Determinants of success of inpatient clinical information systems: a literature review

Success criteria for electronic medical record implementations in low-resource settings: a systematic review

OBJECTIVE

Electronic medical record (EMR) systems have the potential of supporting clinical work by providing the right information at the right time to the right people and thus make efficient use of resources. This is especially important in low-resource settings where reliable data are also needed to support public health and local supporting organizations. In this systematic literature review, our objectives are to identify and collect literature about success criteria of EMR implementations in low-resource settings and to summarize them into recommendations.

MATERIALS AND METHODS

Our search strategy relied on PubMed queries and manual bibliography reviews. Studies were included if EMR implementations in low-resource settings were described. The extracted success criteria and measurements were summarized into 7 categories: ethical, financial, functionality, organizational, political, technical, and training.

RESULTS

We collected 381 success criteria with 229 measurements from 47 articles out of 223 articles. Most papers were evaluations or lessons learned from African countries, published from 1999 to 2013. Almost half of the EMR systems served a specific disease area like human immunodeficiency virus (HIV). The majority of criteria that were reported dealt with the functionality, followed by organizational issues, and technical infrastructures. Sufficient training and skilled personnel were mentioned in roughly 10%. Political, ethical, and financial considerations did not play a predominant role. More evaluations based on reliable frameworks are needed.

CONCLUSIONS

Highly reliable data handling methods, human resources and effective project management, as well as technical architecture and infrastructure are all key factors for successful EMR implementation.

Performance evaluation of public hospital information systems by the information system success model

Objectives

This study was to evaluate the performance of the newly developed information system (IS) implemented on July 1, 2014 at three public hospitals in Korea.

Methods

User satisfaction scores of twelve key performance indicators of six IS success factors based on the DeLone and McLean IS Success Model were utilized to evaluate IS performance before and after the newly developed system was introduced.

Results

All scores increased after system introduction except for the completeness of medical records and impact on the clinical environment. The relationships among six IS factors were also analyzed to identify the important factors influencing three IS success factors (Intention to Use, User Satisfaction, and Net Benefits). All relationships were significant except for the relationships among Service Quality, Intention to Use, and Net Benefits.

Conclusions

The results suggest that hospitals should not only focus on systems and information quality; rather, they should also continuously improve service quality to improve user satisfaction and eventually reach full the potential of IS performance.

The organizational and clinical impact of integrating bedside equipment to an information system: a systematic literature review of patient data management systems (PDMS)

OBJECTIVE

The introduction of an information system integrated to bedside equipment requires significant financial and resource investment; therefore understanding the potential impact is beneficial for decision-makers. However, no systematic literature reviews (SLRs) focus on this topic. This SLR aims to gather evidence on the impact of the aforementioned system, also known as a patient data management system (PDMS) on both organizational and clinical outcomes.

MATERIALS AND METHODS

A literature search was performed using the databases Medline/PubMed and CINHAL for English articles published between January 2000 and December 2012. A quality assessment was performed on articles deemed relevant for the SLR.

RESULTS

Eighteen articles were included in the SLR. Sixteen articles investigated the impact of a PDMS on the organizational outcomes, comprising descriptive, quantitative and qualitative studies. A PDMS was found to reduce the charting time, increase the time spent on direct patient care and reduce the occurrence of errors. Only two articles investigated the clinical impact of a PDMS. Both reported an improvement in clinical outcomes when a PDMS was integrated with a clinical decision support system (CDSS).

CONCLUSIONS

A PDMS has shown to offer many advantages in both the efficiency and the quality of care delivered to the patient. In addition, a PDMS integrated to a CDSS may improve clinical outcomes, although further studies are required for validation.

Effectiveness of nursing management information systems: a systematic review

Objectives

The purpose of this study was to review evaluation studies of nursing management information systems (NMISs) and their outcome measures to examine system effectiveness.

Methods

For the systematic review, a literature search of the PubMed, CINAHL, Embase, and Cochrane Library databases was conducted to retrieve original articles published between 1970 and 2014. Medical Subject Headings (MeSH) terms included informatics, medical informatics, nursing informatics, medical informatics application, and management information systems for information systems and evaluation studies and nursing evaluation research for evaluation research. Additionally, manag^* and admin^*, and nurs^* were combined. Title, abstract, and full-text reviews were completed by two reviewers. And then, year, author, type of management system, study purpose, study design, data source, system users, study subjects, and outcomes were extracted from the selected articles. The quality and risk of bias of the studies that were finally selected were assessed with the Risk of Bias Assessment Tool for Non-randomized Studies (RoBANS) criteria.

Results

Out of the 2,257 retrieved articles, a total of six articles were selected. These included two scheduling programs, two nursing cost-related programs, and two patient care management programs. For the outcome measurements, usefulness, time saving, satisfaction, cost, attitude, usability, data quality/completeness/accuracy, and personnel work patterns were included. User satisfaction, time saving, and usefulness mostly showed positive findings.

Conclusions

The study results suggest that NMISs were effective in time saving and useful in nursing care. Because there was a lack of quality in the reviewed studies, well-designed research, such as randomized controlled trials, should be conducted to more objectively evaluate the effectiveness of NMISs.

The impacts of second generation e-prescribing usability on community pharmacists outcomes

BACKGROUND

The results from past studies about the effects of second-generation e-prescribing systems on community pharmacists' outcomes and practices are inconclusive, and the claims of effectiveness and efficiency of such systems have not been supported in all studies. There is a strong need to study the factors that lead to positive outcomes for the users of these systems.

OBJECTIVE

This paper intends to bridge the above gaps by empirically examining the impacts of user interface usability on the community pharmacists' outcomes.

METHODS

A quantitative survey research method was used and the data was collected from the community pharmacists, who use an e-prescribing system. Data from 152 questionnaires collected in a national survey were used to for the study. Partial Least Squares (PLS) path modeling was used to examine scale reliability, validity and hypotheses.

RESULTS

The scale was found to test well for reliability and validity. Examining the hypotheses illustrated that ease of use (P < 0.01, t = 5.79) and information quality (P < 0.01, t = 6.24) of an e-prescribing system improved pharmacists' outcomes (including communication, facilitation of care, reduction of workload and medical errors) while ease of use of the system was influenced by user interface consistency (P < 0.01, t = 7.35) and system error prevention (P < 0.01, t = 5.29).

CONCLUSION

To improve community pharmacists' outcomes and practices, the ease of use, information quality, consistency and error prevention features of e-prescribing systems should be improved. It was found that information quality had a stronger impact on the outcomes and hence improving the quality of the generated information would have higher impacts on users' outcomes.

Electronic health records implementation: an evaluation of information system impact and contingency factors

OBJECTIVE

This paper provides a review of EHR (electronic health record) implementations around the world and reports on findings including benefits and issues associated with EHR implementation.

MATERIALS AND METHODS

A systematic literature review was conducted from peer-reviewed scholarly journal publications from the last 10 years (2001-2011). The search was conducted using various publication collections including: Scopus, Embase, Informit, Medline, Proquest Health and Medical Complete. This paper reports on our analysis of previous empirical studies of EHR implementations. We analysed data based on an extension of DeLone and McLean's information system (IS) evaluation framework. The extended framework integrates DeLone and McLean's dimensions, including information quality, system quality, service quality, intention of use and usage, user satisfaction and net benefits, together with contingent dimensions, including systems development, implementation attributes and organisational aspects, as identified by Van der Meijden and colleagues.

RESULTS

A mix of evidence-based positive and negative impacts of EHR was found across different evaluation dimensions. In addition, a number of contingent factors were found to contribute to successful implementation of EHR.

LIMITATIONS

This review does not include white papers or industry surveys, non-English papers, or those published outside the review time period.

CONCLUSION

This review confirms the potential of this technology to aid patient care and clinical documentation; for example, in improved documentation quality, increased administration efficiency, as well as better quality, safety and coordination of care. Common negative impacts include changes to workflow and work disruption. Mixed observations were found on EHR quality, adoption and satisfaction. The review warns future implementers of EHR to carefully undertake the technology implementation exercise. The review also informs healthcare providers of contingent factors that potentially affect EHR development and implementation in an organisational setting. Our findings suggest a lack of socio-technical connectives between the clinician, the patient and the technology in developing and implementing EHR and future developments in patient-accessible EHR. In addition, a synthesis of DeLone and McLean's framework and Van der Meijden and colleagues' contingent factors has been found useful in comprehensively understanding and evaluating EHR implementations.

Impact of doctors' resistance on success of drug utilization review system

OBJECTIVES

The drug utilization review (DUR) system, which checks any conflict event of medications, contributes to improve patient safety. One of the important barriers in its adoption is doctors' resistance. This study aimed to analyze the impacts of doctors' resistance on the success of the DUR system.

METHODS

This study adopted an augmented the DeLone and McLean Information System (D&M IS) Success Model (2003), which used doctors' resistance as a socio-technological measure. This study framework is the same as that of the D&M IS Success Model in that it is based on qualities, such as system, information, and services. The major difference is that this study excluded the variable 'use' because it was not statistically significant for mandatory systems. A survey of doctors who used computers to enter prescriptions was conducted at a Korean tertiary hospital in February 2012.

RESULTS

This study is very meaningful in that it is the first study to explore the success factors of the DUR system associated with doctors' resistance. Doctors' resistance to the DUR system was not statistically associated with user usefulness, whereas it affected user satisfaction.

CONCLUSIONS

The results indicate that doctors still complain of discomfort in using the DUR system in the outpatient clinical setting, even though they admit that it contributes to patient safety. To mitigate doctors' resistance and raise user satisfaction, more opinions from doctors regarding the DUR system have to be considered and have to be reflected in the system.

Nurses' perceptions of usefulness of nursing information system: module of electronic medical record for patient care in two university hospitals of iran

INTRODUCTION

For almost fifteen years, the application of computer in hospitals increasingly has become popular. Nurses' beliefs and attitudes towards computer is one of the most important indicators of the application of nursing information system. The purpose of this study was to investigate the perceptions of nurses on the usefulness of nursing information system for patient care.

METHODS

Here, a descriptive study was carried out. Sample was consisted of 316 nurses working in teaching hospitals in an urban area of Iran. This study was conducted during 2011 to 2012. A reliable and valid questionnaire was developed as a data collection tool. The collected data was analyzed using descriptive and inferential statistics.

RESULTS

It was not believed that nursing information system was useful for patient care. However, it was mentioned that nursing information system is useful in some aspects of patient care such as expediting care, making early diagnosis and formulating diet plan. A significant association was found between the demographic background of sample and their perceptions of the usefulness of nursing information system (P<0.05).

CONCLUSION

Totally, it can be concluded that nursing information system has a potential for improving patient care in hospital settings. Therefore, policy makers should consider implementing nursing information system in teaching hospitals.

Physicians' perception and attitude toward electronic medical record

Implementation of an electronic medical record (EMR) system increases efficiency of health services, quality of care and patient satisfaction. Successful implementation of EMRs depends on many factors. The path to quality improvement and financial gain with EMRs lies in getting the greatest number of Physicians to use the system. The main objective of this research is to explore physicians, attitude and perceptions of importance EMRs function, anticipated utilization of EMR functions and also issue impact EMRs. The cross-sectional study was conducted on 133 specialist physicians of three teaching hospitals of Hormozgan Medical Sciences University. The most important finding in this study was the Entry/Display of Diagnoses and Medications (96.3%) and Prescription Alerts drug-drug, allergy and dose checking and formulary management (96.2%) were of greatest importance to respondents. Nuclear medicine, Time trended Clinical Data Display, decision support capabilities, and medical management reporting generated percentage suggesting less than weekly usage. Only a small number of respondents addressed physicians' resistance in compare to another issues impact on EMRs. Understanding physician perceptions and attitude will allow for the development of targeted education to demonstrate the advantages and implementation of EMRs in further and improve physician perceptions of EMRs.

The good, the bad and the early adopters: providers' attitudes about a common, commercial EHR

RATIONALE, AIMS AND OBJECTIVES

To describe primary care providers' (PCP) attitudes about the impact of a mature, commercial electronic health records (EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions.

METHOD

We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression.

RESULTS

One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings.

CONCLUSION

PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement - patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR.

Determining of factors influencing the success and failure of hospital information system and their evaluation methods: a systematic review

BACKGROUND

Nowadays, using new information technology (IT) has provided remarkable opportunities to decrease medical errors, support health care specialist, increase the efficiency and even the quality of patient's care and safety.

OBJECTIVES

The purpose of this study was the identification of Hospital Information System (HIS) success and failure factors and the evaluation methods of these factors. This research emphasizes the need to a comprehensive evaluation of HISs which considers a wide range of success and failure factors in these systems.

MATERIALS AND METHODS

We searched for relevant English language studies based on keywords in title and abstract, using PubMed, Ovid Medline (by applying MeSH terms), Scopus, ScienceDirect and Embase (earliest entry to march 17, 2012). Studies which considered success models and success or failure factors, or studied the evaluation models of HISs and the related ones were chosen. Since the studies used in this systematic review were heterogeneous, the combination of extracted data was carried out by using narrative synthesis method.

RESULTS

We found 16 articles which required detailed analysis. Finally, the suggested framework includes 12 main factors (functional, organizational, behavioral, cultural, management, technical, strategy, economy, education, legal, ethical and political factors), 67 sub factors, and 33 suggested methods for the evaluation of these sub factors.

CONCLUSIONS

The results of the present research indicates that the emphasis of the HIS evaluation moves from technical subjects to human and organizational subjects, and from objective to subjective issues. Therefore, this issue entails more familiarity with more qualitative evaluation methods. In most of the reviewed studies, the main focus has been laid on the necessity of using multi-method approaches and combining methods to obtain more comprehensive and useful results.

A socio-technical assessment of the success of Picture Archiving and Communication Systems: the radiology technologist's perspective

BACKGROUND

With the increasing prevalence of Picture Archiving and Communication Systems (PACS) in healthcare institutions, there is a growing need to measure their success. However, there is a lack of published literature emphasizing the technical and social factors underlying a successful PACS.

METHODS

An updated Information Systems Success Model was utilized by radiology technologists (RTs) to evaluate the success of PACS at a large medical center in Taiwan. A survey, consisting of 109 questionnaires, was analyzed by Structural Equation Modeling.

RESULTS

Socio-technical factors (including system quality, information quality, service quality, perceived usefulness, user satisfaction, and PACS dependence) were proven to be effective measures of PACS success. Although the relationship between service quality and perceived usefulness was not significant, other proposed relationships amongst the six measurement parameters of success were all confirmed.

CONCLUSIONS

Managers have an obligation to improve the attributes of PACS. At the onset of its deployment, RTs will have formed their own subjective opinions with regards to its quality (system quality, information quality, and service quality). As these personal concepts are either refuted or reinforced based on personal experiences, RTs will become either satisfied or dissatisfied with PACS, based on their perception of its usefulness or lack of usefulness. A satisfied RT may play a pivotal role in the implementation of PACS in the future.

Evaluation of a comprehensive EHR based on the DeLone and McLean model for IS success: approach, results, and success factors

OBJECTIVE

The article describes the methodological approach to, and results of an evaluation of a comprehensive electronic health record (EHR) in the shake down phase, shortly after its implementation at a regional hospital in Denmark.

DESIGN

A formative evaluation based on a mixed-methods case study, designed to be interactive and concurrent was conducted at two hospital departments based on the updated DeLone and McLean framework for evaluating information systems success.

METHODS

To ascertain user assessments of the EHR, we distributed a questionnaire two months after implementation to four groups of staff (physicians, nurses, medical secretaries, and physiotherapists; n=244), and at the same time we conducted thirteen individual, semi-structured interviews with representatives from these four groups. Subsequently, seven follow-up focus group interviews were conducted with the four above-mentioned groups, in order to go deeper into specific user assessments. Simultaneously, focus group interviews with two IT departments and the implementation team were conducted, to gain insight into system provider assessments of the implementation process and the EHR. Before, during, and after implementation, 88 h of ethnographic observation were carried out, to give the researchers an understanding of the daily routine of staff, and their use of health records. Finally, daily system performance data were obtained, to gather factual information on system response and downtime.

RESULTS

Overall, staff had positive experiences with the EHR and its operational reliability, response time, login and support. Performance was acceptable. Medical secretaries found the use of the patient administration module cumbersome, and physicians found the establishment of the overview of professionally relevant data challenging. There were demands for improvements to these and other functionalities, and for the EHR to be integrated with other systems and databases.

LIMITATIONS

Evaluations immediately following implementation are inherently difficult, but was required because a key role was to inform decision-making upon enrollment at other hospitals and systematically identify barriers in this respect. The strength of the evaluation is the mixed-methods approach. Further, the evaluation was based on assessments from staff in two departments that comprise around 50% of hospital staff. A weakness may be that staff assessment plays a major role in interviews and survey. These though are supplemented by performance data and observation. Also, the evaluation primarily reports upon the dimension 'user satisfaction', since use of the EHR is mandatory. Finally, generalizability may be low, since the evaluation was not based on a validated survey. All in all, however, the evaluation proposes an evaluation design in constrained circumstances.

CONCLUSIONS

Despite inherent limitations, evaluation of a comprehensive EHR shortly after implementation may be necessary, can be conducted, and may inform political decision making. The updated DeLone and McLean framework was constructive in the overall design of the evaluation of the EHR implementation, and allowed the model to be adapted to the health care domain by being methodological flexible. The mixed-methods case study produced valid and reliable results, and was accepted by staff, system providers, and political decision makers. The successful implementation may be attributed to the configurability of the EHR and to factors such as an experienced, competent implementation organization at the hospital, upgraded soft- and hardware, and a high degree of user involvement.

The digital patient

Despite efforts, the detection of patients who are deteriorating in hospital is often later than it should be. Several technologies could provide the basis of a solution. Recording of vital signs could be improved by both automated transmission of the measured parameters to an electronic patient record and the use of unobtrusive wearable monitors that track the patient's physiology continuously. Electronic charting systems could make the recorded vital signs readily available for further processing. Software algorithms could identify such patients with greater sensitivity and specificity than the existing, paper-based track-and-trigger systems. Electronic storage of vital signs also makes intelligent alerting and remote patient surveillance possible. However, the potential of these technologies depends strongly on implementation, with poor-quality deployment likely to worsen patient care.

Patient portal implementation: resident and attending physician attitudes

BACKGROUND AND OBJECTIVES

Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them.

METHODS

The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients.

RESULTS

Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation.

CONCLUSIONS

Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience.

An information systems model of the determinants of electronic health record use

OBJECTIVES

The prominence given to universal implementation of electronic health record (EHR) systems in U.S. health care reform, underscores the importance of devising reliable measures of factors that predict medical care providers' use of EHRs. This paper presents an easily administered provider survey instrument that includes measures corresponding to core dimensions of DeLone and McClean's (D & M) model of information system success.

METHODS

Study data came from self-administered surveys completed by 460 primary care providers, who had recently begun using an EHR.

RESULTS

Based upon assessment of psychometric properties of survey items, a revised D&M causal model was formulated that included four measures of the determinants of EHR use (system quality, IT support, ease of use, user satisfaction) and five indicators of provider beliefs about the impact on an individual's clinical practice. A structural equation model was estimated that demonstrated a high level of inter-correlation between the four scales measuring determinants of EHR use. All four variables had positive association with each of the five individual impact measures. Consistent with our revised D&M model, the association of system quality and IT support with the individual impact measures was entirely mediated by ease of use and user satisfaction.

CONCLUSIONS

Survey research provides important insights into provider experiences with EHR. Additional studies are in progress to investigate how the variables constructed for this study are related to direct measures of EHR use.

Development and initial evaluation of the Clinical Information Systems Success Model (CISSM)

PURPOSE

Most clinical information systems (CIS) today are technically sound, but the number of successful implementations of these systems is low. The purpose of this study was to develop and test a theoretically based integrated CIS Success Model (CISSM) from the nurse perspective.

METHODS

Model predictors of CIS success were taken from existing research on information systems acceptance, user satisfaction, use intention, user behavior and perceptions, as well as clinical research. Data collected online from 234 registered nurses in four hospitals were used to test the model. Each nurse had used the Cerner Power Chart Admission Health Profile for at least 3 months.

RESULTS

Psychometric testing and factor analysis of the 23-item CISSM instrument established its construct validity and reliability. Initial analysis showed nurses' satisfaction with and dependency on CIS use predicted their perceived CIS use Net Benefit. Further analysis identified Social Influence and Facilitating Conditions as other predictors of CIS user Net Benefit. The level of hospital CIS integration may account for the role of CIS Use Dependency in the success of CIS.

CONCLUSIONS

Based on our experience, CISSM provides a formative as well as summative tool for evaluating CIS success from the nurse's perspective.

Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care

Background

Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals.

Methods

The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics.

Results

The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use.

Conclusions

Primary care professionals have to perceive eCDS guidance useful for their work before they use it.

Factors determining nurse acceptance of hospital information systems

This study proposed an evaluation model, derived from the Technology Acceptance Model and Information System Success Model, to explore factors influencing the acceptance of hospital information systems by nurses. Although many healthcare institutions have applied hospital information systems, relatively few studies have investigated the perceptions of nurses regarding the usefulness, ease of use, or acceptance of these systems. This study recruited the nursing staff of a regional hospital in Taiwan. A total of 297 questionnaires were sent, and 277 were returned, for a response rate of 93.3%. The results indicated that system quality, information quality, and service quality were positively correlated with the perceived ease of use (R=0.69) and perceived usefulness (R=0.72). Information quality has the greatest influence on perceived usefulness (γ3=0.57, P<.001) and ease of use (γ4=0.61, P<.001). Perceived usefulness and ease of use have a significant influence on system acceptance (R=0.75). Perceived usefulness (β1=0.61, P<.001) has a significant influence on system acceptance. These findings indicated that nursing care requires high-quality healthcare information to support the daily activities of nursing professionals. The results of this study also provide a valuable reference for hospital administrators in developing hospital information systems.

Video observation in HIT development: lessons learned on benefits and challenges

BACKGROUND

Experience shows that the precondition for the development of successful health information technologies is a thorough insight into clinical work practice. In contemporary clinical work practice, clinical work and health information technology are integrated, and part of the practice is tacit. When work practice becomes routine, it slips to the background of the conscious awareness and becomes difficult to recognize without the context to support recall. This means that it is difficult to capture with traditional ethnographic research methods or in usability laboratories or clinical set ups. Observation by the use of the video technique within healthcare settings has proven to be capable of providing a thorough insight into the complex clinical work practice and its context - including parts of the tacit practice. The objective of this paper is 1) to argue for the video observation technique to inform and improve health-information-technology development and 2) to share insights and lessons learned on benefits and challenges when using the video observation technique within healthcare settings.

METHODS

A multiple case study including nine case studies conducted by DaCHI researchers 2004-2011 using audio-visual, non-participant video observation for data collection within different healthcare settings.

RESULTS

In HIT development, video observation is beneficial for 1) informing and improving system design 2) studying changes in work practice 3) identifying new potentials and 4) documenting current work practices.

CONCLUSIONS

The video observation technique used within healthcare settings is superior to other ethnographic research methods when it comes to disclosing the complexity in clinical work practice. The insights gained are far more realistic compared to traditional ethnographic studies or usability studies and studies in clinical set ups. Besides, the data generated through video recordings provide a solid basis for dialog between the health care professionals involved. The most important lessons learned are that a well considered methodology and clear formulated objectives are imperative, in order to stay focused during the data rich analysis phase. Additionally, the video observation technique is primarily recommended for studies of specific clinical work practices within delimited clinical settings. Overall, the video observation technique has proven to be capable of improving our understanding of the interwoven relation between clinical work practice and HIT and to inform us about user requirements and needs for HIT, which is a precondition for the development of more successful HIT systems in the future.

Perceived impact of electronic medical records in physician office practices: a review of survey-based research

BACKGROUND

Physician office practices are increasingly adopting electronic medical records (EMRs). Therefore, the impact of such systems needs to be evaluated to ensure they are helping practices to realize expected benefits. In addition to experimental and observational studies examining objective impacts, the user's subjective view needs to be understood, since ultimate acceptance and use of the system depends on them. Surveys are commonly used to elicit these views.

OBJECTIVE

To determine which areas of EMR implementation in office practices have been addressed in survey-based research studies, to compare the perceived impacts between users and nonusers for the most-addressed areas, and to contribute to the knowledge regarding survey-based research for assessing the impact of health information systems (HIS).

METHODS

We searched databases and systematic review citations for papers published between 2000 and 2012 (May) that evaluated the perceived impact of using an EMR system in an office-based practice, were based on original data, had providers as the primary end user, and reported outcome measures related to the system's positive or negative impact. We identified all the reported metrics related to EMR use and mapped them to the Clinical Adoption Framework to analyze the gap. We then subjected the impact-specific areas with the most reported results to a meta-analysis, which examined overall positive and negative perceived impacts for users and nonusers.

RESULTS

We selected 19 papers for the review. We found that most impact-specific areas corresponded to the micro level of the framework and that appropriateness or effectiveness and efficiency were well addressed through surveys. However, other areas such as access, which includes patient and caregiver participation and their ability to access services, had very few metrics. We selected 7 impact-specific areas for meta-analysis: security and privacy; quality of patient care or clinical outcomes; patient-physician relationship and communication; communication with other providers; accessibility of records and information; business or practice efficiency; and costs or savings. All the results for accessibility of records and information and for communication with providers indicated a positive view. The area with the most mixed results was security and privacy.

CONCLUSIONS

Users sometimes were likelier than nonusers to have a positive view of the selected areas. However, when looking at the two groups separately, we often found more positive views for most of the examined areas regardless of use status. Despite limitations of a small number of papers and their heterogeneity, the results of this review are promising in terms of finding positive perceptions of EMR adoption for users and nonusers. In addition, we identified issues related to survey-based research for HIS evaluation, particularly regarding constructs for evaluation and quality of study design and reporting.

A Study on User Satisfaction regarding the Clinical Decision Support System (CDSS) for Medication

OBJECTIVES

Many medication errors can occur when ordering and dispensing medicine in hospitals. The clinical decision support system (CDSS) is widely used in an effort to reduce medication errors. This study focused on the evaluation of user satisfaction with the CDSS for medication at a university hospital. Specifically, this study aimed to identify the factors influencing user satisfaction and to examine user requirements in order to further improve user satisfaction and drug safety.

METHODS

The study was based on survey data from 218 users (103 doctors, 103 nurses, and 15 pharmacists) at a university hospital that uses the CDSS. In order to identify the factors influencing user satisfaction with the CDSS, a multiple linear regression was performed. In order to compare the satisfaction level among the professional groups, an analysis of variance (ANOVA) was performed.

RESULTS

The reliability of information, decision supporting capability, and departmental support were significant factors in influencing user satisfaction. In addition, nurses were the most satisfied group, followed by pharmacists and doctors according to the ANOVA. Areas for further improvement in enhancing drug safety were real time information searching and decision supporting capabilities to prevent adverse drug events (ADE) in a timely manner.

CONCLUSIONS

We found that the CDSS users were generally satisfied with the system and that it complements the nationwide drug utilization review (DUR) system in reducing ADE. Further CDSS evaluation in other hospitals is needed to improve user satisfaction and drug safety.

Impact of electronic medical record on physician practice in office settings: a systematic review

BACKGROUND

Increased investments are being made for electronic medical records (EMRs) in Canada. There is a need to learn from earlier EMR studies on their impact on physician practice in office settings. To address this need, we conducted a systematic review to examine the impact of EMRs in the physician office, factors that influenced their success, and the lessons learned.

RESULTS

For this review we included publications cited in Medline and CINAHL between 2000 and 2009 on physician office EMRs. Studies were included if they evaluated the impact of EMR on physician practice in office settings. The Clinical Adoption Framework provided a conceptual scheme to make sense of the findings and allow for future comparison/alignment to other Canadian eHealth initiatives.In the final selection, we included 27 controlled and 16 descriptive studies. We examined six areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction. Overall, 22/43 studies (51.2%) and 50/109 individual measures (45.9%) showed positive impacts, 18.6% studies and 18.3% measures had negative impacts, while the remaining had no effect. Forty-eight distinct factors were identified that influenced EMR success. Several lessons learned were repeated across studies: (a) having robust EMR features that support clinical use; (b) redesigning EMR-supported work practices for optimal fit; (c) demonstrating value for money; (d) having realistic expectations on implementation; and (e) engaging patients in the process.

CONCLUSIONS

Currently there is limited positive EMR impact in the physician office. To improve EMR success one needs to draw on the lessons from previous studies such as those in this review.

Implementation and expansion of an electronic medical record for HIV care and treatment in Haiti: an assessment of system use and the impact of large-scale disruptions

PURPOSE

System use is a key criterion of success in an electronic medical record (EMR) implementation, and there is little research on long-term use of systems following implementation. The aim of the paper was to describe the development, implementation and use of iSanté, Haiti's national HIV care and treatment EMR.

METHODS

To build a picture of the history of iSanté, we interviewed 11 staff involved with the development and implementation of the EMR, and reviewed organization records. Data entry and report use were ascertained by querying the central patient database.

RESULTS

By the end of 2010 there were 67 sites with iSanté installed, and the scope of the system had been expanded to include primary care and obstetrics and gynecology. New functionality includes data forms specific to subpopulations, the ability to transfer patient records among clinics, and integration with an electronic laboratory system. We observed fluctuations in use over time, with substantial reductions in the number of active sites during times of large-scale disruptions in Haiti. A surge in report use following the January 2010 earthquake suggests that clinics found the EMR to be a valuable source of data during the recovery phase.

CONCLUSION

There is real potential for EMRs in developing countries to improve clinical practice and make data available for efficient reporting, quality improvement and other population health uses. An approach of continuous system improvement, combined with regular assessments of use, is necessary for achieving an effective, national implementation of a standardized EMR. We have achieved successes in terms of rolling out new functionality and expanding to new sites, but more work remains to be done to improve perceptions of data quality and increase use of population data for accurate and timely reporting.

An empirical study of physicians' acceptance of hospital information systems in Taiwan

OBJECTIVE

This study investigates the key factors affecting the acceptance of hospital information systems (HIS) by physicians based on an extensive technology acceptance model. This model consists of six constructs: System quality, information quality, service quality, perceived usefulness, perceived ease of use, and HIS acceptance.

MATERIALS AND METHODS

Survey research targeted physicians in the selected case hospital as subjects. Of 131 questionnaires sent out, 81 completed forms were returned (a valid response rate of 64.8%). The partial least squares approach was used to analyze the collected data.

RESULTS

This study shows that system quality and information quality are significant factors influencing perceived ease of use of HIS, while information quality and service quality are key factors affecting perceived usefulness of HIS. Results indicate that perceived usefulness and perceived ease of use significantly affect HIS acceptance (R(2)=0.545) from the physician's perspective.

CONCLUSIONS

The findings of this study can help managers understand the key considerations affecting HIS development and use and provide important reference material for system improvement.

A holistic framework to improve the uptake and impact of eHealth technologies

BACKGROUND

Many eHealth technologies are not successful in realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in health care practices. To overcome the hurdles with eHealth design and implementation, a new, holistic approach to the development of eHealth technologies is needed, one that takes into account the complexity of health care and the rituals and habits of patients and other stakeholders.

OBJECTIVE

The aim of this viewpoint paper is to improve the uptake and impact of eHealth technologies by advocating a holistic approach toward their development and eventual integration in the health sector.

METHODS

To identify the potential and limitations of current eHealth frameworks (1999-2009), we carried out a literature search in the following electronic databases: PubMed, ScienceDirect, Web of Knowledge, PiCarta, and Google Scholar. Of the 60 papers that were identified, 44 were selected for full review. We excluded those papers that did not describe hands-on guidelines or quality criteria for the design, implementation, and evaluation of eHealth technologies (28 papers). From the results retrieved, we identified 16 eHealth frameworks that matched the inclusion criteria. The outcomes were used to posit strategies and principles for a holistic approach toward the development of eHealth technologies; these principles underpin our holistic eHealth framework.

RESULTS

A total of 16 frameworks qualified for a final analysis, based on their theoretical backgrounds and visions on eHealth, and the strategies and conditions for the research and development of eHealth technologies. Despite their potential, the relationship between the visions on eHealth, proposed strategies, and research methods is obscure, perhaps due to a rather conceptual approach that focuses on the rationale behind the frameworks rather than on practical guidelines. In addition, the Web 2.0 technologies that call for a more stakeholder-driven approach are beyond the scope of current frameworks. To overcome these limitations, we composed a holistic framework based on a participatory development approach, persuasive design techniques, and business modeling.

CONCLUSIONS

To demonstrate the impact of eHealth technologies more effectively, a fresh way of thinking is required about how technology can be used to innovate health care. It also requires new concepts and instruments to develop and implement technologies in practice. The proposed framework serves as an evidence-based roadmap.

A study of factors affecting acceptance of hospital information systems: a nursing perspective

BACKGROUND

Hospital information systems (HISs) are widely used in Taiwan, and HIS performance must be carefully evaluated. Nursing personnel are the largest group of staff in a hospital and are the center of care delivery; thus, they play an important role in the adoption and evaluation of HISs.

PURPOSE

The primary objective of this study was to explore the critical factors affecting the acceptance of HISs in Taiwan from a nursing perspective. On the basis of the technology acceptance model, we used six exogenous variables (system quality, information quality, user self-efficacy, compatibility, top management support, and project team competency) as investigation factors.

METHODS

Survey research targeted nursing personnel in the selected case hospital as participants. A total of 545 questionnaires were sent out, and 501 were returned, indicating a valid response rate of 91.9%. Collected data were analyzed using multiple regression analysis.

RESULTS

: Results indicate that user self-efficacy, top management support, compatibility, and information quality have significant impacts on perceived ease of use. In addition, top management support, compatibility, and information quality were identified as having significant impacts on perceived usefulness. Furthermore, nurses' perceived ease of use and perceived usefulness on HISs was found to impact significantly on system acceptance, with 45.1% of the total explained variance.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Results can help managers understand key considerations affecting HIS development and use and may be applied as a reference for system development and improvement.

Methods to identify, study and understand end-user participation in HIT development

Background

Experience has shown that for new health-information-technology (HIT) to be suc-cessful clinicians must obtain positive clinical benefits as a result of its implementation and joint-ownership of the decisions made during the development process. A prerequisite for achieving both success criteria is real end-user-participation. Experience has also shown that further research into developing improved methods to collect more detailed information on social groups participating in HIT development is needed in order to support, facilitate and improve real end-user participation.

Methods

A case study of an EHR planning-process in a Danish county from October 2003 until April 2006 was conducted using process-analysis. Three social groups (physicians, IT-professionals and administrators) were identified and studied in the local, present perspective. In order to understand the interactions between the three groups, the national, historic perspective was included through a literature-study. Data were collected through observations, interviews, insight gathered from documents and relevant literature.

Results

In the local, present perspective, the administrator's strategy for the EHR planning process meant that there was no clinical workload-reduction. This was seen as one of the main barriers to the physicians to achieving real influence. In the national, historic perspective, physicians and administrators have had/have different perceptions of the purpose of the patient record and they have both struggled to influence this definition. To date, the administrators have won the battle. This explains the conditions made available for the physicians' participation in this case, which led to their role being reduced to that of clinical consultants - rather than real participants.

Conclusion

In HIT-development the interests of and the balance of power between the different social groups involved are decisive in determining whether or not the end-users become real participants in the development process. Real end-user-participation is essential for the successful outcome of the process. By combining and developing existing theories and methods, this paper presents an improved method to collect more detailed information on social groups participating in HIT-development and their interaction during the development. This allows HIT management to explore new avenues during the HIT development process in order to support, facilitate and improve real end-user participation.

Understanding managerial behaviour during initial steps of a clinical information system adoption

BACKGROUND

While the study of the information technology (IT) implementation process and its outcomes has received considerable attention, the examination of pre-adoption and pre-implementation stages of configurable IT uptake appear largely under-investigated. This paper explores managerial behaviour during the periods prior the effective implementation of a clinical information system (CIS) by two Canadian university multi-hospital centers.

METHODS

Adopting a structurationist theoretical stance and a case study research design, the processes by which CIS managers' patterns of discourse contribute to the configuration of the new technology in their respective organizational contexts were longitudinally examined over 33 months.

RESULTS

Although managers seemed to be aware of the risks and organizational impact of the adoption of a new clinical information system, their decisions and actions over the periods examined appeared rather to be driven by financial constraints and power struggles between different groups involved in the process. Furthermore, they largely emphasized technological aspects of the implementation, with organizational dimensions being put aside. In view of these results, the notion of 'rhetorical ambivalence' is proposed. Results are further discussed in relation to the significance of initial decisions and actions for the subsequent implementation phases of the technology being configured.

CONCLUSIONS

Theoretical and empirically grounded, the paper contributes to the underdeveloped body of literature on information system pre-implementation processes by revealing the crucial role played by managers during the initial phases of a CIS adoption.

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application

BACKGROUND

Electronic medication administration records (eMARs) have been widely used in recent years. However, formal usability evaluations are not yet available for these vendor applications, especially from the perspective of nurses, the largest group of eMAR users.

OBJECTIVE

To conduct a formal usability evaluation of an implemented eMAR.

METHODS

Four evaluators examined a commercial vendor eMAR using heuristic evaluation techniques. The evaluators defined seven tasks typical of eMAR use and independently evaluated the application. Consensus techniques were used to obtain 100% agreement of identified usability problems and severity ratings. Findings were reviewed with 5 clinical staff nurses and the Director of Clinical Informatics who verified findings with a small group of clinical nurses.

RESULTS

Evaluators found 60 usability problems categorized into 233 heuristic violations. Match, Error, and Visibility heuristics were the most frequently violated. Administer Medication and Order and Modify Medications tasks had the highest number of heuristic violations and usability problems rated as major or catastrophic.

CONCLUSION

The high number of usability problems could impact the effectiveness, efficiency and satisfaction of nurses' medication administration activities and may include concerns about patient safety. Usability is a joint responsibility between sites and vendors. We offer a call to action for usability evaluations at all sites and eMAR application redesign as necessary to improve the user experience and promote patient safety.

Electronic hand-drafting and picture management system

The Department of Health of Executive Yuan in Taiwan (R.O.C.) is implementing a five-stage project entitled Electronic Medical Record (EMR) converting all health records from written to electronic form. Traditionally, physicians record patients' symptoms, related examinations, and suggested treatments on paper medical records. Currently when implementing the EMR, all text files and image files in the Hospital Information System (HIS) and Picture Archiving and Communication Systems (PACS) are kept separate. The current medical system environment is unable to combine text files, hand-drafted files, and photographs in the same system, so it is difficult to support physicians with the recording of medical data. Furthermore, in surgical and other related departments, physicians need immediate access to medical records in order to understand the details of a patient's condition. In order to address these problems, the Department of Health has implemented an EMR project, with the primary goal of building an electronic hand-drafting and picture management system (HDP system) that can be used by medical personnel to record medical information in a convenient way. This system can simultaneously edit text files, hand-drafted files, and image files and then integrate these data into Portable Document Format (PDF) files. In addition, the output is designed to fit a variety of formats in order to meet various laws and regulations. By combining the HDP system with HIS and PACS, the applicability can be enhanced to fit various scenarios and can assist the medical industry in moving into the final phase of EMR.

A review on systematic reviews of health information system studies

The purpose of this review is to consolidate existing evidence from published systematic reviews on health information system (HIS) evaluation studies to inform HIS practice and research. Fifty reviews published during 1994-2008 were selected for meta-level synthesis. These reviews covered five areas: medication management, preventive care, health conditions, data quality, and care process/outcome. After reconciliation for duplicates, 1276 HIS studies were arrived at as the non-overlapping corpus. On the basis of a subset of 287 controlled HIS studies, there is some evidence for improved quality of care, but in varying degrees across topic areas. For instance, 31/43 (72%) controlled HIS studies had positive results using preventive care reminders, mostly through guideline adherence such as immunization and health screening. Key factors that influence HIS success included having in-house systems, developers as users, integrated decision support and benchmark practices, and addressing such contextual issues as provider knowledge and perception, incentives, and legislation/policy.

The impact of eHealth on the quality and safety of health care: a systematic overview

BACKGROUND

There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.

METHODS AND FINDINGS

We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

CONCLUSIONS

There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.

Competency-based learning program in system analysis and design for health professionals

This study aims to evaluate the effectiveness of a competency-based learning (CBL) approach to an e-learning course on systems analysis and design (SAD). The competency of 18 students who registered for an SAD course was measured at different 3 times during the semester with the use of a competency diary. The changes in the competency scores through the semester were analyzed by a Friedman test, and the factors affecting learning effectiveness were identified by multiple regression. The competency scores increased as the semester progressed. The factors that had a significant effect on learning effectiveness were course management and learning materials. The authors found that the CBL approach worked well for this particular e-learning course on SAD and that nontechnical aspects of the instruction, such as course management and lecture materials, were more important than the technical aspects even in this Internet environment.

Development and Psychometric Qualities of the SEIPS Survey to Evaluate CPOE/EHR Implementation in ICUs

Health Information Technology (IT) implementation can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by the technology. End-user satisfaction is a critical factor in health IT implementation. In this paper we describe the process of developing and testing a questionnaire to evaluate health IT implementation, in particular Computerized Provider Order Entry (CPOE) and Electronic Health Record (EHR) technologies. Results showed evidence for the validity and reliability of the questionnaire. The Systems Engineering Initiative for Patient Safety (SEIPS) questionnaire is relatively easy to administer and allows researchers to evaluate different aspects of health IT implementation. Results of this research can be used for benchmarking results of future studies evaluating health IT implementation.

Clinical information system post-adoption evaluation at the georges pompidou university hospital

The evaluation of a clinical information system (CIS) at different stages of deployment and routine use is a key factor to improve acceptability and use by health professionals. This paper examines on an expectation-confirmation model (ITPAM) the relationships between the determinants of success of a CIS in a cross-sectional survey performed at the Georges Pompidou University Hospital (HEGP). Results for the groups of physicians and nurses that replied to the survey (n=312) suggest that health professional satisfaction (overall R(2)=0.60) is determined by the quality of user support (r=.21, p=<0001), ease of use (r=.19, p=<0001), confirmation of expectations (r=.15, p=.0037), usefulness (r=.12, p=.0068), and compatibility (r=.10, p=.0206). The best predictor of physician satisfaction (R(2)=0.71) was compatibility (r=.21, p=.0072) whereas for nurses (R(2)=0.52) it was user support (r=.22, p=<0001) and ease of use (r=.22, p=.0001). Confirmation of expectations had an impact on post-adoption expectation and user's satisfaction, and confirms its importance for CIS evaluation studies.

A knowledge-based taxonomy of critical factors for adopting electronic health record systems by physicians: a systematic literature review

Background

The health care sector is an area of social and economic interest in several countries; therefore, there have been lots of efforts in the use of electronic health records. Nevertheless, there is evidence suggesting that these systems have not been adopted as it was expected, and although there are some proposals to support their adoption, the proposed support is not by means of information and communication technology which can provide automatic tools of support. The aim of this study is to identify the critical adoption factors for electronic health records by physicians and to use them as a guide to support their adoption process automatically.

Methods

This paper presents, based on the PRISMA statement, a systematic literature review in electronic databases with adoption studies of electronic health records published in English. Software applications that manage and process the data in the electronic health record have been considered, i.e.: computerized physician prescription, electronic medical records, and electronic capture of clinical data. Our review was conducted with the purpose of obtaining a taxonomy of the physicians main barriers for adopting electronic health records, that can be addressed by means of information and communication technology; in particular with the information technology roles of the knowledge management processes. Which take us to the question that we want to address in this work: "What are the critical adoption factors of electronic health records that can be supported by information and communication technology?". Reports from eight databases covering electronic health records adoption studies in the medical domain, in particular those focused on physicians, were analyzed.

Results

The review identifies two main issues: 1) a knowledge-based classification of critical factors for adopting electronic health records by physicians; and 2) the definition of a base for the design of a conceptual framework for supporting the design of knowledge-based systems, to assist the adoption process of electronic health records in an automatic fashion. From our review, six critical adoption factors have been identified: user attitude towards information systems, workflow impact, interoperability, technical support, communication among users, and expert support. The main limitation of the taxonomy is the different impact of the adoption factors of electronic health records reported by some studies depending on the type of practice, setting, or attention level; however, these features are a determinant aspect with regard to the adoption rate for the latter rather than the presence of a specific critical adoption factor.

Conclusions

The critical adoption factors established here provide a sound theoretical basis for research to understand, support, and facilitate the adoption of electronic health records to physicians in benefit of patients.

The Introduction of an Electronic Patient Care Information System and Health Care Providers’ Job Stress

In this paper, the authors explore how the introduction of an electronic Patient Care Information System (PCIS) relates to changes in health care providers’ (HCPs’) perceptions of computer use, quality of patient care and job stress. Data were collected using a mixed-methods case study approach over a 20 month period following the introduction of this system. Initially stress levels appeared to increase, but over time declined significantly. After 3 months, the majority of HCPs reported they spent more time entering, retrieving and searching for patient information than before; however, these increases in computer use were unrelated to HCP stress. The potentially negative impact of the system on the quality of patient care was highly correlated with increased job stress. After 20 months, HCPs reported spending less time searching, entering and retrieving patient information, but these indicators of computer use were now highly correlated with stress. While some negative perceptions of the impact of the PCIS declined over time, HCPs reported ongoing stress related to concerns about quality of patient care even after 20 months of use.