Towards a better understanding of delivering e-health systems: a systematic review using the meta-narrative method and two case studies

Background: The introduction of ‘e-Health’ has profound consequences for the organisation and delivery of health services. However, past studies are inconsistent as to the nature and magnitude of benefits from e-Health or how these might be realised. According to many, e-Health will make healthcare better, safer, cheaper and more integrated. Yet there is also evidence that new services can be introduced without discernible benefits and some authors criticise visions of a technological utopia. e-Health systems are complex interventions, entailing a combination of technology and organisation. They can be described as socio-technical systems. Aims/objectives: Much past research consists of implementation studies. We looked at e-Health systems that are currently in use, in order to learn from how real health services have used technology and adapted to the use of technology. Methods: We performed a systematic review using the meta-narrative approach. We then used mixed methods within a case study approach to look at two healthcare systems using information systems, including observations, interviews and formal risk management approaches (task analyses, prospective and retrospective hazards analyses). Key findings: Our review suggests electronic health records require human input to recontextualise knowledge; and that while secondary work (e.g. audit, billing) may be made more efficient by electronic records, primary clinical work may be made less efficient. The development of e-Health systems can reflect past and ongoing contingencies. There are unavoidable pressures for the localisation and fragmentation of services. There is always a co-evolution of the service and the technology, including the use of workarounds. e-Health is often promoted for its contributions to patient safety, but the evidence base for improvements is weak. Risk management methodologies can be illuminative for studying e-Health systems. However, methods are not individually reliable. Organisational boundaries remain problem areas and threaten the provision of high quality care. Organisational boundaries are a particular issue when ‘interessement’ (the process of recruiting other stakeholders to a solution) has failed, and funding models can be a particular barrier. The medico-legal context is largely untested. Conclusions: The evidence suggests that future research on e-Health systems should not presume a simple, causalist approach (technology X will reliably produce outcome Y). In-use e-Health systems are flexible and contingent. They rely on the ongoing work of healthcare staff to bridge the gap between social requirements and technical feasibility. We suggest a dynamic tension between standardisation and localisation is unavoidable.