Computerized patient records and bar-code medication systems continue to gain favor in healthcare.^1-5 In the hospital setting, 2 of the most important technologies are computerized patient records and medication administration systems.^1,5,6 These systems are expected to bring about improvements in patient safety, work processes, and staff morale,6-11 and reduce rates of medication errors. ^12-14 Research to date has reached mixed conclusions as to whether such improvements have occurred.^10,11,15-24 Several studies demonstrate that the implementation process for hospital health information technology (HIT) is important to determining overall success.^24-28

The US Department of Veterans Affairs (VA) has made one of the largest investments in HIT in the United States, implementing a fully integrated system across its 162 hospitals nationwide.^28,29 The VA is the nation’s largest integrated healthcare system, with more than 7.2 million veterans enrolled for health services.³⁰ Their development of an HIT system can be traced to the 1970s. The VA’s Computerized Patient Record System (CPRS) and Bar Code Medication Administration (BCMA) are central to inpatient care.^28,29 CPRS was phased in over a decade starting in the early 1990s, and consists of a comprehensive electronic patient medical record with computerized physician ordering, covering both outpatient and inpatient services. By 2002, all VA hospitals had implemented CPRS; the vast majority had implemented this system by 2000. BCMA, on the other hand, was implemented over a much shorter time period, with VA headquarters requiring implementation 1 year after the software became available.²⁹ This system created a computerized pharmacy ordering, distribution, and administration system for use in the inpatient setting. Bedside scanning of patient identifi cation wristbands and medications was the key component of the system, providing validation that each medication matched the orders for each patient.

This paper reports the findings from the qualitative component of a national, retrospective, mixed-methods study of the implementation of CPRS and BCMA. There were no prospective systemwide or multisite evaluations of the implementation of CPRS or BCMA. The study focused on the inpatient setting, where nurses are the main patient care providers; thus, the research emphasized the impact of CPRS and BCMA on nurses. The qualitative portion of the study focused on 4 issues: (1) understanding the approaches used to implement the VA’s HIT systems, (2) identifying factors that affected the process of implementation, (3) ascertaining the issues that determined success of implementation, and (4) understanding what nursing staff and leaders believe are the current strengths and weaknesses of CPRS and BCMA. The experience of a large diverse system like the VA, which has a mix of rural, urban, teaching, and community hospitals, provides valuable information about the issues surrounding information system implementation for hospitals in the private sector.

METHODS

We conducted site visits at 7 VA hospitals selected to represent a range of implementation timelines, geography, and staff characteristics. All site visits were conducted after receiving approval from each facility’s Institutional Review Board (IRB), as well as the IRBs of the University of California, San Francisco, Stanford University, and the Boston VA Healthcare System.

In advance of site visits, an Advisory Committee was assembled, consisting of VA medical, pharmacy, and nursing leaders, as well as representatives of the VA headquarters. The committee was asked to identify issues and themes that they anticipated to be important to understanding the impact of the implementation and use of the VA’s HIT systems on nurses. A semi-structured interview guide was developed after this meeting, based on a review of the literature on technology implementation and the effects of IT systems, and the committee’s suggestions. The committee members provided feedback regarding the content of the guide. This guide was used both to conduct the interviews and provide themes for the initial coding of the data. The guide is available in eAppendix A at www.ajmc.com.

Site selection was based on a unique Web-based survey of VA facilities documenting when each major component of CPRS and BCMA was implemented, VA staff satisfaction survey data, facility-level staff turnover data, geography, and the level of care provided by each VA hospital. We initially identifi ed 27 facilities that represented a range of characteristics, and then consulted with the Advisory Committee and the VA Headquarters Nursing Offi ce to recruit a final set of 7 facilities.

A total of 118 interviews were conducted over a 15-month period (June 2006 through September 2007) with nurses, pharmacists, nurse managers, information technology staff, and senior management. At most sites, physicians were not included because the study’s focus was inpatient IT systems, which are primarily used by nurses. Interview subjects were selected by site coordinators, who were recommended by members of the Advisory Committee and/or the VA Headquarters Nursing Offi ce, and were employees of the VA facilities. The principal investigator (PI) provided the site coordinators with a detailed list of the job classifications of the people to be interviewed (see eAppendix B at www.ajmc.com for categorizations and counts of the interview subjects). Interviews lasted 30 to 60 minutes and were held in private meeting and conference rooms, using the semi-structured interview protocol. Notes were taken by the investigators and were entered into ATLAS.ti to facilitate analysis after the site visit was complete.

A thematic analysis was conducted with initial codes drawn from the content of the interview guides. Additional themes were proposed as the coding was conducted and were added if there was concurrence among members of the research team. All coding was completed by the PI, while other members of the research team reviewed codes of 1 to 2 interviews per site. Investigators who visited each site reviewed the themes identifi ed from that site’s interviews.

RESULTS