an experimental electronic patient record for stroke patients. part 2: system description

International Journal of Medical Informatics 58–59 (2000) 127–140

An experimental electronic patient record for strokepatients. Part 2: System description

M.J. van der Meijden a,*, H.J. Tange a, J. Boiten b, J. Troost b, A. Hasman a

a Department of Medical Informatics, Maastricht Uni6ersity, PO Box 616, 6200 MD Maastricht, The Netherlandsb Department of Neurology, Maastricht Uni6ersity Hospital, 6200 MD Maastricht, The Netherlands

Received 2 February 2000; accepted 5 April 2000

Abstract

This article presents an electronic patient record (EPR) for stroke patients. At the neurology department of theMaastricht University Hospital, coordination and communication of the multidisciplinary team for stroke patients isintended to be supported by an EPR. Existing, structured, paper nursing and medical records served as a startingpoint for the development of the EPR. In close cooperation with future users, the database structure, and data entryand data retrieval aspects of the user interface were adapted to the domain of stroke. The result is a combinedelectronic medical and nursing record that has potential to improve record keeping and to truly support dailyroutines. The challenges encountered in the development process were maintaining continuous user involvement andconflicting points of view regarding the relevance of clinical data. Conclusively, we state that intensive userparticipation improved the EPR, coupling with the existing hospital information system and other systems will beadvantageous and the fact that the paper records were structured in advance will smoothen the unavoidable changesin work patterns. © 2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Medical records; Nursing records; Information needs; Medical records systems; Computerized; Systems analysis

www.elsevier.com/locate/ijmedinf

1. Introduction

Computers entered the health care environ-ment decades ago. Since then many adminis-trative and clerical tasks were automated.Additionally, laboratories, pharmacies andradiology departments were automated to a

great extent. The nurses and physicians, how-ever, still report their findings mainly on pa-per. Nowadays, introducing informationtechnology (IT) into the care process is be-lieved to resolve many problems faced byhealth care institutions. Shared care, account-ability, rising costs of health care, these issueswould be facilitated or in the case of costs,reduced by the use of IT. That also thequality of care will, eventually, improve dueto the introduction of IT is widely believed.

* Corresponding author. Tel.: +31-43-3882248; fax: +31-43-3884170.

E-mail address: [email protected] (M.J. vander Meijden).

1386-5056/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.

PII: S1 386 -5056 (00 )00081 -2

M.J. 6an der Meijden et al. / International Journal of Medical Informatics 58–59 (2000) 127–140128

Shared care requires coordination of thework of different disciplines that in turn re-quires more communication about patients.An electronic patient record (EPR) can serveas a means of communication, provided agood quality of the data. Accuracy is oneaspect of the quality of data. Hogan andWagner recognised two distinct features ofdata accuracy in their review on the subject,completeness and correctness [1]. More accu-rate data can be collected for example byproceduralising processes or structuring datacapture [2]. This can be achieved with stan-dard operating procedures (SOPs), for in-stance guidelines, protocols or criticalpathways. SOPs can cover diverse activitiesin the patient trajectory; from medical andnursing tasks to administrative tasks [3].Electronically stored patient data are betteraccessible for other than care purposes, thandata registered on paper [4]. Managementreports, for example, can be made availablemore quickly and accountability will be easierto realise.

Aspects of coordination and communica-tion in relation to shared care, as well as theongoing proceduralisation of work processesprovide a point of departure to automate theinformation exchange in the care process.Easy generation of management reports, datareadily available for scientific research andpossibilities for accountability are welcomeside effects that will ensue from automatinginformation exchange in the care process.

Nowadays, many hospitals have a hospitalinformation system (HIS). The research siteof the current study, a university hospital,has a HIS that contains demographic data,laboratory results, discharge letters of severalspecialisms, the reports of radiologists, abilling function, and a function to keep trackof admitted patients. Currently, theMaastricht University Hospital is adaptingits HIS to a more up-to-date system. A new

user interface in a Windows 95 environment,Mirador (trademark of Hiscom) presents allpatient data stored in the HIS in one view. Inall outpatient clinics, physicians can viewdata stored in the HIS via Mirador. Recently,the hospital started installing computers inthe inpatient clinics so doctors there can alsouse Mirador. Linking to the HIS an EPR, inwhich information can be captured that iscurrently stored in the paper charts, will thusprovide the professionals with useful addi-tional information.

1.1. Objecti6es

This article describes an EPR that wasdeveloped to support the treatment of strokepatients at the Maastricht University Hospi-tal. Time is critically important in case of astroke. After a stroke event a patient shouldbe transferred to the hospital as soon aspossible. Preferably to a hospital with a spe-cial unit, a so-called stroke unit, where pa-tients can receive intensive care and can bemonitored carefully [5]. The research site par-ticipates in a special project (concerningtransmural care for stroke patients) to im-prove the treatment of stroke patients. In thisproject also GPs in the region participate.They refer every patient they suspect of hav-ing had a stroke to the hospital. Before thepatient arrives at the hospital, the GP warnsthe neurologist. At the First Aid departmenta neurologist examines every potential strokepatient. Upon admission, patients are trans-ferred immediately to the stroke unit of thedepartment. At this unit, a multidisciplinaryteam takes responsibility for the treatment ofthe admitted stroke patient. In this team neu-rologists and nurses collaborate with physicaltherapists, social workers, occupational ther-apists and speech therapists to optimise (di-agnostic) treatment and care for each patient.Adequate and timely information exchange is

M.J. 6an der Meijden et al. / International Journal of Medical Informatics 58–59 (2000) 127–140 129

of high importance here. Currently, nursesand physicians document their findings inseparate records. Also other care providersreport in the nursing or the medical recordon separate forms. Besides that, they main-tain their own paper records. An analysis ofwork practices at the research site is de-scribed in detail in part 1 [6].

In the current project an EPR was devel-oped in close cooperation with members ofthe department to support daily routines atthe ward. The decision to develop this systemwas based on the belief that the multidisci-plinary team can function better when usingelectronic record keeping and that a com-bined medical and nursing EPR is betterequipped to serve as a means of communica-tion than the separate paper records. Maingoal was to examine what consequences theintroduction of the EPR would have on dailypractice. A thorough evaluation of this EPRis planned to explore the kind of organisa-tional changes that will be invoked, the ef-fects on individual professionals, theconsequences for communication patternsand the quality of care.

2. Design considerations

The design and development of a valuableand practical electronic record require con-siderable attention and efforts from both de-velopers and future users. A valuable andpractical electronic record is one that fitsneatly into daily practice and offers a sub-stantial gain in comparison with a paperrecord. Our reasons for introducing an EPRin the research setting were twofold: to sup-port daily practice on the one hand and toserve scientific research in the field of neurol-ogy on the other. However, it is more criticalto tailor an EPR to daily routines and prac-tices then to scientific research. Therefore,

our main concern was to develop a systemthat would truly support daily practice at theward of the neurology department of theMaastricht University Hospital. Whether asystem supports or hinders daily practice,depends on several factors. Important issuesthat need to be addressed are what informa-tion needs to be available in an electronicrecord and how this information should beoffered. In our case, the issue of what infor-mation to incorporate in the records wasdetermined by the physicians involved. Priorto the current project, both the medicalrecord and the nursing record were alreadypartly structured.

The second question, how to present infor-mation, is a more difficult one. Researchpurposes, accuracy of data and automatedgeneration of overviews and summaries arebest served by completely structured recordswith only predefined choices. The careprovider, on the other hand, may insist onfree text entries to be able to enter the exactwords he wants. Since entering data is differ-ent from browsing data, a distinction shouldbe made between presentation of data fordata entry and presentation of data for dataretrieval. Actually, the presentation of col-lected patient data is a very important ele-ment of the EPR user interface. We basedour system on an experimental electronicmedical record, developed in a previous re-search project conducted at our department.In that project the ease of consultation ofmedical narratives was subject of study. Thecontents of medical narratives were orderedaccording to source and type of data, andwere presented in a flow sheet. Physicianswere asked to answer a series of questionsconcerning three patients. They used themedical narratives that were offered in moreor less detailed paragraphs, also described asdifferences in granularity of data. The resultslead to the conclusion that both too large and


too small paragraphs slowed the retrieval ofrelevant information [7].

2.1. From user needs to user requirements

In the design phase of the system we com-municated intensively with the future users toobtain their information needs and wishes. Inclose cooperation with them, we formulatedseveral criteria for the system and its userinterface. These criteria can be divided intotwo main categories: the ease of use andintegration. Criteria concerning the ease ofuse were: (a) the EPR simultaneously avail-able at multiple sites; (b) simple data entryforms with predefined (multiple) choices andonly limited free text entries; (c) data entryforms based on the available, familiar struc-tured paper record forms; (d) clear overviewof patient data; and (e) discharge summariesshould be easy to compose and to print.Integration of records and systems is highlydesirable. Patient data are oftentimes regis-tered more than once. Furthermore, healthcare workers often collect the necessary infor-mation in different records and the HIS. Inte-gration of the nursing and medical recordsand coupling of the HIS and the EPR re-solves those disadvantages and eliminates po-tential sources of errors.

We translated those criteria into the fol-lowing functional requirements. In the firstplace several requirements that relate to theease of use. The EPR should provide a multi-user environment, since all care providersneed access to the same records, probablysimultaneously. As a consequence, accessrights needed to be defined for different disci-plines and information must be presentedfrom different user perspectives. Further-more, in an academic setting residents oftenchange and student-nurses come and go.Therefore, the EPR must be easy to learn fornovice (computer) users. The fluid nature of

medical work requires also that users can logon and off the system very quickly and thatswitching between patients is easy and fast.Additionally, on-line help to provide theusers with support and feedback on the usageof the system. And a clear presentation ofdata is indispensable to guide users throughthe system. Offering structured data entrywhere possible is required to increase thelearnability, reduce typing efforts and lead tomore consistent records. A second aspect thatdeserved attention is the intended integrationof our EPR with the HIS. Ideal would be acomplete integration of the two systems.

2.2. The structure of the records

A flexible structure of the record is neces-sary to offer a combined medical and nursingrecord without introducing redundancy in thedatabase. Moreover, transparency of thestructure of the records will increase ease ofuse and thus enhance user acceptance. There-fore, both the medical and the nursing recordwere structured according to the current, fa-miliar categories applied in paper records.

Shared data are data that are necessary toboth physicians and nurses. Currently, in thepaper records this information is copied fromone record to the other. This copying is apotential source of errors. Moreover, copyingdata introduces data redundancy. Therefore,the EPR was constructed in such a way thatdata can be shown in different contexts. Fig.1 shows the basic structure of the records.The gray boxes indicate the presence of(partly) shared information.

2.3. The user interface

A crucial element of an EPR is the userinterface, for the interface represents the sys-tem for its users [8,9]. To accomplish an EPRthat is readily accepted, emphasis should be


placed on the design of the system’s interface.The ease of use can be enhanced by increas-ing the extent to which the system’s be-haviour corresponds with the user’sknowledge [9–11]. Thus users should be in-volved in the design process at an early stage.

Since the users are not yet familiar withEPRs, the layout of the screens should ap-proximate the current paper based records.For instance, care providers are accustomedto processing a lot of information and conse-quently, the interface should show relativelylarge volumes of data on a screen. Addition-ally, the relevance of medical information ishighly related to the context in which thedata is generated or presented. Thus, in theinterface the context of information needs tobe obvious. Apart from that, the lay-out ofthe data entry and the data presentationforms reflect the design delineated in Section2.2 to increase the transparency of the EPR

for the care providers. Furthermore,preestablished response categories were builtin wherever possible. Often, time is criticallyimportant in medical practice. Speed of infor-mation processing is therefore of the utmostimportance [8,12,13].

3. System description

We developed an EPR, consisting of adatabase containing information about boththe structure and the content of de patientrecord, a user interface, several programmingmodules, and a research module with a log-ging function. The system was implementedin a Windows 95 environment. We used anMS Access 97 database and MS Visual Basic5.0 for developing the system. On-line helpwas created with RoboHelp® Office, version7.

Fig. 1. The overview of the EPR structure.


Fig. 2. Example of a structured data entry form of the EPR. The physical examination (motor and sensibilitydysfunctions) is reported in a structured format.

3.1. Data entry

Most data entry forms approximate thepaper forms already in use at the ward. Forthe medical and the nursing record, and thereports of paramedical personnel, separateelectronic data entry forms were designed.The medical record captures most intake datain a structured format (Fig. 2). At admission,results of medical history and physical exami-nation are registered on one data entry form.Tabs are used to distinguish three differentsections of this form. Many questions areformulated as multiple choice items, with anoption to add comments in free text. Fig. 2shows one section of that form. While theadmission form resembles the paper form, theelectronically reported medical progress notesare structured to a much greater extent thantheir paper counterparts. Medical progressnotes are subdivided into eight sections: med-

ication, complications and diagnostic tests,assessment notes, reports of talks with thepatient and his/her family, a progress sum-mary, the notes of consulting physicians anda list of vital signs. Three sections (medica-tion, complications and diagnostic tests) sup-port structured data entry. Four sections arecomposed of free text entries. In each sectionprevious entries are presented chronologi-cally, the most recent entry first. In addition,the list of vital signs filled in by the nurses ispresented in a separate section.

The nursing part of the EPR contains fourdata entry forms: the nursing history, thedaily report, the care list, and the week list.Nursing history is registered on a data entryform, in which some of the topics may al-ready be filled in by the neurologist on medi-cal data entry forms. Most of the remaining,empty topics can be entered by choosingfrom predefined lists. The daily report of


both the stroke unit and the ordinary wardconsists of a free text entry form. On the carelist, the stroke unit of the ward reports vitalsigns, motor and sensory functions, con-sciousness, etc. on a 24-h flow sheet. Otherinformation registered on the care list con-sists of infusions, medication, monitoring ofthe patient, appointments etc. The week list isa structured form, approximating the alreadystructured paper form in use at the normalward. Several aspects of the patient’s healthstatus are scored on a predefined list andpresented in a one-week view. In one glimpsea patient’s health status can be assessed.

Orders communication between nurses andphysicians is registered on a special form.Nurses or the ward’s secretary register andprocess the orders, while physicians just regis-ter orders. Processing an order can vary fromrequesting a test to making an appointmentwith the patient’s family. Nurses enter ques-tions for the physicians to answer. Thesequestions cover practical problems they en-counter or questions from the patient, forexample ‘Patient asks higher dose of anal-gesics. What do we do?’. The orders list ispart of the EPR instead of only part of thenursing record.

New orders are added on top of the list.An order can be either processed or cancelledand the name of the professional who pro-cessed or cancelled the order is registered.The orders list can be sorted on date of entry,on date of processing or on order description.Unanswered questions are marked blue andnot (yet) completed orders are markedyellow.

We implemented this list in such a waythat when opening the medical progressnotes, the care list, the week list or the dailyreport of a patient, the orders list alwayspops up on top. In this way, the orders listcan easily be scanned for newly added ordersor questions.

Not only nurses and physicians need accessto patient data. Also the physical therapist,the social worker, the speech therapist, thecare co-ordinator and the occupational thera-pist do. In the current paper-records theyreport on a special paper form attached tothe nursing record. In the EPR each disci-pline has a separate section of the paramedicsreport form to type its findings in free text.

3.2. Presentation of patient data

Although data are entered in a specificcontext, the same information can have addi-tional value in other contexts. Creating dif-ferent views on the same data by rearrangingclinical items may therefore be advantageous.In the case of the currently described EPRthe items in the database can be arranged andrearranged in a desired view, presenting re-lated items on the vertical axis and the timeon the horizontal axis. This view is thenpresented in the data retrieval form that givesan overview of all patient data (see below). Inthis experimental version of the EPR, userscannot manipulate the structure to their pref-erences without help of the developer.

The data retrieval form contains three sec-tions (Fig. 3), a left pane, an upper and alower right pane. The left pane shows thestructure of the EPR as a hierarchically or-dered list of the clinical items, comparablewith the folders pane of the Windows Ex-plorer. This list can be described as a treewith branches and leaves. By clicking,branches can be expanded to show sub-branches or to show the leaves, calledendnodes. By clicking the endnodes, the pa-tient data are presented in the upper rightpane. This section of the right pane shows anaggregated overview of the selected data in aday by day or week by week view. Data inthe upper right pane can be selected column-wise and row-wise and the complete data arepresented in the lower right pane.


3.3. Database

Like in the experimental electronic medicalrecord, developed in previous research, thestructure of the patient record was stored inthe database [14]. Three tables contain therelevant information. One table consists of alist of clinical items. In the second table thepatient data are stored. These items’ relation-ship, as shown in the left pane of Fig. 3, isstored in the third table. Their position canvary depending on user requirements. Fur-thermore, one clinical item can show up indifferent parts and levels of the EPR. Thesetwo features result in a flexible structure ofthe record, that can easily be adapted tochanging insights or needs.

3.4. Linkage to other systems

A coupling with part of the HIS wasrealised. Demographic data and locationdata are retrieved directly from the HISdatabase any time a patient is loaded intothe EPR. Linkage with other systems, suchas the pharmacy system or the laboratorysystem, fell outside of the scope of this pro-ject.

3.5. Additional features

3.5.1. On-line helpOn-line help is provided to guide (new)

users in using the EPR.

Fig. 3. The data retrieval form. View of both the medical (medisch dossier) and the nursing records (verpleegkundigdossier) in the left pane. The upper right section presents an overview of this patient’s medical, vascular history. Thelower right section presents the complete content of selected items.


3.5.2. Paper outputA preliminary discharge summary and the

nursing transfer notes are easily generatedoverviews of relevant information. The con-tent of these overviews can be easily adjustedand printed.

3.5.3. SecurityAll professionals involved in the multidisci-

plinary treatment team have read-access to theEPR. Each profession has forms to register thedata relevant to its members. Differences existin the writing rights of the professionals; theserights are based on their professional group.

3.5.4. Logging databaseThe users’ navigation through the system

can be recorded in a research, logging data-base. This information will provide insight inthe usage of the EPR. We are interested inanalysing the forms and features that are used.Insight in the navigation through the systemmust result in recommendations to improvethis EPR.

4. First experiences

At present the EPR contains all desiredfunctionality. Users expressed their satisfac-tion with the EPR and are actively participat-ing to improve it. However, during the processof developing the EPR some difficulties had tobe overcome.

4.1. Challenges encountered duringde6elopment

First, we had a problem with translatingspecific information needs into more generallyapplicable statements. Initially, we planned todesign the EPR with help of the users fromscratch. Gradually, it appeared that physiciansgave examples instead of generally applicable

information for a computer program. In theend, we just computerised the existing formsand used them as a starting point. In aninteractive process of prototyping we managedto develop a truly electronic record. Second, inthe development process we were confrontedwith conflicting views related to ‘relevant’ datato collect. One view concentrated on scientificresearch, whereas the other was directed onlyto patient care. The paper based admissionform was structured, mainly to facilitate scien-tific research. This resulted in more specific andmore extensive data capture than strictly nec-essary from a purely clinical point of view. Anopen discussion solved the topic.

Third, we encountered some difficulties re-lated to security aspects. A strict description ofthe responsibilities of each professional groupwas required to implement the read/write ac-cess rights. In the current situation, a healthcare provider can complete information of aday in the past. This may occur for instancebecause time was lacking to write down theinformation or because the record was notavailable at the time and location the data werecollected. In the EPR, that will be impossible.All information is added at the time it isproduced and no information can be changedor erased at a later moment.

4.2. User acceptance

Having overcome all these, some unantici-pated, challenges, it was encouraging to detecta sense of excitement when talking to activelyparticipating users. And also we heard thecuriosity expressed by future users not directlyinvolved in the design process.

5. Planned evaluation

After testing the EPR exhaustively, anevaluation study will be conducted to answer


our research questions. Our principal re-search question is how the use of an EPR willaffect record keeping and the process of careand what effects the addition of decisionsupport will have. In a pre/post designedstudy we will investigate several aspects of thepatient record itself as well as the process ofcare. First of all, completeness of the recordwill be evaluated. Secondly, the communica-tion at the ward as a part of the process ofcare will be evaluated in a qualitative wayusing in-depth interviews and observations[15].

Finally, because the success of the systemwill depend heavily on the acceptance by itsusers, user satisfaction and user attitudes willbe measured in every phase of the implemen-tation. For this reason, we developed a ques-tionnaire, based on questionnaires describedin the literature [16–22]. The users’ naviga-tion through patient data will be recorded ina research database, that will be analysed tocheck how the record is used and what func-tionality users prefer.

6. Discussion

This paper describes an EPR developed tosupport daily practice at the neurology wardof a university hospital. We aimed at an EPRthat would facilitate the process of care inwhich many care providers participate. Therelevance of timely information exchange inthis environment served as a basis for thedesign of the EPR. But what could actuallybe gained with an EPR?

6.1. Electronic 6ersus paper-based recordkeeping

Generally, it is recognised that paperrecord keeping does not suffice in the com-plex environment of modern medicine. In the

study of 1991 the IOM subdivided the weak-nesses of the paper patient record into fourmain headings: (1) content; (2) format, (3)access, availability, and retrieval; and (4) link-ages and integration. They believed thatmany of the objections of paper record keep-ing could be overcome by electronic recordkeeping [4].

Clearly, simply exchanging the paperrecord for an electronic one will not offermany advantages. On the contrary, the regis-tration of data will probably become moretime consuming. And it can be questionedwhether or not the data will become moreaccessible.

What then are the drives to introduce elec-tronic record keeping? Advantages of an EPRover a paper based medical record cover mul-tiple aspects. If we return to the four maincategories of weaknesses of paper records asdefined by the IOM, the currently describedEPR provides an advance in all aspects. As afirst aspect, the IOM mentioned that the con-tent of records requires improvement. Previ-ous research indicates that computerizing(part of) the medical record actually results inmore complete records [23,24]. In addition,legibility of data, coding of data, more uni-form data collection are believed to improverecord keeping [2,23,24]. Since good data en-try is the start of good record keeping, weattempted to enhance the ease of data entry.In our EPR we offer the user an overview ofall possible responses, limited typing and datathat are standardised to a large extent. Asecond weakness, as defined by the IOM, isthe format of records. Already in the earlyseventies alternatives for the traditionalsource-oriented medical records were de-scribed; the problem-oriented record and thetime-oriented record [25,26]. The currentlydescribed EPR combines the source- and thetime-oriented record. This is mainly expressedin the principal data retrieval form.


A third aspect of attention was defined bythe IOM as access, availability and retrieval.Access, availability and retrieval are relatedto each other in the case of paper records.Often, paper records are not available whereneeded and when needed. If they are avail-able data retrieval requires an effort, depend-ing on the size of the record. In an EPRaccess depends on the rights a professionalhas. In our case we based access rights onmembership of a professional group. More-over, ease of use determines if users canactually access the records. In previous re-search it appeared that multiple views of thesame data, integrated systems, multi user en-vironments and a record that can serve as ameans of communication can truly supportthe process of care [27–29].

Our windows based system provides a flex-ible and user friendly environment. Multiplescreens can be opened simultaneously to viewand enter data. Users can log on and offquickly, switching between patients is easyand fast. These features are prerequisites forthe hectic, unpredictable daily work at thestroke unit. The availability of an EPR de-pends on the number and location of com-puters to consult the EPR. At our researchsite, all three physicians have a laptop toguarantee access at any location they requireit. Besides, several desktop computers areavailable at strategic locations at the ward.Because the EPR is provided at several loca-tions it will be readily available in a multiuser environment. The multi-user environ-ment of our EPR is designed to facilitatecoordination and communication. An explicitexample is the electronic orders list. Addi-tionally, all data concerning one patient arepresented in a special data retrieval form togive a complete overview. This means thatmembers of the treatment team can easilysurvey the patient data, without having tobrowse two separate records that are not

familiar to them. In our view, retrieval ofelectronic data is more related to the struc-ture and format of the EPR than to access oravailability.

The fourth aspect addressed was linkageand integration. Because the EPR is partlyintegrated with the HIS, users do not need toretype demographic and location data al-ready available in the HIS. Unfortunately,complete coupling is not yet within reach, butlaboratory results can be checked at the samecomputer simply by toggling between twoapplications.

6.2. Electronic record keeping in health care

The use of IT may have unanticipated,unwanted effects, such as a higher workloador less time with a patient [30]. Health care ispresumed to become more efficient with elec-tronic record keeping. However, researchdoes not unambiguously support this as-sumption [30,31]. Moreover, organisationalaspects or aspects related to the characteris-tics of medical work may limit the antici-pated advantages of electronic recordkeeping. If, for example, an application re-sults in changes in work patterns or isthought to affect professional status and au-tonomy it is likely to be rejected [32]. Someauthors emphasise that it is important todetermine who will use a system and for whatpurposes, and in what context a system needsto function [33,34]. The health care providersand the organisation they are functioning inare very important to consider as well. Intro-ducing IT in a health care environment in-duces changes in coordination andcommunication between individual careproviders and occupational groups, produc-tivity and efficiency, roles and responsibili-ties, working routines and job satisfaction[28,30,35–40]. Thus, the users play a key rolein accepting an EPR. Users in our project


indicated that they were sufficiently involvedin the process of development and implemen-tation. From the beginning some key usersparticipated in the project. Furthermore, weexpect our EPR to fit in with daily routines,because we attempted to stay close to theorganisation of daily work. The introductionof the EPR was not used to redesign workroutines. However, we benefited from the factthat data capture had already been proce-duralised and structured prior to the currentstudy. Not only if the system fits into theusers’ daily practice is of importance, but alsotheir attitude toward IT in general has greatinfluence on the degree of acceptance[16,17,38,41–43]. In an early phase of theproject we questioned the future users abouttheir attitudes towards computerising bymeans of a questionnaire. The results gave usno reasons for concern and we continued theproject as planned. Several months afterstarting the development, the users received asecond questionnaire to measure their knowl-edge of computers. These results were utilisedto develop the training program and the on-line help function.

6.3. Lessons learnt

During the course of the process of designand development some important issues forfuture developments emerged. The intensiveuser participation from the start was advan-tageous for the project. On one hand, wewere constantly aware of the practice ourEPR should support and on the other handthe users had an opportunity to adopt theEPR and influence its development. Gradu-ally users developed initiatives and ideas toimprove the EPR. As the users became awareof the possibilities of computers, however, itproved necessary to define the scope of thestudy very strictly. The availability of theEPR was limited to the neurology ward.

Moreover, no connection was made with an-cillary departments. From the users’ perspec-tive such connections could achieve gainswith respect to double work, reduction oferrors, communication between departmentsetc. In addition, the current HIS was unfortu-nately not yet fully equipped to couple theEPR and the HIS, but that should be strivedfor in future. Facilities to print dischargesummaries and other paper output were anincentive to the users. The written versions oftheir electronic counterparts require filling inexactly the same information several times.

Very important in the whole process wasthe fact that we had the structured paperrecords as a starting point, so we did notneed to interfere with the content of therecords and the organisation of the data inthem. The inevitable changes in daily practicewill therefore be limited to the organisationand not the content of work.

In conclusion, the approach we applied inthis project resulted in an EPR that we be-lieve to have potential to succeed in dailypractice.

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an experimental electronic patient record for stroke patients. part 2: system description

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