BMJ, doi: 10.1136/bmj.38638.497477.68, (Published 3 November 2005)

INFORMATION IN PRACTICE

Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study

J Tim Scott ^1*, Thomas G Rundall ², Thomas M Vogt ³, John Hsu ⁴

¹ School of Management, University of St Andrews, St Andrews KY16 9SS
² School of Public Health, University of California, Berkeley, CA 94720, USA
³ Kaiser Permanente Centre for Health Research, Hawaii, HI 96817, USA
⁴ Kaiser Permanente Division of Research, Oakland, California, CA 94612, USA

^* Correspondence to: jts1{at}st-andrews.ac.uk.

Objective To examine users' attitudes to implementation of an electronic medical record system in Kaiser Permanente Hawaii.

Design Qualitative study based on semistructured interviews.

Setting Four primary healthcare teams in four clinics, and four specialty departments in one hospital, on Oahu, Hawaii. Shortly before the interviews, Kaiser Permanente stopped implementation of the initial system in favour of a competing one.

Participants Twenty six senior clinicians, managers, and project team members.

Results Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed; software design problems increased resistance; the system reduced doctors' productivity, especially during initial implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the implementation; no single leadership style was optimal--a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; the process fostered a counter climate of conflict, which was resolved by withdrawal of the initial system.

Conclusions Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. A transient climate of conflict was associated with adoption of the system.

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(Accepted 20 September 2005)
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