In this section, we present the content of the four themes that relate to what the Health Platform management and the GPs expect of the implementation of Epic in terms of organizational effects. For each of the themes, we contrast the views of the management and the GPs in order provide a broad understanding of the theme as well as point to potential challenges for the future implementation. The themes are as follows:
Accessing patient information anytime, anywhere.
Standardizing patient pathways.
An EHR that responds to evolving needs
Accessing patient information anytime, anywhere
In alignment with the long-term national goal of establishing a nationwide EHR functionality, “one citizen - one record”, the goal in the Health Platform program is to create a comprehensive health service that is well connected within the hospitals and across the hospitals, nursing homes, home-care services, and GP clinics. The aim is to provide all health personnel – and patients – in Central Norway with complete and up-to-date information about the patients’ condition and medication. The management explains that eighty existing systems will be replaced by Epic, which is particularly welcomed in the municipal health service (nursing homes and home-care services) where modernization of the EHRs is much needed. The regional scope of Epic also means that there is little need for integration among systems because all the patient’s data are expected to reside in Epic. This will improve data quality:
‘It is important that health workers understand that this means an improvement also on the integration side. Because today they actually print documents from different systems and enter this data into Doculive [the current EHR] with the sources of error this can cause. So, hunting for duplication of this kind of work for especially the medical group, is something we are going to do intensely in the preparation phase.’ (Director, top)
Management also expects much improvement in access to clinical data for healthcare professionals, including GPs:
‘When the EHR is updated, everybody [with proper access rights] can see the data. In a way, it will be the kind of core electronic record we have been dreaming of since 2004. Also, the patients can log on and look at their data.’ (Director, municipalities)
‘The biggest change for GPs is that they do not have to look in a continuous patient record: "When was the last time you were here: one year ago ... oh, well ... was it two years ago?" They will have a database that provides everything they need in real-time and just in one workspace with good overview’ (Director, municipalities)
However, some of the GPs raised the concern that the mere possibility to access the hospital record to find additional information about their patients might create expectations about looking it up just to be sure. One of them stated:
‘The problem is that when we have the whole hospital EHR at our disposal, it becomes an active choice not to use it.’ (GP-4)
To illustrate the point, the GP compared the situation with how physicians generally want not to over-diagnose patients:
‘If we can compare the situation to diagnostics. Physicians try not to order each and every test and image examination and everything like that because if they find something, they must follow up on it etc. This does not lead to better health; it instead becomes a kind of precautionary medicine.’ (GP-4)
The GPs’ views reflect a concern about the usefulness of Epic in their daily work in their GP clinics. The overall worry for the GPs is to be burdened with too much information. They have no wish to access the whole hospital record to read all the details of what has happened with a patient during a hospital stay. Several of the GPs state that they almost drown in information already and that having to read even more would be an additional burden.
‘A great amount of data in the hospital record is not relevant for us.’ (GP-3)
What the GPs consider essential, though, is to receive information that is relevant for their follow-up and treatment of a patient, most prominently the discharge reports from the hospitals. The GPs explain their use:
‘What matters to a GP is the reason the patient was admitted, what assessments were made during the hospitalization, and what should be followed up (...) For example, in a way, it is good that the surgeons write short discharge reports because the technicalities around a surgery are not that useful for us.’ (GP-3)
Generally, the GPs are quite happy with the discharge reports they receive from the hospital. If the GPs need additional information, they prefer to talk to the hospital physician who wrote the report rather than to try to find the sought-for information in the hospital EHR, “because in that case, the report is missing something” (GP-9).
For their part, the Health Platform management invites the GPs to see the potential in a shared system, i.e. a system that is useful to many user groups. It also tries to appeal to the GPs by arguing that there might be some benefits for them.
‘We tell them that some things will become easier: Today, the GPs don't have information in real-time, they are dependent on an electronic discharge letter. If the GP meets a patient who was at the outpatient clinic yesterday, they may not get the report until a week later, and that is a drawback.’ (Director, medical GPs).
To some degree, the GPs acknowledge that access to information that presently is unavailable to them might be useful. According to one of the GPs, an example might be when hospital physicians request tests on a hospitalized patient without putting the GP as a copy requisitioner. Then the GP will not see the result.
Standardizing patient pathways
An essential goal in the Health Platform program is to streamline workflows and standardize patient pathways across organizational boundaries. Standardization is expected to ensure smooth workflows where each step is predefined and necessary information is available. For each workflow step, Epic should require the prescription of certain medications, the administration of certain tests, and the order in which the tests should be administered. In the outpatient clinic, standardization is for example envisaged for referral letters from the GPs. Here, Epic will be able to impose standardized content:
‘For example, when a GP refers a patient to us for a hip transplant examination, we want to standardize what information is necessary: we require certain results from the GP, we require a certain x-ray examination, we require certain blood tests, and we require a certain function score.’ (Director, medical hospitals).
In addition, standardized patient pathways are closely connected to structured content of the major documents. Structured content will serve as the foundation for warnings whenever a registration is outside defined limits. It may also serve as the foundation of decision support in both this step and later ones. Furthermore, structured content is expected to provide for more efficient reporting and research. Predefining the order of tasks for patients with certain conditions could make patient visits to hospital more efficient. It may ensure that the patient can go through required examinations in one visit instead of multiple visits. Still, such standardization is expected to make the work process more rigid:
‘This will be new to everyone: You need to enter some data before you can move on to the next step in the workflow. Therefore, we have to make sure there will not be too many hard stops. And we will ensure that you can get help, if needed.’ (Director, medical GPs)
The Health Platform managers recognize that it takes longer to work in a process-oriented system such as Epic, both to fill in the required data and comply with the structured form. However, the managers believe that the contribution of a shared EHR to the strategic goal of “one citizen - one record” outweighs the costs for some user groups:
‘Getting the users to embrace the solution and getting them to see the big picture really improve the overall quality of the healthcare service. It may mean more clicks for you, but you perform these clicks for your patient and for your colleagues.’ (Director, top)
After establishing a standardized patient pathway for one municipality, the Health Platform aims to disseminate it to other municipalities to ensure efficient work processes across the health region. This is supposed to ensure that all patients get the same level of treatment and care. The standardization of work processes across healthcare contexts is also attractive in a maintenance perspective because it will ensure that those who configure these processes in Epic, will only need to maintain one work process.
The GPs for their part are aware that the process-oriented nature of Epic will be a huge change to their work practices. They will have to start documenting in real-time where their tasks are but one step in a larger, standardized, and structured work process. They are troubled about this and concerned about the local consequences:
‘There is a lot of focus on making new patient pathways, but it will require a lot of work to do the necessary adjustments... I think it will be difficult to configure a platform that fits all the medical offices and the nursing homes. I really don't think it's possible.’ (GP-7).
The GPs are also worried about how Epic inscribes a fixed pattern of use:
‘What worries me as a GP is the rigidity of the system with structured documents (…) In order to move forward in the registration process, you must have a structured [entry], but I don’t have time to struggle half an hour for producing a referral letter because it lacks some code.’ (GP-8)
The GPs are not unfamiliar with structured data entry. Today, some blood-pressure values are archived as numbers to make them easy to extract, compare, and present in a laboratory sheet instead of reading the values from the notes. While this is considered useful, the GPs simultaneously point out that structured data entry is a lot of work for the user:
‘A lot more is required from the user if there are lots of boxes to click or selections from a list. Instead, we use many abbreviations for Latin words that are demanding to write. So, it often becomes "A." or something for artery, instead of writing it out, looking it up, or finding it.’ (GP-1)
To underscore the point of extra work related to structured content, the GP referred to a case where they had experimented with going from a paper-based medication chart to a structured electronic medication chart:
‘After requesting 1 liter of Ringer, i.e. liquid, you could write "Ringer, 1000 ml i.v., x 4" on the paper-based medication chart. In comparison, on the electronic chart there were 18 clicks, because first you had to choose fluid treatment, intravenous, find which fluid, what volume... Yes, it was a lot of things. That's the danger of structuring.’ (GP-1)
An EHR that responds to evolving needs
In the preparation phase, Epic will be configured for many different settings: hospital departments, nursing homes, home-care services, and GP clinics. Given Epic’s large scale, a regional organization under the direction of the Central Norway health authority will have the responsibility of running the system. This organization will also have the responsibility for coordinating configuration activities after the system is put into operational use, thus responding to evolving user demands. The management considers this a big advantage and compares it will traditional EHR development:
‘This is a completely different division of labor between the customer and the supplier than we have been used to. Until now, we have had to specify requirements and deliver these to a supplier who has then developed the system. This will happen to a much lesser extent here because Epic is such a configurable system.’ (Director, top)
‘You do not have to do what you have traditionally done - to call a supplier who does not have time to do this or that. It takes an eternity before something can be done. Here it is so configurable that you can set up, fix and mix (...) then you run what Epic refers to as continuous optimization processes that you as a customer control yourself. You are actually building this system yourself.’ (Director, benefits realization)
The Health Platform management has presented two benefits for the GPs. It has been arguing that the GPs will be released of the cumbersome responsibility of running an EHR solution - a responsibility that every autonomous GP clinic has today. The GPs will also be released of the responsibility of coordinating software-change initiatives vis-à-vis a vendor because such changes now can be configured.
Despite this, the core of Epic is still a large-scale system with common functionality. There are limits to what it can be configured to do, both in response to the GPs’ technical requirements and in relation to standardized patient pathways (see Section 5.2). The Health Platform management sees this as a natural consequence of implementing a shared system for the whole region:
‘I think some users will lose some of the most specific functionality of their specialist system, but I think they are willing to sacrifice this when they see the benefits of sharing information with others.’ (Director, top)
However, the point for the GPs is not only about losing some functionality in their daily practices. It also involves strategic considerations about what type of system they would like to have for the future. The GPs are skeptical toward Epic because it represents a “closed” large-scale suite system. One of the GPs questioned whether it made sense to invest in such a closed platform and felt that discarding more open systems was like going back in time. Another raised a similar worry:
‘I fear that Epic will be a huge colossus... It may not be as user-friendly as one had hoped for.’ (GP-8)
Several of the GPs emphasized that it might be better to have several small and lightweight EHRs that are capable of communicating with other parts of the healthcare sector through message-based services. An example of such EHRs is the GPs’ present EHRs. These EHRs stand in contrast to Epic, which is perceived as big and heavy.
The GPs find that their EHRs are intuitive and user-friendly. Typically, new employees and interns do not need much training before they can use these systems. The GPs are also happy with the support from their vendors. They receive support over the phone, and if needed the vendors can access the EHR remotely and fix problems. For the CGM system, the users and the vendor share a Facebook group where they frequently interact and exchange advice. Several of the GPs find it very useful. One of them put it like this:
‘We support one another indirectly because if someone asks a question that someone else has answered earlier, we often respond in pure solidarity: "You do so and so...". This takes ten seconds and then they are online.’ (GP-6)
Ideas for new EHR functionality may also be presented and discussed in the Facebook group, and changes may happen quite quickly. One of the GPs contrasts this situation with how their hospital colleagues experience the vendor relationship:
‘When the physicians at the hospital call [the vendor] with an IT question they may not get anything solved in six months. In comparison, I experience that our vendors are quite good at solving things.’ (GP-9)
The GPs experience almost no system downtime with their current EHRs and are, therefore, concerned over reports from Denmark about downtime with Epic. As potential users of Epic, the GPs worry that they will not be first in line for getting help in case of system downtime:
‘If the system crashes, I suspect that the hospital will be prioritized over us. And that would be dramatic for us. As self-employed GPs, we have no income when the system is down.’ (GP-4)
Another concern for the GPs is how Epic may be used for managerial purposes. Given Epic’s region-wide scope, they are worried that it may be used for surveillance and control, for instance to monitor the number of patients per GP, the time spent on each patient, etc. According to one of the GPs, it is extremely important that the integrity of the GP clinics is maintained and that these clinics control the access rights of “outsiders” who want access.
In sum, the GPs are not resisting a system change per se. Actually, they realize that a system change will be needed in the not so distant future to stay abreast with the technological development. However, they regard other alternatives as more promising than the “heavy” Epic. Many GPs would prefer to pursue more open and innovative systems that follow a technological pattern (small and light) similar to their present systems.
The strategic concerns of Epic include a long-term dimension in which the implementation of Epic will make it possible to move tasks across sector boundaries.
‘Depending on how the [Norwegian] financing system eventually turns out, there will be some relocation of tasks. But it is quite clear, all the health trusts have their development plans where 30% of what they do at the outpatient clinic today will go to the municipalities.’ (Director, medical GPs)
Along similar lines, one of the GPs explained that the university hospital in Central Norway plans to transfer 10–15% of its tasks to the GPs (GP-3). This will be possible because all health professionals use the same system and have access to the same information in real time. Many find this possibility to be an essential motivation for participating in the implementation of Epic:
‘If this program had only been aiming for the hospital sector, it would have been really demotivating (…) But since the aim is to procure a system for the whole healthcare service in Central Norway with its future potential, it warrants taking a risk like this.’ (Director, medical hospitals)
Nonetheless, for the municipal health personnel, the relocation of work includes more responsibility in relation to the monitoring, treatment, and medication of the patients in nursing homes and home-care services. In this regard, the Health Platform management considers it crucial to efficient coordination that everybody use the same system:
‘[When it comes to really ill persons in the municipalities], it is extremely important that the nursing staff in the municipalities, the specialists in the hospital, and the GPs are on the same system, and especially the GPs who are the ones who will do most of the coordination work.’ (Director, medical hospitals)
However, the GPs are worried about the prospects of increased coordination responsibilities. One of them put it like this:
‘Obviously, we are much better at detecting cancer in our patients than they are in the hospital because we know them (...) But I can't follow up on a cancer coli Dukes B or whatever it is called without knowing what it is, without having time to learn it, and without getting paid for it. So, it must be a second step. I'm afraid that having all these opportunities with the Health Platform will drag us down completely.’ (GP-2)
While these worries concern the future, the GPs see the implementation of Epic as an immediate driver for many new tasks and responsibilities that are coming their way. They are therefore protective of their current work situation:
‘I receive around 40 discharge letters daily and maybe 100-150 lab results. I process a to-do list after seeing the last patient, I have the e-prescriptions and a pile of documents. We don’t want this pile of documents to grow any larger. So, we are very concerned about how we should shield ourselves from new tasks when Epic comes about.’ (GP-3)
An illustration of a new task introduced in the health service in Central Norway is the dialogue-message service that was set up during the autumn of 2018 (i.e. prior to Epic). This service allows for asking short free-text questions about a patient’s treatment and care. It enables the staff in the nursing homes and home-care service to ask questions to GPs (and vice versa). However, the GPs experience that the messages from the municipal health service come straight to the GPs without any screening. One of them elaborated on a typical message: What diagnoses did this patient have when he was with you last time, what are his regular medications, what happened today when he was with you? From the GPs’ point of view, the home-care staff uses the message service as a chat function where they ask quite trivial questions and expect an answer straight away. While the Health Platform management has said to the GPs that this message service will be discontinued after Epic is implemented, this is an illustration of but one new task that the GPs have to manage. They are concerned about the present trend of getting a lot of unscheduled tasks. In this regard, the Health Platform management has suggested that if the GPs participate in configuring Epic, they will be able to exercise more influence on the interorganizational workflow and will take part in deciding how work is distributed.
Still, the GPs are not convinced. As they see it, some of the potential changes to their work situation will happen because Epic provides opportunities that are seized by some staff, but unattractive to the GPs. One GP provided an example related to accessing their appointment books:
‘It is evident that it would be very beneficial for the nurses and the physicians at the hospital to be able to say: “GP NN has a free slot in 14 days, you [the patient] can have that one for the in-between controls.’ (GP-2)
While this example is about what might happen, the GP substantiates the concern with a recent experience with a hospital specialist:
‘An orthopedist wrote to me: "Request that the GP orders an MRI of the spine before the next outpatient check”, and then I had to answer: “Thank you very much for having confidence in me, but I believe you can manage this yourself. Sincerely, NN”. We cannot have it like that.’ (GP-2)
The GPs are concerned that they will increasingly get a role as secretaries for the hospital physicians.