Making way for new technology: de-implementation of paper-based medical history forms and insights from a rapid ethnography

Redundant and time-consuming paperwork is considered by patients to be a form of low-value care. The implementation of new digital health technologies, such as electronic medical history forms, continues to increase in healthcare settings to replace paper forms. However, implementation is often not as simple as merely installing new technology; de-implementation of pre-existing practices or artifacts may be needed for successful integration. Understand factors that promoted or inhibited de-implementing paper-based medical history forms within a complex academic healthcare setting through the lens of Normalization Process Theory (NPT). Observations of 10 community and faculty clinics utilizing rapid ethnography approaches with NPT as a guiding framework. A total of 106 staff (medical assistants, patient care coordinators, front desk staff), managers, and physicians/nurses were interviewed during 10 site visits. Paper-based history questionnaires continued to exist in many settings, either retained as “backups” or reintroduced without management’s knowledge. Four findings related to the success of de-implementation mapped onto all four constructs of NPT: 1) De-implementation benefits from clearly communicating how patients will benefit (coherence); 2) De-implementation benefits from a holistic, team-based perspective (cognitive participation); 3) De-implementation requires attentive training and resources to build new habits (collective action); and 4) Sustaining de-implementation benefits from on-site observation (reflexive monitoring). These findings highlight both how implementation and de-implementation work can go hand-in-hand, but also in how de-implementation can have unique factors and outcomes that may necessitate distinct strategies: ensuring that all staff understand the ways in which patients will benefit and are equipped to communicate the change to their patients, and utilizing observational methods to monitor, audit, or evaluate de-implementation.