Barriers to implementation

Difficulties in implementing ePrescribing, electronic dispensing, and/or electronic administration of medicines in hospitals consisted of obstacles at both an individual and organisational level. Healthcare professionals faced numerous challenges with various system implementations. As illustrated in Table 3.4, 12 main themes emerged when synthesising findings from a combination of all studies: technical problems; altered work practices; weakened interpersonal communication; practice-related medication errors; poor access to systems;

logistics of education and training; unsupportive management teams;

implementation roll out; cost; circumvention of the system; security; and deskilling. Several themes that were viewed as facilitators by healthcare professionals were also perceived as barriers to system implementation inclusive of interpersonal communication, patient safety, time availability, information access, and staff training. A description of each of the barriers perceived by healthcare professionals is now detailed.

Technical problems

The greatest obstacle physicians perceived prior to system implementation was technical malfunctions (310). Physicians expressed concern with the integration of the new and current system in relation to being logged out and information not saved. Nurses complained about the associated complication of workflow due to malfunctions and cumbersome access procedures post-implementation of the automated medication storage and retrieval system.

“There is great potential for abuse. Narcotics are exposed because of drawer malfunctions, and wastes are not being witnessed until later, because it takes too long to find a finger that works”. (Nurse, post-implementation) (317)

Nursing staff also identified problems with poorly functioning proximity badges which resulted in an inability to log into the eMAR system with CDS (320).

Doctors and nurses protested that they would not tolerate a slow system prior to implementation of the ePrescribing system with CDS (318). Other concerns centred on functionality such as how the system would cope with access to a patient’s chart by different users at the one time, and whether the entire medication record would be visible on one screen. Pharmacists voiced the added problem of current pharmacy information systems not being able to integrate with the proposed new system resulting in pharmacists having to work in different system environments. Network and hardware problems were also identified by healthcare professionals post-implementation of the BCMA system (319). Difficulties with miscoded medications, items not scanned, and empty unit-dose packages delivered to wards were identified. Batteries that did not hold charges or were recharged regularly, mobile carts that were large and difficult to move, and network problems were additionally voiced as problems by healthcare professionals. Nurses stated that they had “a computer that is buggy”, that the

“computer would just kick you out”, and that “the machine will crash in the middle of a medication pass”. Problems with scanning patient wristbands were also reported.

Altered work practices

A concern expressed by doctors, nurses, and pharmacists was the effect of system implementation on ward rounds (318). Traditionally, written changes to patient’s medications are documented during a ward round contemporaneously with medical decisions. There was apprehension that the new system would not facilitate this process, with participants doubting the system would have enough mobility or flexibility. Concern was verbalised that “remote ordering”, when changes are made to a patient’s medication chart away from the patient or ward, could introduce new errors as doctor-patient contact declines. Some nurses perceived the current model of total patient care in which a number of patients are allocated to one nurse could be at risk and expressed unease regarding the possibility of the re-emergence of task allocation practice. Included in this area of discussion was the anxiety that some staff were “computerphobic” and would not use the system resulting in a model of care delivery that moved away from a

patient-centered approach. There was also apprehension that agency staff would be unable to use the system and that permanent staff members would be relegated to performing their medication administration work. Some staff had little prior contact with computers resulting in concern that there was a level of computer illiteracy that would make training difficult. Participants expressed apprehension towards the limited access to computers and the time taken to log on or off resulting in fewer opportunities to scan through a patient’s record online. Pharmacists also expressed disquiet regarding changes that may ensue, mainly centred around time available on the wards.

Use of the BCMA system interrupted the flow of care for many physicians and nurses (319). Nearly all staff found the system placed substantial demands on their time during implementation, but most sites could not allocate additional nursing or pharmacy staff during this time. A number of nurses used terms such as “frightened”, “nervous”, and “scary” to describe how they felt about the system at first. The most resistant nurses and physicians reportedly left the organisation through retirement or turnover. Managers reported older nurses were less likely to be comfortable with technology.

Excessive time for logging into an eMAR system with CDS was also identified by nurses as a significant barrier to implementation and a deterrent to documenting patient medications at the point of care (320).

‘‘Log-in times slow you down…it’s too slow…you tend to wait until you can chart more than one patient…’’. (Nurse, post-implementation) (320)

The cumbersome process of co-signing orders was also considered time consuming and an additional barrier.

Weakened interpersonal communication

Healthcare professionals perceived more time would be spent on technology and less time on face-to-face interaction with system implementation (318).

Pharmacists were particularly concerned that their visibility on the wards would decrease resulting in less personal communication with other professionals and patients, and less opportunities for informal discussions around medication issues.

“Face-to-face is less confronting than on the phone…lots of doctors say that whenever the pharmacist’s number comes up on their pager, they think oh, what have I done now?”. (Pharmacist, pre-implementation) (318)

This feeling of preference for face-to-face communication was reinforced by doctors. Loss of an unofficial means of communication using paper medication was also expressed as a barrier by healthcare professionals as well as reduced contact with patients as routinely paper charts are located at the patient’s bedside which directs doctors, nurses, pharmacists, and other allied healthcare professionals towards the patient. For similar reasons, diminishing patient contact was identified as challenging by physicians in the study by Rahmner et al (310). A lack of physicians’ knowledge when communicating with staff was also perceived to be more exposed with system implementation causing potential conflict.

Practice-related medication errors

Nurses identified an increased potential to administer medications at the incorrect time as a barrier to adoption as drug times appeared in the system without a record of when the last dose was administered (320). This was especially problematic with new admissions and in departments not linked to the eMAR system with CDS.

In contrast to relying on technology, physicians perceived important factors when choosing medications depended on personal experience, knowledge, patients desires, and consulting colleagues and guidelines (310).

Poor access to systems

Another perceived barrier by nursing staff was long wait times in the medication room for electronic access.

‘‘I think it has slowed down our work processes…for example, in our unit medications are centrally located, and if four nurses are in the medication room waiting to get on the system at 10am, they may get impatient...’’.

(Nurse, post-implementation) (320)

These problems were frustrating to participants during the implementation period when more time was needed to become familiar with the technology (320).

Medical, nursing, and pharmacy staff also expressed concerns about access to computers and who would get priority if multidisciplinary professionals requested use at the same time (318).

Logistics of education and training

Healthcare professionals envisaged training staff prior to and during system implementation would be problematic (318). It was also acknowledged that training within a hospital might be difficult due to shift work. Some participants reported difficulty in getting staff to attend training due to resistance or busy schedules (319). Many healthcare professionals believed support staff would need to be available after training and system implementation (318). Concern was expressed regarding ward staff having to spend time training others at the expense of their own work (318).

Unsupportive management teams

More challenges were evident both during and after implementation of the BCMA system with unsupportive management teams or where staff did not respect the ability of management.

“If nurse managers were in support you could get a lot further”. (Leader, post-implementation) (319)

Implementation roll out

The implementation period prior to the introduction of an ePrescribing system with CDS was perceived to be a time for potential stress and errors, in particular with a phased roll out with areas both on-line and off-line (318). Healthcare professionals with system implementation experience believed short timelines increased pressure.

“The software wasn’t ready, and the hardware had not been researched”.

(Staff member, post-implementation) (319)

Cost

Healthcare professionals raised concern about the cost of the ePrescribing system with CDS and feared cutting cost may result in the implementation of an inferior system (318).

Circumvention of the system

Circumvention of the automated medication storage and retrieval system was verbalised by nurses three months post-implementation (317). Even though the system was designed to track and supply medications through a biometric scanner where nurses specify medications to be removed at that time and return for additional medications as required, they accessed medications on override or retrieved more medications than entered. Interview findings and observations demonstrated misuse or non-use of key elements of the system by nurses such as retrieving all medications required for an entire shift.

“We find ourselves breaking a lot of rules just to help our patients get meds on time”. (Nurse, post-implementation) (317)

Nurses shared perceptions of "learning to live with the system" and this "black hole" in the process was viewed as a failure of management, lack of training, lack of design input, and a deficiency in the quality of the technology itself.

Security

Participants perceived online patient medication details may be more visible to others than paper charts and that networked information could be accessible either legitimately or illegitimately (318).

Deskilling

Doctors felt they may become dependent on the ePrescribing system with CDS and would be unable to function confidently in another hospital without the same level of decision support (318).