Implementation of large-scale health information systems.

AutorLuz, Ricardo
  1. Introduction

    The world scenario, characterized by frequent changes in the social, economic, political and technological spheres, directs organizations to constantly reviewing their roles and processes. Without being an exception, institutions related with public health end up being deeply influenced by the environment and see themselves obliged to update their management policies and practices. The perspective of such institutions, which used to be devoted to assistance and devoid of the obligation to present management evidence, changed and they are currently on the path toward an entrepreneurial orientation, guided by performance, results and transparency (Lima, Schramm, Coeli & Silva, 2009; Botega, Andrade & Guedes, 2020).

    The complexity of these organizations demands the generation, processing and availability of an expressive volume of information, which is essential for their processes and make up subsidies for decision-making in public health policies (Cresswell, Bates & Sheikh, 2013). These information include those referring to patients' health records (electronic health records), medical and nursing practices, management of clinical environments, knowledge and learning management, organization of administrative practices in the environment where the health care takes place, among others (Marin, 2010). By obtaining, processing and making them available for multiple stakeholders, an effective assessment is enabled not only in terms of administrative and operational efficiency, but of the greater purpose, i.e. the well-being of society (Morrison, Robertson, Cresswell, Crowe & Sheikh, 2011).

    Within such context, government initiatives to implement health information systems (HISs) through information technology (IT) have been taking place internationally in countries with different development levels in order to improve patients' health and the quality and efficiency of health care services (Ludwick & Doucette, 2009; Rozenblum et al., 2011; Sligo, Gauld, Roberts & Villa, 2017; Haried, Claybaugh & Dai, 2019). As for these countries, we mention Germany (Deutsch, Duftschmid & Dorda, 2010), the United States of America (Payne, Detmer, Wyatt & Buchan, 2010), England (Sheikh et al., 2011), Denmark (Aanestad & Jensen, 2011), Australia (Morrison et al., 2011), Greece (Katehakis, Halkiotis & Kouroubali, 2011), Canada (McGinn et al., 2012), India (Aanestad, Jolliffe, Mukherjee & Sahay, 2014), Lithuania (Vedluga & Mikulskiene, 2017), Brazil (Mussi, do Valle Pereira, de Oliveira Lacerda & dos Santos, 2018), among others.

    These initiatives are commonly characterized as complex programs or megaprojects (Price, Green & Suhomlinova, 2018), as they occur on a regional or national scale (large-scale) and involve the coordination of multiple stakeholders, who usually have distinct interests and perspectives (Klecun, Zhou, Kankanhalli, Wee & Hibberd, 2019). Given the increasing frequency of implementation of large-scale HIS, researchers have reported the need to maximize knowledge and understanding of the perspectives utilized in such implementation (Cresswell & Sheikh, 2009; Cresswell, Williams & Sheikh, 2020b). A few scholars have been arguing (Ross, Stevenson, Lau & Murray, 2016; Sligo et al.,2017; Klecun et al.,2019) that there is a broad previous literature on punctual implementation of HIS and on local and organizational coverage of HIS. Research that addresses implementations with a broader comprehensiveness, i.e. large-scale, is still found, however in a smaller number, especially those of literature review, which is the case of the present proposal.

    Therefore, this article aims to fill the literature gap identified, contributing to the selection and bibliometric and systematic analysis of a bibliographic portfolio about the phenomenon through a constructivism-structured process--Proknow-C (Knowledge Development Process-Constructivist) (Ensslin, Mussi, Chaves & Demetrio, 2015; Carvalho et al., 2020). As indicated by Carvalho et al. (2020), the selection of relevant literature through a structured process is a critical step in the development of systematic reviews.

    The previous literature reviews on programs for implementation and assessment of large-scale HIS usually aim to describe the program focusing on one or more specific countries (e.g. Ludwick & Doucette, 2009; Price, Green & Suhomlinova, 2018) and on specific health information technologies. In addition, these studies are not structured around the literature selection and bibliometric and systematic analysis in an integrated way through a bibliographic portfolio.

    Thus, the present research provides a broader focus and contributes to the previous literature in three different ways: (1) by integrating concomitantly bibliometric and systematic review data of published literature, (2) by analyzing international initiatives of implementation of large-scale health information technologies without predefining technologies or specific countries, which will emerge from the selection process itself and (3) by making use of a structured review process from a constructivist perspective (Proknow-C).

    Therefore, we intend to answer the following research issue: What is the state of art in the qualified literature about the implementation and assessment of large-scale HISs? More specifically, we intend to (1) select a bibliographic portfolio composed of a relevant, scientific bibliography aligned with the established theme; (2) to carry out the bibliometric analysis of this portfolio, exploring variables of the selected articles and their references; and (3) to carry out the systematic analysis of the portfolio by exploring the predominant countries identified in our research, the most studied technologies, implementation approaches, expected benefits and the difficulties faced by different countries.

    This study may help and direct current and future investigation processes with the same nature. The research process and the main findings may be used by different researchers aiming to develop studies on the issue and may be used as a guide for practitioners, including those involved in initiatives of implementation of large-scale HISs.

    In the upcoming section, HISs and the characteristics of their large-scale implementation will be described. In section 3, we will present the methodological procedures adopted, as well as the research framework. Subsequently, the application of Proknow-C and the outcomes of such method will be presented. Then, in the last section of this article, we present the conclusions and suggestions for future research.

  2. Health information systems

    The purpose of HIS is to produce and organize information and knowledge generated and used in the health care area in order to support the planning, the improvement and the decision-making process of the multiple actors involved in related processes (Lippeveld, Sauerborn & Bodart, 2000). The use of HIS can improve not only the health of individuals but also the performance of health care providers, providing increased levels of quality, financial efficiency and greater participation of patients in the care of their own health (Blumenthal & Tavenner, 2010).

    Several acronyms have emerged over time to designate electronic HISs, such as electronic health record (EHR), electronic medical records (EMR), health information exchange (HIE), computerized physicians order entry (CPOE), hospital information system and telemedicine/telehealth/e-health (Blumenthal, DesRoches, Donelan, Rosenbaum & Ferris, 2006; Jha, Doolan, Grandt, Scott & Bates, 2008; Rosenthal, Seeman & Gibson, 2005; Lakbala & Dindarloo, 2014; Petroudi & Giannakakis, 2011; Spil, LeRouge, Trimmer & Wiggins, 2009).

    Considering the national scope of implementation of such technologies, this sort of venture comprises the government definition of policies and standards that encourage the convergence of public and private interests in the development of an effectively functional national system (Coiera, 2009). Coiera (2009) still proposes a typology for regulatory models of implementation of large-scale HIS (top-down, middle-out, bottom-up), categorizing them according to the level of influence of government authority and the level of autonomy experienced by provider institutions in the process of developing, implementing and using the systems. While the top-down approach is characterized by a centralized management accomplished by the government, in the bottom-up approach the health care institutions make their own decisions about the system to be implemented, following the minimum interoperability standards. In an intermediate way, the middle-out approach combines elements of the other two approaches (Coiera, 2009, Morrison et al., 2011).

    The implementation of electronic HISs at the national level has been considered a complex process full of challenges (Greenhalgh, Morris, Wyatt, Thomas & Gunning, 2013; Rippen, Pan, Russell, Byrne & Swift, 2013; Cresswell & Sheikh, 2013, Cresswell et al., 2020a, b). Technical, human, social and organizational problems are frequently reported, which compromise the efficiency and effectiveness of these initiatives (Sheikh et al., 2011; Greenhalgh et al., 2010; Murray et al., 2011; Peute, Aarts, Bakker & Jaspers, 2010; Spetz & Keane, 2009; Warth & Dyb, 2019), which--in turn--involve several interested parties necessary for the success of the implementation.

    The actors involved in large-scale implementation programs comprise the government, health organizations, health professionals, patients, IT professionals and IT companies (McGinn et al., 2012; Sheikh et al., 2011; Rozenblum et al., 2011; Haried, Claybaugh & Dai, 2019). The wide range of interrelations among these actors generates a complex network of relationships, impairing the alignment of mutual interests (Greenhalgh et al., 2013; Greenhalgh et al., 2010; Robertson et al., 2010; Klecun et al., 2019; Cresswell et al., 2020). Amongst the several...

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