If integrated into clinical practice with due consideration, technology has the potential to improve healthcare delivery. Electronic patient records, e-prescribing and robotic pharmaceutical dispensing can improve the efficiency of healthcare operations. However, ensuring these tools facilitate positive change requires a deeper understanding of the network of multidisciplinary stakeholders that interact with these technologies. Moreover, care must be taken during implementation to avoid reinforcing and deepening social boundaries that exist between the key users of these systems.
Electronic patient records – keeping staff involved
The traditional ward round with paper based records is a very interactive affair. The clinical team can gather round the paper-based record at the bedside of the patient and lead consultant is the focal point for the group. With staff working in a multidisciplinary team during the ward rounds, group interaction is challenged by the introduction of electronic patient records as these are designed to be used by one user at a time.
Research has shown that when wards first switched over to electronic records, the computer was often situated away from the patient. This meant that the consultant was focused on reading the electronic record with less regard for the patient as the clinical team all gathered around the computer. Since electronic records are designed for single users, eye contract between the consultant and the rest of the staff in attendance was inhibited. Being unable to easily read the patient records, clinical staff often formed side conversations as they were left out of the conversation.
Over time, clinical staff have adapted to the use of electronic records. Monitors are now situated closer to patients’ bedsides during ward rounds and the use of printouts of the key information on each patient helps staff to remain engaged in the conversation. Surprisingly, these paper printouts have been found to be more helpful that the use of PDAs. Although it took around a year for hospitals to adapt to the use of electronic patient records, this technology is now well integrated into clinical practice and the pre-existing roles of staff on ward rounds have been able to be maintained.
Electronic prescribing – shifting workloads
In some cases, the introduction of technology into clinical practice has led to a shift in the workload of staff. With the introduction of the NHS England Electronic Prescription Service, evidence suggests that this has reduced turnaround time for repeat prescriptions issued by general practitioners. The introduction of this technology has primarily reduced time spent on administration. The need for staff to handwrite messages to doctors, sort and staple paper forms, log prescriptions in books, file paper prescriptions and search for prescriptions at the time of collection is eliminated under e-prescribing.
However, the time it takes for doctors to sign electronic prescriptions was not found to be reduced significantly. This is because once a prescription has been signed electronically doctors need to wait for it to be uploaded onto the system before they can start to read and sign the next prescription. This makes signing repeat prescriptions in batch more onerous for doctors. Moreover, doctors are required to bear in mind that the receiving pharmacy of the electronic prescription could be closed, for example over weekends, and therefore switch to a paper-based prescription in these cases.
With the introduction of e-prescribing, it was found that work was redistributed away from nurses to doctors. One example of where this occurred is medication reviews. Prior to electronic prescriptions, nurses could take responsibility for informing patients when a medication review was needed since nurses would be able to keep track of the prescriptions issued. However, the system design of e-prescribing meant that this responsibility was shifted from the nurse to the doctor. The nurse was no longer able to keep track of issued prescriptions so the doctor had to add a message onto the prescription to inform the patient that a medication review is due. This illustrates how constraints imposed by technological systems can disrupt traditional workflow processes.
Despite some increased administrative workload for doctors, in the case of complex prescriptions time could be saved as the software easily linked the digital prescription to the patient’s record. At the time of signing the prescription, doctors could more easily understand a patient’s case history without having to manually search for the patient record. Moreover, e-prescribing saves time for patients by eliminating the need for them to visit the practice to collect their prescription.
Dispensing robots – reinforcing social boundaries
Technology can also reinforce existing social boundaries between clinical staff. This can be seen through research looking at the impact of the introduction of dispensing robots in two UK hospital pharmacies. The pharmaceutical robotic technology aimed to reduce dispensing errors and improve pharmacy efficiency
In the traditional hospital pharmacy, assistants worked in the back-end organising the stock whilst pharmacists and technicians worked in the front-end labelling, dispensing and checking orders. Prior to the installation of the dispensing robot, only the pharmacists and technicians were involved in the discussions with the vendors. Pharmacists expected the robot to reduce the routine work of dispensing and allow them to spend more time doing research or consulting with patients. Technicians were keen to develop skills in using the robot to carve out a new role for themselves in managing the use of robotic technology. Not having been involved in initial consultations, assistants did not expect the dispensing robot would provide significant work benefits to them.
Upon implementation, the dispensing robot further entrenched the defined roles of the pharmacists, technicians and assistants. The introduction and use of the robot allowed a continued co-operation between pharmacists and technicians to emerge with each party’s role becoming more tightly defined. The robot allowed pharmacists to maintain control of the dispensary at a distance and freed up their time to engage in additional research and patient-centred work. As pharmacists reduced their engagement in dispensing work, technicians upgraded their technical skills and abilities, to become the primary caretakers of the robot. In this case of digital innovation, neither the pharmacists nor the technicians perceived the robot as deskilling their work or downgrading their jobs and the dispensing robot was perceived as mutually beneficial.
However, the relationship between assistants on the one-hand and pharmacists and technicians on the other became more strained following the introduction of the dispensing robot. Pharmacists did not solicit input from assistants when robot implementation was being planned so the interests of assistants were not incorporated into the implementation process. Despite lack of initial consultation, the robot was inserted into assistants’ daily practices, rearranging their workflows and workspaces and restructuring their tasks and schedules. Although assistants expected that pharmacists would help them solve key difficulties that arose in using the robot to execute their distribution tasks, they found in practice that pharmacists were now less focused on their needs since they were undertaking more research and patient interaction. Moreover, loss of autonomy by assistants arose as technicians in their new capacity as overseers of the dispensing robot exercised more control over the stocking process. This illustrates how, without proper consultation of all stakeholders at the planning phase of technological change, the needs and responsibilities of key stakeholders can become overlooked and certain users of technology can become disenfranchised.
The future of technological integration
Going forwards, there is huge potential for technology to continue to improve healthcare delivery. Personal patient records could facilitate easier access to clinical records, wearable sensors could provide round the clock monitoring that improves preventative care, and artificial intelligence could be used to speed up and increase the accuracy of diagnoses. However, looking at historic examples, it is evident that the way technology is integrated into healthcare delivery needs to be a carefully managed process. The rolling out of technology to improve the productivity of healthcare delivery is not just a simple numbers game. When trying to quantify efficiency gains it is important to consider the social context within which the technology will operate. By engaging key stakeholders up front, the impact of technology on frontline healthcare delivery can be better understood and new technologies can be integrated more seamlessly into the healthcare system.