Multi-level analysis of electronic health record adoption by health care professionals: a study protocol

An examination of large-scale electronic health records implementation in Primary Healthcare Centers in Saudi Arabia: a qualitative study

Introduction

Digital transformation has become a buzzword in almost every industry in the twenti first century. Healthcare is not an exception. In the healthcare industry, digital transformation includes the utilization of electronic health records (EHRs), telemedicine, health information exchange, mobile health, and other interactive platforms. The importance of digital transformation in healthcare cannot be overemphasized as it has proven to be critical in improving patient outcomes, making healthcare delivery more efficient, and reducing costs. The positive impact of electronic health records was noticed almost immediately in the field of primary healthcare. It has been suggested that implementing electronic health records will enhance the accessibility and the process of distribution of health records between authorized users. As part of Saudi vision 2030, all healthcare organizations in Saudi Arabia are going to shift to digital transformation.

Methods

This study follows a qualitative, semi-structure, face-to-face interview approach. The collected data were analyzed using NVivo V10 software. Inductive thematic analysis approach was used to analyse the collected data from the interviews.

Result

Seventeen project team members, from different positions and backgrounds were purposively chosen to be interviewed. Three main themes and 38 codes were generated from the analysis of transcripts. The informants describe the implementation of electronic health records in the PHCs based on two different experiences. The participants reported that a previous attempt failed due to inappropriate infrastructure, lack of technical support, and low level of user acceptance. Therefore, the policymakers adopted several steps to increase the level of success and avoid failure causes. They initially established well-defined requests for proposals followed by continuous commendation among the project team and conducted a consultation on multiple levels (country level; organizational level and individual level).

Conclusion

This study concluded that the main causes that lead to the failure of the large-scale project were lack of connectivity, lack of technical support, and staff changes, particularly those who occupied high-level positions in the Saudi ministry of Health. The success rate of EHRs implementation can be directly impacted by the size of the project. Large-scale projects are complicated and may be subject to numerous challenges compared with small projects. Significant factors such as training, support, legal issues, and organizational workflow and redesign were a concern of the project team during the pre-implementation phase. In addition, other factors related to technology and end-users were included in the EHRs implementation plan.

The Integrated Electronic Health System in Iranian health centers: benefits and challenges

BACKGROUND

Electronic Health Records (EHRs) were introduced to all Iranian medical universities in 2015 with the launch of Integrated Electronic Health System (which is known as SIB: a Persian backronym in Persian meaning apple), and a number of studies were conducted on SIB. However, most of these studies did not consider the benefits and challenges of adopting SIB in Iran. Therefore, the present study aimed to identify the benefits and challenges of SIB in health centers of Khuzestan Province, Iran.

METHODS

This was a qualitative study using qualitative conventional content analysis conducted on 6 experts and 24 users of SIB in six health centers of three cities in Khuzestan province, Iran. The participants were selected using a purposeful sampling method. Maximum variation was considered in selecting the group of users, and snowball sampling was used in the group of experts. Data collection tool was semi-structured interview. Data analysis was performed using thematic analysis.

RESULTS

Overall, 42 components (24 for benefits and 18 for challenges) were extracted from the interviews. Common sub-themes and themes were identified for challenges and benefits. The components formed 12 sub-themes, and they were placed in 3 main themes, namely structure, process and outcome. 1) Structure included four sub-themes of Financial resources, Human resources, Facilities, and Access to the Internet; 2) Process involved three sub-themes of Training, Providing services, and Time and workload; and 3) Outcome incorporated five sub-themes of Quality of health services, Access, Safety and personal distance, Screening and evaluation, and Research.

CONCLUSIONS

In the present study, the benefits and challenges of adopting SIB were examined in three themes: structure, process, and outcome. Most of the identified benefits were related to the theme of outcome, and most of the identified challenges were related to the theme of structure. Based on the identified factors, by strengthening the benefits of SIB and also trying to eliminate or reduce its challenges, it is possible to institutionalize and use it more effectively in order to solve health problems.

Factors to Overcoming Barriers Affecting Electronic Medical Record Usage by Physicians

Background

Hospitals are adopting electronic medical records (EMRs) in larger numbers; however, the barrier to derive its full utility is the low acceptance by physicians.

Aims and Objectives

This study is done with an objective to identify the factors to overcome the barriers preventing the adoption of EMR by physicians.

Materials and Methods

This study is cross sectional in natures and a self-administered questionnaire is developed based on the Technology Acceptance Model.

Results

The four identified factors are positive attitude toward EMR, reliability, difficulty to use, and adaptability, these factors together, have explained 62.54 percent variance in the data set.

Conclusion

The physician's acceptance for EMRs can be improved by focusing on the identified four factors, which are "positive attitude toward electronic medical records," reliability of electronic medical records," "difficulty level of use," and "adaptability of electronic medical records."

Consumer perceptions of health IT utilization and benefits

Objectives

The objective of this article is to examine consumer perceptions of health information technology (health IT) utilization and benefits through an integrated conceptual framework.

Materials and Methods

This article employs an integrated conceptual framework to examine consumer perceptions of health IT. A consumer survey yielded 1125 completed responses. A factor-based scale was developed for each sub-construct. Bivariate analysis using χ² tests was performed to determine differences in the percentage of respondents who agreed with each sub-construct based on whether their physician used an electronic health record (EHR) system. Multivariable logistic regression that controlled for demographic characteristics of respondents was performed to determine adjusted odds of agreeing with selected opinions of health information exchange (HIE).

Results

Results indicate that respondents whose physicians used an EHR system were significantly more likely to agree that there was a perceived benefit with HIE and to care provided; that the patient should have control over the record; that they trust the physician and security of the medical information; that they understand the need for HIE, and that HIE must be easy to use.

Discussion

The results suggest that consumers who have experienced the use of one technology in the healthcare setting can recognize the potential benefit of another technology. Race/ethnicity, gender, and education played some role in respondents’ views of EHRs and HIE, more specifically, non-Hispanic African American participants indicated lower levels of trust in HIE when compared with non-Hispanic Whites.

Conclusion

This cross-sectional survey indicated that physician use of EHRs significantly increases the odds of consumers’ seeing perceived benefits of HIE and understanding the need for HIE.

Taxonomic framework for factors influencing ERMS adoption in organisations of higher professional education

An electronic records management system (ERMS) is tightly linked with most of the daily activities of educational organisations and leads to enhance their performance and decision-making. The aim of this article is to identify the significant factors that could influence the ERMS adoption in higher professional education (HPE). The methodology of this article started with identifying the factors through theory analysis and literature and also recommended by experts. Technology–organisation–environment (TOE) theory was used for factor classification. Qualitative approach was used through the interview with experts to validate and verify the proposed framework. This article presents the results of a study which identifies the issues involved in the utilisation and adoption of ERMS. More than 100 previous works and six well-known theories were critically reviewed to identify the main factors for successful ERMS adoption in different areas with the aim of proposing a taxonomic framework that can depict and identify the main factors that have an impact on the success of ERMS adoption. The proposed framework includes 11 factors categorised into three dimensions. The framework is validated and verified by experts. The adoption factors identified here provide a sound theoretical basis for research to understand, support and facilitate the adoption of ERMS to HPE benefit. The proposed framework could help to improve educational outcomes and the successful implementation of ERMS.

The Performance of Educational Institutions Through the Electronic Records Management Systems

This article discusses the relationship between educational institutes that use ERMS and the performance of those institutions. This article uses a mixed explanatory method that incorporated quantitative and qualitative approaches. The quantitative method collected the responses from 364 participants. This was followed by a qualitative approach where experts were interviewed to verify the model. The results generated using the quantitative approach demonstrated that the quality of the system, information, and service as well as the security provided by the system had a significant positive relationship with the successful adoption of ERMS, which in turn improved performance. Moreover, the qualitative results that gathered through the experts confirmed the findings and contributed to enriching the understanding of the adoption of ERMS in educational institutions.

Connecting Professional Practice and Technology at the Bedside: Nurses' Beliefs about Using an Electronic Health Record and Their Ability to Incorporate Professional and Patient-Centered Nursing Activities in Patient Care

The purpose of this research is to determine the effects of implementing an electronic health record on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities, attitudes and beliefs related to implementation, and changes in level of nursing engagement after deployment of the electronic health record. Patient-centered activities were categorized using Watson's Caritas Processes and the Relationship-Based Care Delivery System. Methods included use of an Attitudes and Beliefs Assessment Questionnaire, Nursing Engagement Questionnaire, and Rapid Modeling Corporation's personal digital assistants for time and motion data collection. There was a significant difference in normative belief between nurses with less than 15 years' experience and nurses with more than 15 years' experience (t₂₁ = 2.7, P = .01). While nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, time spent in relationship-based caring behavior categories actually decreased in most categories. Nurses' engagement scores did not significantly increase. These results serve to inform healthcare organizations about potential factors related to electronic health record deployment which create shifts in nursing time spent across care categories and can be used to explore further patient centered care practices.

Determinants of primary care nurses' intention to adopt an electronic health record in their clinical practice

A provincial electronic health record is being developed in the Province of Quebec (and in all other provinces in Canada), and authorities hope that it will enable a safer and more efficient healthcare system for citizens. However, the expected benefits can occur only if healthcare professionals, including nurses, adopt this technology. Although attention to the use of the electronic health record by nurses is growing, better understanding of nurses' intention to use an electronic health record is needed and could help managers to better plan its implementation. This study examined the factors that influence primary care nurses' intention to adopt the provincial electronic health record, since intention influences electronic health record use and implementation success. Using a modified version of Ajzen's Theory of Planned Theory of Planned Behavior, a questionnaire was developed and pretested. Questionnaires were distributed to 199 primary care nurses. Multiple hierarchical regression indicated that the Theory of Planned Behavior variables explained 58% of the variance in nurses' intention to adopt an electronic health record. The strong intention to adopt the electronic health record is mainly determined by perceived behavioral control, normative beliefs, and attitudes. The implications of the study are that healthcare managers could facilitate adoption of an electronic health record by strengthening nurses' intention to adopt the electronic health record, which in turn can be influenced through interventions oriented toward the belief that using an electronic health record will improve the quality of patient care.

Addressing critical issues in the development of an Oncology Information System

PURPOSES

This paper presents the experience on the design and implementation of a user-centered Oncology Information System developed for the Medical Oncology Department at the "Hospital Universitario Virgen de la Victoria", in Málaga, Spain. The project focused on the aspects considered in the literature as critical factors for a successful deployment and usage of a health information system.

METHODS

System usability, adequate technology, integration of clinical routines, real-time statistical analysis of data, information confidentiality and standard protocol-based external interconnection were the key aspects considered.

RESULTS

The developed system is based on a web application with a modular and layered architecture accounting for usability, ease of maintenance and further system development. Evaluation of system usability was carried at three and fifteen months after system deployment to analyze the advantages/disadvantages experienced by the end-users.

CONCLUSIONS

A thorough prior analysis of clinical activities and workflows, the use of the adequate technology, and the availability of data analysis tools will almost guarantee success in the deployment of an Oncology Information System.

Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change

BACKGROUND

Social cognitive theories on behaviour change are increasingly being used to understand and predict healthcare professionals' intentions and clinical behaviours. Although these theories offer important insights into how new behaviours are initiated, they provide an incomplete account of how changes in clinical practice occur by failing to consider the role of cue-contingent habits. This article contributes to better understanding of the role of habits in clinical practice and how improved effectiveness of behavioural strategies in implementation research might be achieved.

DISCUSSION

Habit is behaviour that has been repeated until it has become more or less automatic, enacted without purposeful thinking, largely without any sense of awareness. The process of forming habits occurs through a gradual shift in cognitive control from intentional to automatic processes. As behaviour is repeated in the same context, the control of behaviour gradually shifts from being internally guided (e.g., beliefs, attitudes, and intention) to being triggered by situational or contextual cues. Much clinical practice occurs in stable healthcare contexts and can be assumed to be habitual. Empirical findings in various fields suggest that behaviours that are repeated in constant contexts are difficult to change. Hence, interventions that focus on changing the context that maintains those habits have a greater probability of success. Some sort of contextual disturbance provides a window of opportunity in which a behaviour is more likely to be deliberately considered. Forming desired habits requires behaviour to be carried out repeatedly in the presence of the same contextual cues.

SUMMARY

Social cognitive theories provide insight into how humans analytically process information and carefully plan actions, but their utility is more limited when it comes to explaining repeated behaviours that do not require such an ongoing contemplative decisional process. However, despite a growing interest in applying behavioural theory in interventions to change clinical practice, the potential importance of habit has not been explored in implementation research.

Adoption of telemedicine: from pilot stage to routine delivery

BACKGROUND

Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery.

DISCUSSION

We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur.

SUMMARY

The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.

Statistical synthesis of contextual knowledge to increase the effectiveness of theory-based behaviour change interventions

Tailored implementation strategies targeting health professionals' adoption of evidence-based recommendations are currently being developed. Research has focused on how to select an appropriate theoretical base, how to use that theoretical base to explore the local context, and how to translate theoretical constructs associated with the key factors found to influence innovation adoption into feasible and tailored implementation strategies. The reasons why an intervention is thought not to have worked are often cited as being: inappropriate choice of theoretical base; unsystematic development of the implementation strategies; and a poor evidence base to guide the process. One area of implementation research that is commonly overlooked is how to synthesize the data collected in a local context in order to identify what factors to target with the implementation strategies. This is suggested to be a critical process in the development of a theory-based intervention. The potential of multilevel modelling techniques to synthesize data collected at different hierarchical levels, for example, individual attitudes and team level variables, is discussed. Future research is needed to explore further the potential of multilevel modelling for synthesizing contextual data in implementation studies, as well as techniques for synthesizing qualitative and quantitative data.