All units in this study faced difficulties in using CIS data collected during patient care for clinical and service audits that could contribute to clinical process improvement. Contrary to their own prior expectations, units in this study had been unable to derive immediate benefit from their CIS data after purchasing a CIS. Health professionals had to undertake extra work to repurpose the data either through entering it differently than would be necessary for direct clinical care or manipulating into a machine-readable format for audit purposes. Units were confronted with a tension over who was responsible for this extra work of producing audit data.
Units responded by developing strategies that motivated data entry by health professionals or mitigating its need through reformatting data in other ways. We identified 11 strategies that clinical customizers can use in their own units. Although the specific implementation varied from unit to unit depending on the CIS capabilities and the skill and time resource available, each strategy category was seen in at least three units. This suggests that they are neither CIS nor unit dependent. As such, these strategies can provide inspiration for units looking for ways to increase their usage of CIS data for clinical process improvement.
Many of the strategies relied on distributing the extra work between a number of roles so that the responsibility of data entry and reformatting did not rest entirely on front-line health professionals while carrying out their care duties. For example, clinical customizers rebuilt interfaces to make data collection easier, auditors worked from semi-extracted data to reduce data entry, and IT companies provided solutions for difficult tasks of data reformatting. The distribution of this extra work was not achieved in the same way in all units, but emerged in each over time as they negotiated their own circumstances, resources, and priorities. Distribution of extra work in such situations is an essential process that needs recognition.
It is notable that many of the strategies do not rely solely on sophisticated technology, but on human skill in its application to work processes. Our analysis indicates that clinical customizers play a pivotal, if often unrecognized, role in both shaping the CIS and its technological capabilities and in supplying leadership within the unit. They carry out much of the redistributed work. Given the need for a detailed understanding of the work processes and staff attitudes, it is perhaps not surprising that most people in this role were senior nurses with extra IT training. Providing appropriate recognition of this role and necessary training is likely to have a substantial influence on units' capabilities to develop appropriate strategies to use the CIS productively for both direct clinical care and clinical process improvement.
These findings provide some practical guidance on how units might repurpose the data that they collect during clinical care for clinical process improvement. Unlike previous studies, which articulate the problem of extra work and associated issues of system failure
[5–9, 19], this study suggests a more positive direction of enquiry, by considering strategies that foster compromise between different data needs. The ethnographic methods used to produce such findings however, can say little about the particular impact of a given strategy and is not able to ‘verify’ that it works beyond interviewees’ suggestions that it did so.
We would suggest that these findings are relevant to all health settings with the following characteristics: multidisciplinary teams; user-customizable CIS; and settings using their own data for clinical process improvement. For example, similar strategies might be used in hospital-based services, community services, or mental health services as advanced CIS start to become available in these less data-intensive environments
. These findings are not directly relevant to settings that give data to others to analyze, either for performance monitoring or to gain greater data manipulation capabilities. Such situations have the additional issue of data ownership, which has been explored elsewhere
, as well as access to a set of skills and expertise not usually available in a clinical unit
The results have several implications for those providing resources to health settings that are using their own data for clinical process improvement, both larger governing bodies, such as hospitals and NHS funding bodies, as well as policymakers. First, the process of distributing the extra work described above is not a standardized process and will take units time. In our study, units took about 4 years before they began to extract data regularly. Second, financial resources are needed to support those who have had work redistributed to them, such as those carrying out audits, doing customization work, or paying IT contractors. Units reported that little recognition was given to the efforts required in repurposing data, and compensation was never offered for the clinical customization time needed.
In addition to recognizing the costs of repurposing data, it is important to consider the role leaders might play in encouraging unit development that facilitates the use of CIS data for clinical process improvement and other secondary uses. In units in which research nurses were plentiful, but IT skills less so, nurses were used to input and extract data, as it was organizationally easier in the short term and more reliable to use nurses rather than invest in customization expertise. This would not seem to be desirable in the long term, however, if secondary use of data is to be promoted across the sector as a whole. Leaders can provide incentives to move towards greater automation of repurposing data.