the also paid obtained data files in option is addition to other available) materials (books and cloud articles) used in this storing study space Google Free web- To translate some words Translate based and phrases from / translation Swedish to English that utility existed in the interviews and the questionnaire and to check the translation of the prepared guiding questions Lexin Free web- To translate and double based check the translations n/ translation provided by the utility previously mention provided by translation tool The Institute for q

84 Language and Folklore and Royal Institute of Technology (KTH) Respondents age groups Age group User(s) Percentage % % % % Less than % The amount of users with respect to experience with the legacy system Year(s) User(s) Percentage % % % Less than 1 year 5 9% The amount of users with respect to experience with the new system Year(s) User(s) Percentage % % r

85 Less than a year 8 15% % Periodicity of usage of the legacy systems by the respondents Answer Number Percentage Once per month 17 32% Once per week 12 23% At least once a day 11 21% Information that is searched for using the legacy systems by the respondents Type of information Number of picks Notes Personal Information 14 Referrals 24 Notes 35 Lab Results 24 Medication 30 Warning 15 Other 3 ECG (Electrocardiogram) Respondents choices from the proposed solutions Solution Amount of Users Percentage Chosen information categories must be transferred 16 30% Get access to the 16 30% s

86 information in the legacy system via a portal that connects it with the new system Use both systems (the legacy system to read information and the new one to input new data) at the same time during a defined period of time 11 21% Everything must be transferred (from the legacy to the new system) 6 11% Somebody should manually write a summary of the most important information in the new system 4 8% Respondents choices of the types of information that should be transferred from the legacy to the new systems Type of information Amount of Percentage users Medication 23 26% Notes t

87 Warning 21 23% Notes 14 16% Lab Results 13 14% Personal Information 7 8% Other 5 6% Assessment, ECG, Acute Notes, Epicrisis Respondents influence on the already done transitions Users Percentage 60% 19% 8% 9% 2% 2% u

88 Appendix D Number of daily responses Number of respondents from each professional group v

89 Female to Male respondents Respondents using/not using the legacy systems w

90 Checked information categories by the respondents in contrast with each other Chosen information types in contrast with each other x

91 Influence of respondents on the performed transitions y