The purpose of this thesis is to make a contribution to the improvement of electronic collaboration across organizational borders in the health care sector. I have studied this problem from a sociotechnical1 point of view and have tried to find out what we can learn from the process and how lessons learned could potentially influence further development and deployment of collaboration systems at a national level. I have used electronic referrals as a case. Practice consultants are General Practitioners (GPs) who work in part-time positions at the hospital, and I have paid special attention to their potential role in collaboration projects. I have also discussed the need for electronic collaboration as a basis for the coming Coordination Reform (Samhandlingsreformen).
My research questions are the following:
Q1 What is the status and what are the needs for electronic collaboration in the health sector in Norway?
Q2 How can practice consultants influence the development and deployment of electronic referrals?
Q3 How can general practitioners influence national ICT-strategy processes and national electronic collaboration projects?
Q4 How can a basis for more widespread electronic collaboration, including referrals, be established from a sociotechnical perspective?
My work has been based on use of mixed methods, both qualitative and quantitative. I initially did a review to get an overview of large referral projects. I did a database search, and I also used national strategy documentation, action plans and project documentation as a basis for the review.
To supply the review data, I conducted a national survey of the development of electronic referrals in collaboration with the Directorate of Health and their project Meldingsløftet (The Message boost project).
I have done four case studies:
1. Case study of the coordination reform and the role of electronic collaboration. A situation analysis of eight trajectories that span primary and secondary care was performed.
2. Case study of the specification and development of a Core EHR.
3. Case study of the GP’s National Reference Group.
4. Case study of a hospital and six GP practices that were involved in the introduction of decision support in the referral process.
Information for the case studies has been gathered by:
- Observations though my participation in the projects.
- Semistructured individual interviews and group interviews.
- Reading of project documentation as minutes from meetings, reports and plans.
- Reading of national strategy documentation.
C1.Suggestions on how practice consultants can influence the development and deployment of electronic referrals (Q2)
Practice consultants should be involved in design of modules and systems that support the GP’s work processes regarding electronic referrals. They should be considered for the role of pilot users in electronic referral projects and should be used in anchoring processes and take part in processes to make agreements about the content and structure of information that should be transferred.
C2. Suggestions on actions that national bodies can take to make more reliable plans for the development and deployment of ICT systems that support collaboration (Q1, Q3, Q4)
National bodies need longer strategic planning periods and should plan for more stepwise implementation of ICT systems than the practice is today. The Coordination Reform is not supported by necessary electronic collaboration solutions, and more attention should be paid to improve electronic collaboration systems from a national view. National projects need to be anchored at a local level and reference groups like the GPs’ EHR reference group should be considered used. Decision support and booking are commonly used in other countries. There is a need for further development in Norway, but it was also hard to see quality improvements for the hospital from the decision support case in the thesis.
C3. Suggestions on how clinicians can influence national ICT-strategy processes and national electronic collaboration projects (Q3)
Experiences from national EHR reference group show that the group can be used to coordinate input from GPs to national authorities, vendors and national projects. National authorities should consider funding of the group.
C4. Suggestions on how the design and deployment of electronic collaborations in the health sector can be supported from a sociotechnical viewpoint (Q4)
The design and deployment of collaborative systems can benefit from the use of frameworks such as the Locales and Boundary frameworks to ensure that sociotechnical aspects are addressed. New functionality to support collaboration must be integrated into the GPs EHR systems. GPs and specialists may have a different view on, and different use of, information that is transferred (e.g., a discharge letter or referral). Common understanding and agreement are needed and the practice consultants can be used as mediators.
This thesis is based on the status and needs of the health care system in a Norwegian context. The results from my work are not necessarily transferable to other countries because many factors, such as the organization of the health sector, incentive models, legislation and the installed base of information systems, differ substantially between countries