The use of a nursing informatics system as an ...

The use of a nursing informatics system as an exemplar to investigate business value of IT in healthcare Peter Haddad & Nilmini Wickramasinghe

Health and Technology ISSN 2190-7188 Health Technol. DOI 10.1007/s12553-015-0100-8

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Author's personal copy Health Technol. DOI 10.1007/s12553-015-0100-8

ORIGINAL PAPER

The use of a nursing informatics system as an exemplar to investigate business value of IT in healthcare Peter Haddad & Nilmini Wickramasinghe

Received: 8 September 2014 / Accepted: 24 February 2015 # IUPESM and Springer-Verlag Berlin Heidelberg 2015

Abstract Researchers and decision makers in healthcare are taking great interest in clinical practices where there is a high potential to improve healthcare outcomes and reduce costs by incorporating a myriad of technology solutions. However, to date very few, if any of these IS/IT (information systems/ information technology) solutions have realised the expected improvements to quality care with the expected cost reductions. This makes the need to evaluate the impact of IT on overall performance of clinical practices i.e. business value of IT a key strategic imperative in healthcare. To address this key need, we propose a comprehensive framework that conceptualises business value of IT in healthcare in different layers. To illustrate the proposed framework, a case study is used, which serves to examine the proposed conceptual model. The exemplar case study is an Australian-made nursing documentation system; an enterprise system that caters for multiple clinical users in acute healthcare contexts and hence provides appropriate richness to validate the proposed model.

Keywords Information technology . Information systems . Value . Business value . Healthcare . Nursing documentation . Ecosystems

P. Haddad (*) RMIT University, Melbourne, Australia e-mail: [email protected] N. Wickramasinghe Deakin University, Melbourne, Australia e-mail: [email protected] P. Haddad : N. Wickramasinghe Epworth HealthCare, Richmond, Australia

1 Introduction The unremitting quest to improve healthcare outcomes and reduce escalating costs has encouraged decision- and policymakers in the healthcare industry to invest more in information systems/information technology (IS/IT) [1, 2]. This has been driven largely by success stories for such investments in other sectors of the service industry such as retail, education and logistics. The noteworthy international tendency for healthcare to invest more in IS/IT to both enhance healthcare quality and reduce cost [3] has called for further studies and investigations about the role IS/IT may play to improve healthcare outcomes [4]. Furthermore, because the Internet has created new opportunities and challenges to the traditional health care IT industry, e-health presents both opportunities and challenges [5]. Electronic patient records (EPR) are being introduced and used by more and more healthcare organizations nowadays in different contexts of healthcare delivery [6]. Moreover, nursing documentation is one of the areas where IS/IT is being used, and the shift from paper-based to electronic-based documentation has raised questions regarding the way nursing documentation should be organized and presented in EPR [7]. The impact of IS/IT investments on organizational performance (namely ‘Business Value of IT’) has been a major point of research since 1992 [8] in different industries [9, 10]. Business value of IT in healthcare, however, is yet to be fully investigated. This is largely due to the fact that healthcare delivery is complex and consists of many systems and subsystems [11] or one can think of these as ecosystems which must all be considered if a true sense of value is to be established. In the light of these circumstances, developing a robust and suitable framework to assess the value of these IT investments clearly becomes a strategic imperative and vital step toward designing sustainable e-health solutions.

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This paper outlines an exploratory research study that aims to examine the business value of IS/IT in healthcare, especially it focuses on a new IS/IT system developed in Australia for nursing documentation. To do so, this study proposes a framework for the evaluation of cost versus quality outcomes utilizing different layers within healthcare delivery. This proffered framework is based on two well-known conceptual models [12, 13] that represent IT portfolio and healthcare delivery as will be described in the following sections.

2 Literature review This section mainly aims at giving a brief summary of the meaning of “business value of IT” and its applications and prior research. Current healthcare delivery challenges and conditions will be briefly summarized. The two conceptual models used to develop the proposed conceptual model will be given. Then, a few available prior studies to highlight ITbased nursing documentation will be summarised. 2.1 Business value of IT in healthcare Investing in IS/IT as a strategy to improve quality of the medical procedures have been appealing [5, 14]. For example, investing more in health information technology ($10 billion annually for 5 years) and paying healthcare providers based on quality of care, not quantity of services, were among the few key points of Mr. Obama’s healthcare plan declared in his speech delivered in December 11, 2008 [15]. Same trend was taking place in Western Europe, where healthcare IT spending was expected to increase from $9 billion in 2006 to $12 billion in 2011 [16]. These escalating investments were mainly driven by the success of IS/IT investments, whose impacts were studied in details in different industries than healthcare. The term business value of IT is commonly used to refer to the organizational performance impacts of IT [17]. In their review of research on business value of IT [17] used different measurements of performance, including cost reduction, profitability improvement, productivity enhancement, competitive advantage and inventory reduction to measure business value of IT. One of the first researchers to study business value of IT was Peter Weill [8]. Since then, studying business value of IT has not stopped [18]. Although the business value of IT has long been investigated, the current literature is still to develop better understanding of the relationship between IT investments and firm performance [10]. Contradicted findings in this area of research are common, and this could be the reason why researchers believe that a productive approach is to move from the question of whether IT creates value to how, when and why benefits occur or fail to do so [17].

The healthcare informatics literature is relatively new [19], and the term business value of IT is still to be studied in this industry, especially that healthcare providers have started to invest heavily in various healthcare IT systems to enhance “quality of patient care,” which has therefore been a major criterion for related studies on hospitals [20]. To cover this new trend, a number of studies tried to limitedly investigate the impact of implementing specific types of healthcare IT systems, such as electronic patient records (EPRs) using limited sample sizes, with less possibilities to generalize the findings on healthcare industry in total [21]. Investigating business value of IT in healthcare, thus, is a clear void in the current literature, and investigating that would be a key step to help focus IS/IT investments on value generating technologies and systems. To further clarify the term business value of IT, this paper adopts the IT portfolio conceptualization as described in the next section. 2.1.1 Information technology portfolio The IT portfolio of an organization is its entire investments in IT, including all of the people dedicated to providing IT services, whether centralized, decentralized, distributed, or outsourced [12]. Principally, firms invest in IT to achieve four fundamentally different management objectives: transactional, infrastructure, informational, and strategic [12]. These management objectives then lead to informational, transactional, infrastructure, and strategic systems, which make up the IT investment portfolio, and will be used as a representation of IT whose potential business value will be evaluated in this research. Figure 1 depicts these objectives, and Table 1 describes the four management objectives. The figure and the table both were adopted from [12]. 2.2 Healthcare delivery: current trends and conditions Healthcare delivery, as a whole, is ‘fragmented, disorganized, and unaccountably variable’, and the main reason, we don’t hear about a “healthcare delivery system”, is that healthcare delivery was never designed as a system and does not operate as one, and 75 % of patients consider the healthcare system fragmented and fractured, a “nightmare” to navigate, and plagued by duplication of effort, lack of communication, conflicting advice regarding treatment, and tenuous links to the evolving medical evidence base [22–23]. The complexity of improving healthcare delivery, on a global perspective can be identified from current statistics. According to [24] for example, more than 98,000 Americans die every year and more than ten times this number injured as a result of “broken healthcare processes and system failures”. These figures are getting worse with time, soaring to 180,000

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Fig. 1 Management objectives for the information technology portfolio [12]

patients in Medicare alone in a given year [25] and between 210,000 and 440,000 patients [26]. The 21st Century healthcare must be: safe, effective, patient-centred, timely, efficient and equitable [27]. To meet these six objectives, the committee emphasized the role the engineering community can play to facilitate the complex process of transforming the healthcare delivery systems [27]. Rouse and Cortese [13] suggest architecture for the healthcare delivery enterprise, shown in Fig. 2. The efficiencies that can be achieved at the lowest level (clinical practices) are limited by the nature of the next level (delivery operations). For example, functionally organized practices are much less efficient than delivery organized practices that focus on processes. Table 1

Similarly, the efficiencies that can be gained in delivery operations are limited by the level above (system structure). Functional operations are driven by organizations structured around specialties, e.g. anaesthesiology and radiology. And efficiencies in system structure are limited by the healthcare ecosystem in which organizations operate. Healthcare providers in different countries have different healthcare delivery experiences. 2.2.1 Defining value in healthcare delivery Healthcare commentary often revolves around universal availability and cost control, i.e. access and cost. People are not likely to want the lowest cost; the central issue should really be

The objectives of IT portfolio [12]

Objectives

Description

Infrastructure

• The foundation of information technology capacity, which is delivered as reliable services shared throughout the firm and coordinated centrally. • Includes both the technical and the managerial expertise required to provide reliable services. • Having the required infrastructure services in place significantly increases the speed with which new applications can be implemented to meet new strategies. • Processes and automates the basic, repetitive transactions of the firm. These include systems that support order processing, inventory control, bank cash withdrawal, statement production, account receivable, accounts payable, and other transactional processing. • Transactional systems aim at cutting costs by substituting capital for labor and handling higher volumes of transactions with greater speed and less unit cost. • Provides information for managing and controlling the firm. • Typically supports management control, decision-making, communication and accounting. These systems can summarize and report this firm’s product and process performance across a wide range of areas. • Two examples of these systems come from Ford Australia (Electronic Corporate Memory), and from the consulting firm Bain & Company that developed Bain Resources Access for Value Addition (BRAVA). • Strategic investments are made to gain competitive advantage or to position the firm in the marketplace, most often by increasing market share or sales. • Firms with successful strategic information technology initiatives have usually found a new use of information technology for an industry at a particular point an time. • Two good examples of these strategic initiatives are inventing automatic teller machines (ATMs), and designing a system that provides immediate 24-h, 7-day-a-week loan approvals in car dealerships using expert systems technology. Both of these innovative systems have changed their industries forever.

Transactional

Informational

Strategic

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the creation of a healthcare system that provides the highest value [13]. Value is often defined in terms of the expenditure outcome benefits, divided by the expenditure costs. The healthcare benefits, from a patient’s perspective, include the healthcare outcomes quality, the safety of the delivery process, and the services associated with the delivery process, and from society perspective benefits might include the availability of healthy and productive people who contribute to society in many ways. When people are not healthy, their contributions diminish [28]. To examine business value of IT in healthcare, in this research we use a new IS/IT system developed in Australia to facilitate electronic nursing documentation, which we give a brief summary of in the next section. 2.3 Electronic nursing documentation Nursing documentation plays a key role in the success of nursing activities, as it supports nursing staff efforts to improve healthcare outcomes by developing customized care plan for patients [29]. To further improve nursing documentation, IS/IT has been used to introduce electronic documentation systems, in an attempt to minimize documentation efforts and times, and to maximise the interaction between caregivers and patients [30]. Nursing Documentation systems aim at documenting nursing notes that describe the care or service to that client. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, emails, audio or video tapes and images. Through documentation, nurses communicate their observations,

decisions, actions, and outcomes of these actions for clients. Documentation software tracks what occurred and when it occurred [31]. This migration from paper-based to electronic-based documentation, which should not be a mere replication of paper forms in an electronic format [32, 33], have encouraged research in the area of finding the impact of introducing IT-based nursing documentation on healthcare outcomes. Time consumed for documentation [34] and better healthcare outcomes, and efficiency are the main parameters that have been studied in this regard [35, 36]. A number of studies have focused on time taken for documentation, with contradicted findings and results. For example, time reduction could be monitored and seen after the introduction of different electronic nursing documentation [37, 38], while this introduction could not make any change in time consumed for nursing documentation [39, 40], and others found that electronic nursing documentation caused documentation time to increase [41]. Another aspect of research on electronic documentation is efficiency. For example [34] studied an electronic nursing documentation system in an Australian residential aged care facility and found that introducing this system may not lead to efficiency in documentation, and using both paper and electronic means for documentation might be a barrier to achieve better efficiency. In general, the impact of the introduction of electronic nursing documentation to improve the patients’ outcomes remains unclear, and further socio-technical studies are needed to investigate the daily interaction between nurses and electronic nursing documentation systems [32].

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3 Research design and the proposed conceptual model This paper is a part of a larger research project that aims at answering the following key research question: How can information technology facilitate the generation of business value in healthcare firms? To operationalize the IT resource, from a technical perspective, we align with the classification of IT portfolio into infrastructure IT, transactional IT, informational IT, and strategic IT [12] (See Fig. 1). From an organizational perspective, this study will build upon The Enterprise of Healthcare Delivery Model (See Fig. 2),

Fig. 3 The proposed conceptual model

and adapt it to find the business value of IT from a socio-technical aspect in four interrelated levels: (i) Clinical practices (people); (ii) Delivery operations (processes); (iii) System structure (organizations) (iv) Healthcare ecosystem (society). Figure 3 shows the proposed conceptual model for this research with a key that shows the definitions of clinical IT applications. This research aims at investigating the business value of different IT investments across different layers of healthcare delivery. For the purpose of this paper, we examine a nursing informatics system, and the business value potentially generated by it.

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3.1 Case vignette: the case of a nursing informatics solution Case study is a useful method to illustrate critical issues or key points [42]. Thus, in this study we use the case of a nursing informatics solution (NIS) to study the business value of this system. The studied (NIS) is a new nursing information system designed and developed in Australia to be used at the point of care in both private and public hospitals. The developers envisage that this (NIS) system will replace the paperbased nursing documentation in hospital acute wards. The system aims at maximizing the time for patient care by eliminating paper works, which in turn would create a better record of patient care, and provide a positive enhancement to nurses’ work experience. Table 2 maps the case study to the proposed conceptual model. According to [12], this solution would fit in Informational IT, as it typically supports management control, decision making, communication and accounting. Table 2

To investigate the business value of this system, a series of 13 semi-structured were conducted between 2013 and 2014. All interviews were held at a leading private hospital in Melbourne-Australia. All interviews were audio-recorded and transcribed, and qualitatively analysed using Nvivo software package.

4 Findings The fidelity and usability of this system was investigated by a team of researchers from both nursing and health informatic areas. The summary of findings shows that the system has shifted the location of nursing documentation activities towards the ward rather than nursing stations (61.3 % of nursing documentation took place at the bedside after the implementation of this system compared to 24.8 % prior to it). The time consumed to make the required documentation fell from 15.7 to 6.4 %, which freed up over 9 % of nurse time, which in turn

Mapping (NIS) to the proposed conceptual model

Healthcare delivery

Main components

(NIS) Case study

Healthcare ecosystem

Payers

(NIS) is expected to be implemented in both public and private healthcare sectors after its validity, usability and other required tests would have been done and research shows that this system would enhance healthcare outcomes.

Regulators

(NIS) needs to meet the regulatory environments of targeted countries. In Australia, for example the regulator is the Australian Government Commercially, there is a number of nursing documentation systems. The designers of (NIS), however, introduce this system as a new and unique nursing information system [43]. Australian healthcare sector is 2-teir structure (private and public). Thus, (NIS) aims to get through both sectors. According to its designers, (NIS) aims to allocate more time for patients’ care by putting (NIS) terminals at patients’ bedsides, which would create more interaction between nurses and patients [43]. (NIS) is meant to allow higher level of collaboration between ward nurses and other healthcare professionals both within a healthcare organisation and between different healthcare organisations enabling nursing staff to document key information, retrieve and share the documented information with other nursing, medical and allied health professionals to provide safe, continuous and high quality care for the patients in the ward [43], which would be investigated in this research.

Competitors HC Providers Patients

System structure

Collaboration

Integration Internal Delivery operations

Clinical practices

External Detection

Diagnosis Treatment Recovery ND: Nursing documentation

The system aims to evaluate, filter and process clinical data to ensure the quality of data entry, to support nursing decision making, to provide alerts and prompts to prevent treatment errors such as errors or omissions in medication administration, to 1) improve nursing information access (real time and flexibility); 2) improve quality (accuracy and legibility); 3) reduce time collecting information from multiple sources [43].

Nursing documentation systems Nursing Documentation systems are meant to document nursing notes that describe the care or service to that client. Through documentation, nurses communicate their observations, decisions, actions, and outcomes of these actions for clients [31]. (NIS) aims to meet these requirements electronically according to the designers [43].

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increased the proportion of nursing activities devoted to patient assessment from 5.2 to 9.1 %.1 For the purpose of this paper, we asked whether, or not, these positive findings would lead to generating business value out of the studied system. As a result, a number of enablers and burdens were identified, along with some requirements this system will need to meet in order to generate business value. Enablers One of the biggest problems for IT systems is its users. The majority of the healthcare professionals work as visitor medical officers (VMO’s). This has caused many problems for other IT/IS solutions in hospitals. With the studied NIS system, the users are the nurses, who are employed and salaried by their hospitals. This makes the use of this system unrestricted and open. Another enabler for this system to generate business value is what was called “Face value” by some of the interviewees. The visible end of the system is a state-of-the-art tablet computer, and the nurses are to use these terminals to take notes and input observations. According to a number of the interviewees, at a private hospital, this enhances the reputation of the hospital and generate “face value” to the hospital. I.e. this would increase the business of the hospital, and more people would be inspired by the use of this system. Burdens Although there are positive indicators about the potential of this system, a number of burdens to generate business value were identified. First, the system does not cover the whole process of healthcare, and it is limited to the ward. This concerns the majority of the interviewees, who believe that any IS/IT solution should be clearly articulated to fit within the healthcare strategy of a hospital. The second burden is that the system is still under development, so, hospitals, which are “healthcare business, not an IT shop” according to the clinical chief information officer, would not be interested in being the bleeding edge as the CIO described. Further requirements The introduction of this system represents a cultural shift according to the majority of the interviewees. Thus, adequate training is needed, for not only the functionality this system provides, but also the cultural readiness and acceptance to give up the traditional documentation using pen and paper, and start adopting computer based documentation systems. Apart from the training, the system should extend its scope to cover the healthcare process, from pre-admission to discharge. This would enhance the fit with the healthcare strategy of the hospitals adopt this system. 1 These results are the summary of a research project to evaluate the fidelity and usability of the NIS system. The reference is available upon request.

5 Conclusion This research contributes to the extant body of knowledge in several ways. First of all, current literature lacks rigorous research on the business value of IT in healthcare, so this exploratory study serves as one of the first detailed investigations in this regard. Second, the research question “How can information technology facilitate the generation of business value in healthcare firms?” and more specifically, the business value of informational IT, the case of (NIS) to improve clinical practices and delivery operations from a socio-technical perspective is significant in today’s healthcare environment. Furthermore, this study provides strategies and methods for service providers who are attempting to balance costs (the input) and the quality of service (output). To examine the proposed framework operationally, the case of (NIS) would serve as a testing environment to highlight the breadth and depth of the proffered framework. This exploratory study has developed the first steps for providing significant and last benefits in the determination of business value in healthcare contexts. Future studies will leverage from this work and test various segments of the proffered framework in various healthcare contexts. The future of effective and efficient healthcare provision is linked to IT in one way or another from electronic healthcare devices through the modern e-health delivery models; thus it is likely that the issue of business value of these IT investments will also becoming increasingly more important. In closing, we note as more and more e-health solutions specifically and IS/IT initiatives generally in healthcare appear we must have a systematic framework to aid in the important assessment of the value of these solutions. The proffered framework is both robust and systematic but another advantage is it is as applicable irrespective of the health system and thus enables us to not just assess value of a specific system but also compare and contrast the value of different systems in a systematic fashion.

Conflict of interest The authors declare that they have no conflict of interest. Ethical Statement • The manuscript has not been submitted to more than one journal for simultaneous consideration. • The manuscript represents a continuous research project. Therefore, some parts of it may be found in our other publications (all cited). The findings though are new and have not been published previously. • No data have been fabricated or manipulated (including images) to support your conclusions • No data, text, or theories by others are presented as if they were the author’s own (“plagiarism”). • Consent to submit has been received explicitly from all co-authors, as well as from the responsible authorities—tacitly or explicitly—at the institute/organization where the work has been carried out, before the work is submitted.

Author's personal copy Health Technol. • Authors whose names appear on the submission have contributed sufficiently to the scientific work and therefore share collective responsibility and accountability for the results.

References 1. Berner ES. Implementation challenges for clinical and research information systems: recommendations from the 2007 Winter Symposium of the American College of Medical Informatics. J Am Med Inform Assoc. 2008;15(3):281–2. doi:10.1197/jamia.M2581. 2. Kilbridge PM, Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008;15(4):397. doi:10.1197/jamia.M2735. 3. Eysenbach G. What is e-health? J Med Internet Res. 2001;3(2):E20. doi:10.2196/jmir.3.2.e20. 4. Lawler EK, Hedge A, Pavlovic-Veselinovic S. Cognitive ergonomics, socio-technical systems, and the impact of healthcare information technologies. Int J Ind Ergon. 2011;41(4):336–44. doi:10.1016/j. ergon.2011.02.006. 5. Wickramasinghe N, Schaffer J. Realizing value driven e-health solutions. Washington DC: IBM Center for the Business of Government; 2010. 6. De Veer AJE, Francke AL. Attitudes of nursing staff towards electronic patient records: a questionnaire survey. Int J Nurs Stud. 2010;47(7):846–54. doi:10.1016/j.ijnurstu.2009.11.016. 7. von Krogh G, Naden D, Aasland OG. Testing a Nursing-Specific Model of Electronic Patient Record documentation with regard to information completeness, comprehensiveness and consistency. J Clin Nurs. 2012;21(19–20):2930–9. doi:10.1111/j.1365-2702.2012. 04185.x. 8. Weill P. The relationship between investment in information technology and firm performance: a study of the valve manufacturing sector. Inf Syst Res. 1992;3(4):307–33. 9. Silvius AG. The Business Value of IT: A Conceptual Model for Understanding. Enterprise IT Governance, Business Value and Performance Measurement; 2010: p. 102. 10. Masli A, Richardson VJ, Sanchez JM, Smith RE. The business value of IT: a synthesis and framework of archival research. J Inf Syst. 2011;25(2):81–116. doi:10.2308/isys-10117. 11. von Lubitz D, Patricelli F. Network-centric healthcare operations: data warehousing and the associated telecommunications platforms. Int J Ser Stand. 2007;3(1):97–119. doi:10.1504/IJSS.2007.011830. 12. Weill P, Broadbent M. Leveraging the new infrastructure : how market leaders capitalize on information technology. Boston: Harvard Business School Press; 1998. 13. Rouse WB, Cortese DA. Engineering the system of healthcare delivery. Amsterdam: IOS Press; 2010. 14. Gagnon MP, Godin G, Gagne C, Fortin JP, Lamothe L, Reinharz D, et al. An adaptation of the theory of interpersonal behaviour to the study of telemedicine adoption by physicians. Int J Med Inform. 2003;71(2–3):103–15. doi:10.1016/S1386-5056(03)00094-7. 15. Ryan L. System overhaul. Society of Hospital Medicine. 2009. http:// www.the-hospitalist.org/details/article/184492/System_Overhaul. html. Accessed 1 Sept 2014. 16. Silvia Piai JD. Western Europe, Healthcare Sector, IT spending forecast update, 2007–20112008. 17. Melville N, Kraemer K, Gurbaxani V. Review: information technology and organizational performance: an integrative model of IT business value. MIS Q. 2004;28(2):283–322. 18. Kohli R, Grover V. Business value of IT: an essay on expanding research directions to keep up with the times. J Assoc Inf Syst. 2008;9(1):23–39.

19. Dalrymple PW. Data, information, knowledge: the emerging field of health informatics. Bull Am Soc Inf Sci Technol. 2011;37(5):41. 20. Burke DE, Menachemi N. Opening the black box: measuring hospital information technology capability. Health Care Manag Rev. 2004;29(3):207–17. 21. Das S, Yaylacicegi U, Menon NM. The effect of information technology investments in healthcare: a longitudinal study of its lag, duration, and economic value. IEEE Trans Eng Manag. 2010;58(1): 124–40. doi:10.1109/TEM.2010.2048906. 22. Wolper LF. Health care administration: managing organized delivery systems. 5th ed. Sudbury: Jones and Bartlett Publishers; 2011. 23. Picker Institute, Eye on patients: a report by the Picker Institute for the American Hospital Association. Picker Institute: Boston, Mass; 2000. 24. Medicine Io. Building a better delivery system: a new engineering/ health care partnership: Institute of Medicine; 2005. 25. Levinson DR. Adverse events in hospitals: national incidence among Medicare beneficiaries. Department of Health and Human Services Office of the Inspector General; 2010. 26. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122–128. 27. Institute of Medicine (US). Committee on Quality of Health Care in America, Crossing the quality chasm: a new health system for the 21st century. 2001: National Academy Press. 28. Porter ME, Teisberg EO. Redefining health care: creating valuebased competition on results. Boston: Harvard Business School Press; 2006. 29. Bjorvell C, Wredling R, Thorell-Ekstrand I. Improving documentation using a nursing model. J Adv Nurs. 2003;43(4):402–10. 30. US Department of Health and Human Services, Electronic health records and meaningful use. Retrieved September, 2014. 8: p. 2010. 31. HIMMS Analytics Database [database on the Internet] 2009. Available from: http://www.himssanalytics.org/hcproider/ emradoption.asp. Accessed 5 Mar 2012. 32. Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality of patient care. J Nurs Scholarsh. 2011;43(2):154–62. doi:10.1111/j.1547-5069.2011. 01397.x. 33. Ball MJ. Nursing informatics: where caring and technology meet. 3rd ed. New York: Springer; 2000. [with] forewords by Sue Karen Donaldson and Ulla Gerdin. ed. 34. Munyisia EN, Yu P, Hailey D. The impact of an electronic nursing documentation system on efficiency of documentation by caregivers in a residential aged care facility. J Clin Nurs. 2012;21(19–20):2940– 8. doi:10.1111/j.1365-2702.2012.04157.x. 35. Moody LE, Slocumb E, Berg B, Jackson D. Electronic health records documentation in nursing—nurses’ perceptions, attitudes, and preferences. CIN Comput Inform Nurs. 2004;22(6):337–44. 36. Lee TT, Yeh CH, Ho LH. Application of a computerized nursing care plan system in one hospital: experiences of ICU nurses in Taiwan. J Adv Nurs. 2002;39(1):61–7. 37. Bosman RJ, Rood E, Oudemans-van Straaten HM, Van der Spoel JI, Wester JPJ, Zandstra DF. Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Med. 2003;29(1):83–90. doi:10.1007/s00134-0021542-9. 38. Wong DH, Gallegos Y, Weinger MB, Clack S, Slagle J, Anderson CT. Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system. Crit Care Med. 2003;31(10):2488–94. doi:10.1097/01.ccm.0000089637. 53301.ef. 39. Hakes B, Whittington J. Assessing the impact of an electronic medical record on nurse documentation time. CIN Comput Inform Nurs. 2008;26(4):234–41. 40. Menke JA, Broner CW, Campbell DY, McKissick MY, EdwardsBeckett JA. Computerized clinical documentation system in the

Author's personal copy Health Technol. pediatric intensive care unit. BMC Med Inform Decis Mak. 2001;1:3. doi:10.1186/1472-6947-1-3. 41. Saarinen K, Aho M. Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care? Acta Anaesthesiol Scand. 2005;49(1):62–5. doi: 10.1111/j.1399-6576.2005.00546.x. 42. Yin RK. Case study research: design and methods. 5 ed. Los Angeles: SAGE Publications; 2014.

43. Wickramasinghe N, Kent B, Moghimi F, Stien M, Nguyen L, Redley B, et al. Using technology solutions to streamline healthcare processes for nursing: the case of an Intelligent Operational Planning Support Tool (IOPST) solution. In: Wickramasinghe N, Al-Hakim L, Gonzalez C, Tan J, editors. Lean thinking for healthcare. Healthcare delivery in the information age. New York: Springer; 2014. p. 405– 30.