International Journal for Quality in Health Care; Volume 19, Number 5: pp.

259 266
Advance Access Publication: 23 August 2007

10.1093/intqhc/mzm031

Improving quality through effective

implementation of information
technology in healthcare
JOHN VRETVEIT1,2, TIM SCOTT3, THOMAS G. RUNDALL4, STEPHEN M. SHORTELL4
AND MATS BROMMELS1,5
1

Medical Management Centre, The Karolinska Institute, Stockholm, Sweden, 2Faculty of Medicine, Bergen University, Norway, 3School of
Management, University of St Andrews, UK, 4School of Public Health, University of California, Berkeley, CA, USA, and 5School of Public
Health, Helsinki University, Finland

Abstract
Objectives. To describe an implementation of one information technology system (electronic medical record, EMR) in one
hospital, the perceived impact, the factors thought to help and hinder implementation and the success of the system and
compare this with theories of effective IT implementation. To draw on previous research, empirical data from this study is
used to develop IT implementation theory.
Design. Qualitative case study, replicating the methods and questions of a previously published USA EMR implementation
study using semi-structured interviews and documentation.
Participants. Thirty senior clinicians, managers, project team members, doctors and nurses.
Results. The Swedish implementation was achieved within a year and for under half the budget, with a generally popular
EMR which was thought to save time and improve the quality of patient care. Evidence from this study and ndings from
the more problematic USA implementation case suggests that key factors for cost effective implementation and operation
were features of the system itself, the implementation process and the conditions under which the implementation was
carried out.
Conclusion. There is empirical support for the IT implementation theory developed in this study, which provides a sound
basis for future research and successful implementation. Successful implementation of an EMR is likely with an intuitive
system, requiring little training, already well developed for clinical work but allowing exibility for development, where clinicians are involved in selection and in modication for their department needs and where a realistic timetable is made using
an assessment of the change-capability of the organization. Once a system decision is made, the implementation should be
driven by top and departmental leaders assisted by competent project teams involving information technology specialists and
users. Corrections for unforeseen eventualities will be needed, especially with less developed systems, requiring regular
reviews of progress and modications to systems and timetables to respond to user needs.
Keywords: evaluation, health care, information technology, quality

Information technology has great potential for improving

quality and safety as well as for reducing costs and creating
new service innovations [1]. Electronic medical record (EMR)
is at the centre of a health information technology system and
most western countries, and services have plans for, or have
already introduced EMRs. Prescription order entry is often
part of an EMR system and has been found to reduce
medication errors and adverse drug events [1]. Many safety

problems are the result of poor communication between

shifts and across professions and departments: EMRs can
improve communications, but there is no strong evidence of
the impact of EMRs on communication processes and safety
outcomes, or efciency and savings gains [1].
Although there are many advantages with EMRs and
information technology, healthcare has not been able to
make use of the potential in the same way as many other

Address reprint requests to: John vretveit, Medical Management Centre, The Karolinska Institute, Floor 5, Berzelius vag 3,
Stockholm SE-17177, Sweden. Tel: 46-31-69-39-28; Fax: 46-31-69-1777; E-mail: jovret@aol.com
International Journal for Quality in Health Care vol. 19 no. 5
# The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

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Setting. Large Swedish teaching hospital shortly after a merger of two hospital sites.

J. vretveit et al.

industries. In particular, implementation experience has been

varied and sometimes negative, notably in public health care
systems, and where the EMR is part of a larger health information system serving many purposes and connecting different organizations [2]. One example is the slow progress in
the UK: by 2003 3% of NHS hospitals were meeting the
target to have an electronic patent record by 2005 [3], but
the target has now been put back to 2007 and possibly
beyond.

Previous research

260

The objectives were to describe and assess an implementation

in one hospital and analyse this in relation to factors suggested
by previous research to be important for successful
implementation as well as in relation to a published USA case
study, which used similar methods [22, 4, 23]. The Swedish
study reported here and used prospective and concurrent
semi-structured interviews of a selected sample of 30 informants half way through and 3 months after implementation.
Selection criteria were that the informants were knowledgeable
about how the system was chosen, designed, implemented
and about a wide range of perceptions and results. The informants were: the project leader, four part-time project leaders,
three persons from a supervisory group, four heads of division, seven heads of clinics, one instructor, ve nurses, four
doctors and one doctor secretary. These data were supplemented by hospital documentation and observation visits.
The interviews were transcribed, coded and collated to create
themes. Unclear responses and contradictory reports were
claried with informants. Themes were only retained when
more than four respondents described the same items
(Table 1).

Findings
Preparation
In 2003, two Stockholm hospitals 40 km apart merged to
form the one Karolinksa University Hospital. Interviewees
reported that there was a need to form a common EMR
to increase integration and allow communication between
the two sites, and, ultimately, other services. Three independent appraisal studies were carried out. The reports
were made to one session of heads of department: interviewees describe a dening moment when the chief
medical ofcer asked for a show of hands from the
group about which system should be adopted, and nearly
all voted for one system. The meeting recommended that
all departments at one site (Solna) would move from ve
different types of medical records to the one system used
by the other site, and this was accepted by top management. The new system would need to be installed in
40 clinics with 7000 users at the Solna site. Some new
hardware had to be installed, as well as considerable
changes to software. The new system contained patient
administration, clinical medical records and referral- and
replies to referral information, but it was not an entirely
paperless record: there were still many documents such as
EKG and pictures (e.g. radiology).
Analysis of documents and interviews show four key
choices, which were confronted and made before
implementation, all related to making the key main change
within 1 year using limited internal implementation
capacity, and delaying other changes to later phases. The
rst choice was about the extent to which top-level
management and the IT department should prescribe the

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The review of research for this study found a little research,

which could help more successful implementation and a lack
of theory about implementation of this type of intervention
to an organization [4]. These ndings were also described in
earlier reviews which report studies of the implementation
and impact of EMRs being relatively few, mostly retrospective, without controls, with most data from informants selfreports, and often from surveys. Many of the studies are in a
small number of well-resourced US health systems, which
have developed EMRs suited to their needs over a number
of years, and this experience may not be generalizable. The
research does not reect experience with some more userfriendly EMR systems developed in recent years in this
fast-moving eld.
There are large differences in the settings, implementation
processes and the type of EMR system studied. Studies
dene the start, nish and scope of implementation differently: guidance given by a nurse to a junior doctor about
how to use the system is considered an implementation
activity in one study and routine operation in another. Some
studies include factors, such as physician champion actions,
as part of the intervention, others separate these as conditions, which help or hinder implementation. Success is
dened differently, with some studies not considering the
perspectives and assessments of different stakeholders, or
work- and clinical-process redesign as part of implementation
or as a benet.
However, some ndings are reported repeatedly, especially
factors for successful implementation. These may be classied in terms of features of the EMR system [1, 5 13], the
implementation process [6, 8, 11, 14 16], or of the leadership [11, 14 16], resources [1, 5, 6, 8, 14, 15, 17] and the
recipient organizations culture [15, 18 20]. There is some
weak evidence that implementation is more difcult where
there is a culture of undeveloped or antagonistic relations
between professions, departments or with management, and
that implementation can either improve or reduce
cooperation. One study of diffusion of innovation in many
different settings found that new techniques spread rapidly
when the technique fulled these conditions: relative advantage ( perceived as better), compatible with values and needs),
low complexity (ease of understanding and use), trial-ability
( possibility of experimentation) and observability (visible
examples elsewhere) [21].

Methods

Information technology in healthcare

Table 1 Interview questions

system and its details, and how much and what type of
independence the departments should have. The preparation process involved the departments, and top leadership
made the timetable and managed the project tightly, but
departments could choose at what time during the year
they would implement and some of the details of the
screens which would be created by the hospital IT department. The second key issue was whether to use an outside
implementation service or use the limited in-house
resources for implementation. The solution was to manage
the project internally, phase-in the change over time, and
to use external consultants for specic changed which
needed to be made. This was possible because of a third
choice and decision, which was not to attempt to
implement computer physician order entry (CPOE) to
order medications at the same time but to phase this in
after the EMR and in the following year. The disadvantage
was that some departments would loose CPOE, which was
functional in the current system. The fourth choice was
not to implement functions which different departments
needed for research during the EMR phase, but to modify
the EMR in the second year to allow this.

Project process to introduce the EMR

Once the decision was made in 2004 about which system
to introduce, interviewees reported that senior leadership
made it clear that departments only had choice about
small screen modications and their date for implementation in 2005. Each department was required to nominate staff internally to form a department project group
to work with the information technology department to
ne-tune the system for the department and carry out
implementation. During 2005, all clinics had the same
interventions from the project members and the plan was
almost exactly followed.

Effects of the system on personnel and work

An analysis of the interviews carried out half way through
implementation (June, 2005) through to 3 months after
implementation (March, 2006) identied common themes
that are listed below and illustrated with typical quotes from
informants. Approximately 95% of the comments were positive about the implementation process and the new system.

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How is the new system intended to be different from the old?

What were the objectives, expected costs, results and timetable of the implementation of the new system?
Exactly which activities were planned to implement the system?
Which activities have been carried out to implement the system?
What are the effects of these changes so far for personnel? For management? For patients?
Are there any objective data to show the effects?
What further activities to implement the system and results are expected?
What helped and hindered the implementation activities and what could have been done differently?
Practice culture. And how would you describe the culture of your unit/practice/department/hospital/region? What makes it
unique in terms of the way things are done around here? E.g. Like a family; Entrepreneurial; Bureaucratic; Is efciency of
operation highly valued; Other.
Cultural mediation. Would you say that the culture of the unit/organization(s)/region has affected how the system was
implemented? In what ways? (E.g. Pace of implementation; Choice of initial implementation sites; Clinical leadership for the
system).
Leadership. Do you think leadership styles inuenced system implementation in this clinic/hospital/region?
Dening moments/critical events/turning points. Have there been any dening moments in the implementation of the system: any
critical event marking a turning point in clinicians interpretation and use of the system?
Previous IT implementations. How has your experience of system implementation been affected by previous IT implementations?
Use of EHR. In your experience, what changes has system implementation of actually made to clinical practice or care
processes? E.g. Has it changed how consultations are conducted? How a clinicians work is organized? How clinical work is
coordinated between individuals/across sites? Automation of existing care processes? Redesign of care processes? For chronic
disease management?
Chronic disease management. Would you say that the system is an effective vehicle to develop more effective chronic disease
management programs (at unit/org/regional levels)? E.g.: Diabetes? Asthma? Congestive heart failure? Depression? Other
illnesses?
System functionality. Which, in your view, are the most useful aspects or functions of System to improve chronic disease
management? E.g. Electronic patient record? Access to records from other clinicians and sites? Tests and procedures
ordering? Diagnosis and treatment outcomes reporting? Drug order entry? Automated alerts and reminders? Electronic
communication with patients? Health history?
Any other comments. Can you think of anything else that might help us to learn from implementing system at the hospital?
Anyone else that we should talk to about this?

J. vretveit et al.

More complete and better information on the system

and likely increase in patient safety (e.g. clearer medications information)

taken to start using the new system. More details of the

implementation and impact are provided in a full report [23].
Factors hindering and helping the change

A lot easier to nd patient information. I am certain it saves

time because of this, and improves patient care because we
dont have to wait to get the information from another system

New and better ways to work were being discovered.

In the emergency room the new system allows a real time list
of patients in ER with basic information which doctors easily
and quickly see. This is very useful where two or more doctors
are involved with a patient before one patients information
could have been held on ve different systems, many of which
could not be accessed

The factor most often reported to hinder implementation

was not allowing for extra personnel time:
It was difcult to be able to prepare for TC and at the same
time do the ordinary work
Staff had to work over time to be able to do all that was
expected of them

One interviewee thought that the earlier experience implementing an EMR in 2000 was a hindrance because,

Likely increase in patient safety (e.g. clearer medications

information)

The last change like this was complicated. It took a lot to learn
the new system, and there were many problems. So our experience with large IT changes like this was not entirely positive

A lot easier to nd patient information. I am certain it saves

time because of this, and improves patient care because we
dont have to wait to get the information from another system

The merger had happened recently, so new heads of units

were covering both sites and other personnel had been
changed. There were also some initial disagreements about
whether or how much departments should pay for the
system.

Time savings (for example far fewer telephone calls as a

result of the whole hospital using the same system)

Improving integration of the two merged sites

Potential for development (e.g. clinics could to use electronic prescriptions and electronic dictation in the
future).
There were a few disadvantages reported:
The speed of implementation prevented developing new
procedures
People did not get time and help to adjust their routines to the
new system. It would have been much better to change routines
while changing the system. There was no time for development.
Mostly we just put what we did on the computer

Personnel time was diverted from clinical work for

implementation (Difculties getting the time of physicians and personnel to attend training and help adapt
the system to their department needs)
Some local project groups had difculties getting time for
working with TC. Not all head of clinics and head of units
understood that it had to take time to prepare for TC

The costs of the implementation at this 700 bed 7000

employee site of the teaching hospital was $700,000 USD,
under half of the $1.5 m budgeted for consultants, development of integration, education, equipment, information
material and to upgrade the hardware server. However, this
does not include the costs of working time used by clinic
project personnel and other personnel in planning and
making adaptations, implementation, training or other time

262

We needed better information about how much time and money

we should have set aside in the department for this project.

The short time for implementing the system hindered the

possibility to give all staff better preparation.
If you had a detailed doctor- or, clinic-specic question you did
not ask it because there were too many different people there;
secretary nurses and people from different clinics.

Interviewees at Karolinska reported that the following

factors helped implementation:
Personnel saw the benets of having the same system
covering two sites (e.g. allowing easy staff and patient
information transfer).
Once the merger was decided and we could see it was happening, we were all motivated to get a common record for all
departments and sites: everyone could see the benets and
necessity for this

The other site was already using the EMR and had
developed it to be user-friendly. The IT department did
not have to make major changes apart from increasing
the capacity of the system.
The system had a good reputation and many people did
not like the old systems. The new EMR was said by the
users to be a very easy and usable.
The system itself is intuitive and can be tted to the medical
work which is done now and also to the work if it is
reorganised
This new system saves time because it is quicker to see where
to go for information and to access it

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Emergency room personnel are very positive as the new system

allows them to follow patients minute to minute and see which
part of the department the patient is in. This saves work

Information technology in healthcare

Table 2 Summary of EMR implementation

Type of implementation
change

A two teaching hospital merger led to a change of an existing EMR used by Karolinska site
to the EMR used at the other site. Implementation successful

.............................................................................................................................................................................

System selection
Design and testing
Implementation process
Main factors helping
implementation

Main factors hindering

implementation

Main impact

Personnel were already used to EMR systemsit was

not a change-over from a paper system, but a new
EMR system.
Many were dissatised with their system, and with
having ve different medical record systems in the
hospital.
The system demanded little extra work to operate it and
needed little time-off for training or to adjust to it,
Senior management said it was the highest priority
project and made it so, as did heads of clinics. There
was no problem getting resources. The hospital management group continually pointed out the importance of
the project.
The project leader was said by many to be very competent and that the project was well planned and organized, in part because of previous experience of
introduction at the other site and familiarity with the
system. A well-functioning local IT-department in the
hospital helped in the implementation process (Table 2).
Comparison to findings from other studies
The review of research identied factors found by previous
studies to be important to successful implementation. This
could be viewed as the best evidence-based theory of EMR
implementation given the current state of scientic knowledge in the eld. Following case study methods for analytic
generalization [24], empirical ndings from the study are
compared with these factors in Table 3.

Table 3 Factors important for implementation shown by

previous research
Factor important for
implementation

Karolinska EMR
implementation

....................................................................................

The EMR System

Ease of navigation, efciency in use and
accessibility
Physician acceptance and implementers
responsiveness to concerns
Absence of system failures
No conicting suitability (managerial/
clinical)
Implementation process
User involvement in selection and
development
Education provided at the right times,
amount and quality
Previous computer or EMR experience
Leadership
Strong management support
Physician champion
Resources
Adequate people and nancial resources
Organization culture and climate
Academic medical centre more change
ready

Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes

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Cost of implementation

Selection of the system was made locally by the hospital with extensive consultation with
clinical personnel
Already tried and tested at the other site, but also successfully piloted in one department at
the Karolinska site
Selection, planning and full implementation made as planned and for half the budget
Consultation before implementation
Consensus about need for the system and which system was best
Prioritzation and driving by management team
Competent IT project leader and team
Tried and tested system
User friendly intuitive system needing little training
Potential for development of system
Order entry not difcult to integrate
Recent merger not complete with new people in post
Time spent by department personnel on implementation was taken from ordinary work time
Some had difculties involving doctors in the preparation work
Initial disagreements about much departments should pay for the system
No extra time burdens and increased efciency
Better coordination of long term patients reported
$700,000 for 700 bed, 7000 employee hospital site

J. vretveit et al.

Table 4 Presence of features predicting successful innovation

implementation (Rogers, 1995)
Rogers 1995 theory

Karolinska implementation

....................................................................................

Relative advantage
(perceived as better)
Compatibility (consistent
with values and needs)
Complexity (ease of
understanding and use)
Trialability (possibility of
experimentation)
Observability (visible
examples elsewhere)

Yes (in pre-implementation

assessment, and with experience
during implementation)
Largely (but prescription order
entry and use for research would
need to be developed in year 2)
Yes (intuitive)
Yes (piloted in one department)
Yes (at the other hospital site)

Comparison to Rogers theory of diffusion

of innovation

Discussion
A recent review found serious shortcomings in most studies
of information technology in health care, but also some evidence of improved quality of care for patients. It found that
most health care providers needed more information about
how to implement IT successfully [1]. The research reported
in this paper used observation and documentation but relied
largely on self reports by a limited sample of informants,
which is one of the limitations found in many studies. The
EMR system and the implementation process are both
similar and different to other EMR systems and to
implementations under other conditions. The study site did
not change-over from a paper system, but replaced ve old
systems with one system, and personnel were already used to
working with EMRs. Many EMR implementations require
more development work before or during implementation,
and some are of paper to computer systems, which are a far
more substantial change.
Generalizations in this eld need to be make with caution:
complex interventions in complex social organizations
depend for their effectiveness on the conditions under which
they are introduced (the conditionality of interventions [25].
However, the ndings from this study are stronger than

264

Practical implications
In this study, the comparison with other research suggests
general lessons for others implementing an EMR system in a
hospital:
Choose a system which allows a range of needs to be
met and is a tried and tested in a similar setting,
The overriding choice criteria should be a system that
works for clinical personnel and saves time. Resistance
is not always irrational. If personnel do not think it is
easy to use and will save time then implementation will
be signicantly more difcult and possibly impossible.
The system should be intuitive, requiring little or no
training,
The system should be easy to modify and develop,
within limits, for different departments and uses.
The decision about the system should be participatory,
but once made, implementation should be directed and
driven.
Balance local control of selection, implementation and
clinical participation with meeting higher-level
requirements.
Involve each level in different ways, with clear and
appropriate parameters about which decisions can be

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Rogers theory for the successful adoption of an innovation

is based on research of different interventions and different
situations. Evidence from these studies provides some
limited conrmation of Rogers theory [21] (Table 4).
One possible starting point for future research to develop
EMR implementation theory is to combine the above framework with Rogers theory. The two models above were
derived from empirical research but the above only provides
conrmatory evidence of both modelsresearch to disconrm each of the factors is needed.

some other studies because the research was carried out

prospectively and concurrently, drew on detailed project
documentation and involved a systematic comparison with a
theory of information technology implementation derived
from research evidence and a previous study before the
empirical data gathering.
Although there are limitations there are some tentative
conclusions, which may be drawn about why the implementations took the course it did, and why the ndings differed
from the less successful Kaiser implementation, which was
studied using the same methods. The elements of the theory
summarized above also support these conclusions. The relatively successful Karolinska implementation could be due to:
Consultation before implementation
Consensus about a need for the system and which
system was best
Prioritzation and driving by management team
Competent IT project leader and team
Tested, user-friendly and intuitive system needing little
training
Potential for development of the system
Medication order entry not difcult to integrate after
implementation
The evidence from this and other research is that an EMR
designed to meet many different needs often does not meet
local clinical work needs, is more difcult to implement, and
can reduce productivity and access to information critical for
patient care and safety. A new system will need to have
benets which signicantly outweigh these disadvantages and
which are clearly communicated, if it is perceived to be less
user-friendly and requires extra time for operation, which is
often reported to be the case in previous research. Time and
resources will be needed to develop the system.

Information technology in healthcare

made locally and which require higher-level decisions

about common standards.
Assess and address the presence and absence of prior
and concurrent factors, which have been repeatedly
shown in research to help and hinder implementation.
Findings from other research and these case studies suggest
that EMR implementation is a conditional intervention and
success depends on many prior and concurrent environmental factors [25]. The less change the EMR system
demands and the fewer other changes, which are occurring
at the same time, then the more likely implementation will be
successful. Organizations, which have strong formal and
informal change capacity may be able to manage more
changes at the same time.
Future research is needed of implementations of different
EMRs in different situations, reported in a standardized way
to allow comparisons. Theory and knowledge could be developed if studies built on previous research to test hypotheses,
especially about which conditions are critical for successful
operation for particular systems and how this is dened by
different parties.

Conclusions

Funding
Funding for the Sweden study was provided by Stockholm
County Health care and other sponsors of the Medical
Management Centre. Ethical approval. Granted under existing
agreements for research with Stockholm County Health care,
Sweden. The Kaiser Permanente Hawaii Institutional Review
Board gave ethical approval for the USA study. Statement of
independence of researchers from funders. All researchers were independently funded and have no non-research relationships to
the organizations studied or to any information technology
suppliers or consultants.

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