Masters Thesis Final Draft

Research Methods Thesis 21419990
Research Methods
The impacts of Electronic Health Records

(EHR) system adoption, implementation and
interoperability on patient safety and
information security.
A thesis written in partial fulfilment of the requirements for the Masters’ degree
programme leading to award of
Msc. Health Informatics
Submitted
by
Abayomi Awoyemi
21419990
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Table of Contents
ACKNOWLEDGEMENTS
I would like to use this opportunity to thank the head of the department of …
Professor Jose Abdelnour-Nocera, the academic staff of the department and other
co-students that in one way or the other our paths have crossed in the course of this
Masters programme.
My indebtedness and special thanks go to my supervisor Dr Laden Husamaldin for

all her welcoming and with her reassuring smile, unending guidance and feedback
which has enabled has been pivotal to completing this work.
The profundity of my gratitude goes to my friend and colleague, Frank Briggs, who
earnestly provided emotional support all through the writing of this thesis.
Lastly, I would also like to use this opportunity to thank my families and my children
for the unending support all through this academic journey.
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ABSTRACT
The complexity of the health system has resulted in the development of information
technology (IT) infrastructure in view of the potentiality in expediting efficiency and
error risk reduction. Traditionally, the service providers are in control of the access to
the patient's information which is now being transferred and controlled by the EHR
system across various domains. However, the Electronic health records (EHR) are
progressively being used in healthcare settings and now thought to have brought
essential benefits not only to the patients, but also to the healthcare services as a
whole. Conversely, the EHR is being used in aggregating patients' data through an
exclusively constructed health information network towards producing a holistic view
of healthcare services (). In essence, the EHR systems are sometimes characterised
with underlying risks which include electronic data forms that are sent through a
network, accessed at numerous locations by authorised person and sometimes by
unauthorised persons with the least affiliation with the said patient.
The literature review proved that there are some benefits, disadvantages as well
difficulties accruable to adoption, implementation and interoperability of EHR
systems. Some of the articles accessed during the literature review identified some
potential benefits of implementation and interoperability of EHR system and these
include: clinical decisions making improvement, supporting triage decisions,
enhancing team collaboration (including patients), reducing time to care and
improving productivity through tasks automation. The mixed methodology was
deployed by the author, using triangulation as well as quantitative, qualitative data
collection in generating some validation by presenting findings from research
perspectives towards understanding impact.
The research questions and hypothesis were analytically used, and the research
work addresses these questions within the context of implementation and
interoperability of the EHR system. The crucial findings consist of the following: (a)
The patients, services providers and other stakeholders have concerns regarding
privacy and private inputs into the EHR system. (b) the stakeholder has exercised
countermeasures in view of protecting private information in the EHR system. (c)
The patients have been identified and made the secondary stakeholders in the EHR
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system (d) That substantial and sufficient efforts have been channelled towards
privacy protection in EHR system, but the various breaches are caused through
human error. As such, data protection alone has been established to be unable to
prevent the breaches from happening and in promoting patient safety.
The recommendations made from conducting this research is to support in creating

awareness on the importance of EHR adoption, implementation and interoperability
to promote the provision of quality health care as well as patient safety. In essence,
the value creation and the development of system with user-centered / user-friendly
design and reduced cost will involuntarily lead to improved quality in healthcare
provision outcomes as well as patients safety.
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Table of Content
Chapter 1: Introduction
a. Introduction…….…………….…….........................................................................5
b. Background...…….….…........................................................................................6
c. Aim………………...……...……………....................................................................9
d. Objective…………………………............................................................................9
e. Problem statement………………...........................................................................9
f. Research Questions.………….............................................................................10
Chapter 2: Literature Search and Review
a. Review Purpose..…….….....................................................................................11
b. Utilised database…….….....................................................................................10
c. EHR's adoption, implementation and implementation associated principles.......10
I. Availability................................................................................................10
II. Protection................................................................................................10
III. Integrity….................................................................................................10
d. Results & findings…………..................................................................................10
e. Summary..……...……………................................................................................10
Chapter 3: Research Methods and design
a. Research Methods and design………………...……...............................................7

b. Research methods.................................................................................................7
c. Research Design....................................................................................................7
d. Sampling Method....................................................................................................8
e. Research Appropriateness.....................................................................................8
f. Data Organization, Themes, and patterns generation...........................................9
g. Hypotheses Testing................................................................................................9
h. Ethics issues, Informed Consent and Confidentiality.............................................9
Chapter 4: Findings and Analysis
a. Analysis and Results......................................................................................10

b. Statistics…………………………………...….…………....................................10
c. Research Questions.......................................................................................10
Chapter 5: Conclusions and Recommendations
a. Summary of Findings……………….……….………..............................................10
b. Discussion…………………………...….…….………….........................................10
c. Limitations of findings…………...….………………...............................................11
d. Conclusions..........................................................................................................11
e. Recommendations……………….………………...................................................11
Chapter 6: References, Appendices and Tables
a. References...........................................................................................................12
b. Appendices…….………........................................................................................12
c. Tables……….…….…………………...….…………................................................12
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Chapter 1: Introduction and background

Introduction
There have been numerous challenges facing global the health system in terms of
ever-growing size of the population, the data security compliance problems, adoption
degrees and data standards inconsistent have all impacted on the adoption.
implementation and the implementation of Electronic Health Record (EHR) (Akhlaq
et al., 2017; Anderson, Baskerville & Kaul, 2017). Similarly, the complexity of the
health system has led to a renewed interest in the information technology (IT)
potentiality in expediting efficiency and error risk reduction. As such, the EHR is a
digital patient health record of various processes with the care delivery setting
containing information such as medications, demographics and associated
problems, vital signs, laboratory data and radiology report, past medical history etc.
However, the current EHR initiatives had been progressively driven by wider political
concepts of accomplishing extensive interoperability. Thus, in view of EHR systems
enormous potential benefits (especially in relations to its increased information
availability across various healthcare settings and its secondary users), numerous
countries across the globe have implemented EHRs, but the adopted strategies for
EHR implementation varies significantly across all countries that have adopted it,
most especially here in the United Kingdom (UK) (Adler-Milstein & Jha, 2017;
Kanakubo & Kharrazi, 2019; Tavares & Oliveira, 2018).
The UK centrally implemented the EHR using the “top-down” approach which is
characterised by a strategy to develop local systems in which information or records
are not only made available centrally, but to provide access to these records locally
and for various organisations (Currie, 2014; Hertzum & Ellingsen, 2019). Although,
there has been numerous efforts to use the EHR to deal with the emergent
information needs which is not without associated difficulties especially in an attempt
at connecting to local systems and share such information. Therefore, this research
work will be structured to include research design, research methodology, population
sample, data collection procedures, the survey variables table, as well as
documentation quality and quantity will be highlighted. In essence, the research
analyses how EHR adoption, Implementation and interoperability would have
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impacted on patients’ safety. In addition, the author of the proposal will be referred to
as “the researcher” in the contest of report.
Background
Florence Nightingale is one of the protagonists of improved patient health records
and this had led to the evolvement of Computer based records now known as the
Electronic Health records (EHR) (Aravind & Chung, 2010). Additionally, the World
Health Organization (WHO) has acknowledged that Health Information Systems
(HIS) is part of the ‘building blocks’ or part of the six key elements of a health system
(WHO, 2007; 2010). Leadership and governance, Health workforce, health service
delivery, essential medicines access and health systems financing are the other
listed building blocks considered to be essential to Health system, while HIS was
highlighted to be critical in decision-making within the context of other listed building
blocks (WHO, 2007; 2010) In essence, WHO stressed the need for high quality HIS
for tackling the global health challenges and forming strong public health systems
(Manyazewal, 2017).
Researchers on the other hand, have postulated the need to for EHR system to be
adopted and implemented as product of necessity in the health (Mobin et al., 2018).
The initial insight into the health record could be traced back to the fifth century (BC)
during which the Greek physician (Hippocrates) in his ‘Hippocratic Oath’ highlighted
the essentiality of medical record being used to replicate the disease classification
and to also hypothesise the cause of the disease. However, what was close to the
adoption of the EHR was done by about Seventy three Hospitals in United State
(USA) in the 1960’s, but in 1991 the Institute Of Medicine (IOM) in its landmark
report that recommended the general implementation of EHR within the following 10
years in world health system, but this could not be accomplished as according to the
report from the recent research report; only about 65% or less of the providers of
healthcare services across the globe only managed to do the adoption
(Waegemann, 2004; Tavares & Oliveira, 2018).
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Meanwhile, communication and information technologies advancement had

necessitated the need for storing health records in an electronic form. Equally, the
medical care provisions intricacies and the essentiality of maintaining the related and the
vast patient health records in an organized manner for efficient retrieval and sharing ease
amongst the various health departments (i.e. administration, Xray and radiography,
laboratory, clinical, nursing etc.) necessitate EHR adoption (Adler-Milstein & Jha,
2017). Therefore, the EHR could then be described as a universal and unavoidable
technological advancement with the potential benefits for national electronically
storage and sharing of patients’ information with the aim of improving the legibility of
available information and effective access to health records (Adler-Milstein & Jha,
2017). In essence, the EHR adoption, implementation and interoperability was
argued to have created the prospect of removing the healthcare associated
challenges e.g. saving of money, time (cost cutting) and saving of lives
simultaneously (Rasmi et al., 2018).
On the other hand, the distribution of sensitive and personal patient information
amongst various health departments electronically could make challenges such as
privacy issues and information security breach inevitable. Nonetheless, the previous
studies in EHR systems have highlighted the associated risks needed to be
mitigated towards the universal adoption, implementation and interoperability of EHR
system which include citizens’ privacy and health data ownership rights, databases
security and the surveillance society complexity, service denial resulting from
communication exposure to an open and unsecured internet, unauthorized access,
etc. These were stressed to impact on patients’ outcome and invariably expose the
patients to undue harm (Mobin et al., 2018). The EHR records include individual
patients’ details, demography, medications, immunizations records, past medical
history, laboratory data, progress notes, radiology reports and vital signs (Feldstein.
et al., 2017).
However, most of the numerous studies into public and patient perceptions of EHR
system and its accompanying data tend to have focused on peoples’ concerns and
fears over EHR, rather than on how the adoption, implementation of EHR bring
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about healthcare improvement and positive patient outcome. In addition, the

previous research has highlighted the concerns associated with EHR to include the
use and misuse of data, privacy, and the control over access and security (Kruse, et
al., 2016; Mobin, et al., 2018). However, this study seeks to extend these findings by
examining additional patient and public characteristics, including health services use,
and by examining a broad range of attitudes towards a universal EHR system.
Aim
The aim of this study will revolve round the need to understand and provide adequate
answers and recommendations that could instruct further research and strategy concerning
the impact of EHR adoption, implementation on patient safety and health outcome.
Objective
The outcome of this study will not only be beneficial to the patients, but to the
healthcare professionals and healthcare providers or organizations as it will allow for
a collaborative promotion of the positive adoption, implementation and
interoperability of the EHR. As such the objectives of the research work would be
enumerated as follows:
 To critically analyse any existing literature about the chosen research topic
in view of exploring the relationship between EHRs implementation,
adoption and interoperability on patient safety and health outcome.
 To highlight the implications of EHR implementation strategies, adoptions
and interoperability on the quality of care being provided.
 To analyses how EHR data quality has enabled higher efficiency in
healthcare delivery
Problem statement
Privacy, confidentiality, and security has been part of the part of the associated
revolving round the effective adoption, implementation, and interoperability of EHR.
The EHR is a system for the storage of patients’ personal and sensitive information
which are adopted by the physicians, the nurses and the pharmacists in the
provision of quality services (Rasmi, et al., 2018; Mobin, et al., 2018). In essence,
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the EHR has been configured as an electronic health information repository system
for the support of data flow within the healthcare continuum and also for the
promotion of a comprehensible and quality healthcare that focuses more on patients’
safety as well as in enhancing the effective, efficient and accurate provision of
patient EHR at the point of care (Charles et al., 2015; Deokar & Sarnikar, 2016).
Meanwhile, Walker & Diana (2016), Lin, Jha, & Adler-Milstein (2018) and Charles et
al., (2015) have all argued that although the EHR might work well in any healthcare
settings, its non-interoperable as a system could result in difficulty of sharing any
associated patients records that could potentially impact negatively on quality of care
being provided (Blijleven, et al., 2017; Tavares & Oliveira, 2018). Thus, it is
imperative to ask the question on what impact of adoption, implementation and
interoperability of Electronic Health Record on information security and patient
safety? The incompatibility of the EHR system within an organisational or hospital
system and the inability to use the system or access the necessary information by
medical personnel across different health facilities could threatens the provision of
an efficient and quality health care services (Charles et al., 2015; DesRoches et al.,
2013; Walker & Diana, 2016; Kruse, et al., 2016). In view of the above argument, it
was found from the research earlier conducted by scholars between the year 2010
and 2014 in some USA hospitals that adopted the EHR system that only about 25%
were able locate, obtain, send and make use of the electronic health information
without resulting into using the manual data entry intervention (Lin, Jha, & Adler-
Milstein (2018); Kanakubo & Kharrazi, 2019). Therefore, it essential to have an
effective and efficient adoption, implementation and interoperability of EHR systems
as this plays an important role in reducing the chances of patients’ privacy being
compromised and this hitherto leads or contributes to the overall quality of care
provision.
Research questions:
1. Has the implementation or adoption of EHRs enhanced the quality care

provision or promotes patients’ safety?
2. Are usability issues also a factor contributing to the failure of EHR
implementation?
3. Will time be saved, and health services delivery efficiency improved with
adoption, implementation, and interoperability of EHR?
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4. What are the stakeholder's risks perception and attitudes towards the sharing
of personal sensitive health information through the secured network for the
EHR system?
5. What are the barriers preventing comprehensive adoption, implementation,
and interoperability of the EHR system from being accepted on a larger
scale?
Chapter 2: Literature Search and Review
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As patient safety and care needs are prioritised in healthcare, it is essential for every
health providers to manage patients’ information effectively and efficiently.
Inadequate or poor data quality has greater impact on patient safety, inefficient and
poor finance of health facilities, as well as increase in cost ().
Review Purpose
The EHRs was adopted and implemented with the objectives of improving the health
records quality, improve patient care and safety as well as to reduce the overall cost
in healthcare. Thus, an effective and efficient adoption and implemented EHR will
enhance the clinical decision support systems to improve care quality provision. As
such, the literature review was analyse the available literature with a view of getting
an insight and background knowledge into the impact of EHR adoption,
implementation on patient safety and health outcome.
The utilised database
During the literature search attempts were made at exploring the contemporary
studies as well as scholarly peer-reviewed articles / journals about the efficient of the
adoption, implementation, and interoperability of the EHR systems in the healthcare
settings. Therefore, in order to accomplish this research objectives, a comprehensive
search of primary and secondary literatures which involves the use of the University
of West London Library (UWL) Library electronic databases relating to healthcare
(MEDLINE, PsycINFO, PubMed Cumulative index, CINAHL, Computer Science and
Engineering) and using keywords like Electronic Health Records (EHR), Health
information technology, Interoperability, Person-centred care, Safety, the inclusion
and the exclusion criteria, content and the specific publication date as the filters for
generating the needed literatures. Meanwhile, the search produced about 47,496
literatures, but with application of earlier listed filters 6378; 1501; 832; 224; and 981
were further generated, respectively. However, 7 articles were adjudged to be
suitable for the purpose of the review after the initial review, each literature abstract,
discussion, and conclusion.
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EHR's adoption, implementation associated principles.
There are various guiding principles for EHR adoption, implementation and
interoperability and this includes Availability, protection and integrity.
Availability: According to Chen et al. (2016) the data and information accessibility
should timely and usable based on the demand by authorized users (individual or
organization) as this will guarantee the readiness of such essential data/information
as at when needed. Thus, the stakeholder should endeavour to determine the
redundancy levels as well as the contingency plans for handling associated risk
such as the non-availability of electronic information (Chen et al. 2016; Fenton et al.,
2017; Hess, 2015; Osborne et al., 2017; Peixoto et al., 2016).
Protection: The protection principle necessitates the need to guard against the
inappropriate access, acquisition, disclosure, or the use of protected health
data/information, as well as the protecting against loss, interference, and the
alteration of health data/information (Plachkinova & Grispos, 2017). Therefore, the
information governance protocol should ensure adequate protection level against
security infringements or data being compromised to enable confidentiality, data
classification and business continuity (Chen et al. 2016; IHE, 2013; Plachkinova &
Grispos, 2017; Wehbe, 2016). In addition, there is need for information governance
protocol to incorporate distinct processes of audits that will operate within every
organization’s procedures and policies in compliance Healthcare applicable laws or
laid down guidance and business practices (AHIMA, 2015; Anthony et al., 2013;
Chen & Benusa, 2017; Cram et al., 2017; IHE, 2013).
Integrity: The integrity principle is the organizational ability in maintaining the data
structure and attributes with protection against interference or modification in the
process of transmission and storage. Thus, the integrity principle is a crucial
component necessitates the dependability, trustworthiness and maintenance of
data/information so as to enable the data/information to remains accurate, authentic
and complete (AHIMA, 2015; IHE, 2013; Patil & Seshadri, 2014; Plachkinova &
Grispos, 2015; Wehbe, 2016). In addition, the Integrity principle necessitates the
need for information governance policies and procedures to be adhered as
approved as it a prerequisite for achieving regulatory and legal compliance by
various associated organisation (AHIMA, 2015; HIMSS, 2015; IHE, 2013).
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Conversely, it is pertinent for organizations to establish the roles, responsibilities and

the processes of compartmentalizing and processing of received information from
other department, groups or other sources (AHIMA, 2015; IHE, 2013; Plachkinova &
Grispos, 2015).
Result and findings
Data entry, input, output and transfer problem: Data entry has always been a
major obstacle to healthcare professionals' acceptance of electronic records. On the
other hand, the Patients records form a large quantity of created information within
the EHR and its inadequate adoption are often considered to be associated with
increased harm to patients (Adams et al., 2017; Ndifon, Edwards, & Halawi, 2016).
For instance, most inputs require the use of structured data entry where the user(s)
would have to select relevant clinical terms from a predefined list. This is highlighted
to be restrictive, as information extraction creates more work from the clinical
professional users (clinician). Thus, it is essential to create a standardized clinical set
of terms and tools that would not only be interactive, but also be continuously be
kept up to date. is resource intensive (Wisner, Lyndon, A & Chesla, 2019; Wang,
2018).
Similarly, the poor and improper human use of a system could sometimes be
dependent on the organisation communication context types, the available staff
training, employees/ staff/ users experience and characteristics and which could be
militating against positive or adequate adoption, implementation and interoperability
of EHR (Palojoki et al., 2017; Chao, 2016;). Tanner et al., (20150 and Clarke et al.,
(2016) argued errors rectifying laxity, hand offs, communication fatigue and transition
contributes to inadequate EHR adoption, implementation. They further stressed that
staff competence and education about the use the of EHR should have a clear
connection rather than having a “blame culture or inability to accept errors or ask for
help” which could lead to error and then adversely impact on patient safety.
Poor Technical & system design problems: Device dysfunction, downtime etc.
could contribute to inefficient use of EHR and this could also be another source of
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harm to the patient (Strudwick et al., 2018). In essence, it that system design
(system navigation) and functionality issue (i.e. the ease of finding information) was
stressed create difficult towards the efficient use of EHR and thus a potential source
of harm to the patients (Clarke et al., 2016; Adams et al., 2017; Ndifon, Edwards, &
Halawi, 2016).
Sustainability
The EHRs sustainability in clinical research was regarded to be dependent on the

materialization of its supposed functionality efficiencies. The sustainability of using
EHRs for pivotal registration clinical trials will depend on regulatory acceptance of
the approach and whether the efficiencies support a business case for their use.
Summary
Universally, the healthcare industry used to rely extensively on paper records
documentations and this was considered to be an organization's asset with its level
of accessibility and availability restricted for public user, while limited access were
also granted to authorized organizational stakeholders (Bullard, 2016; Kumar et al.,
2017; Abdullah & Bakri, 2016; Simon et al., 2013). Conversely, the evolution of EHR
system, which is the digitalized version of the paper record documentations of
diagnosis, treatment and monitoring of a patient's data as used by healthcare
providers in social care and Healthcare settings brought a different dimension to
healthcare data usage (Esposito et al., 2017; Heart et al., 2017; Kohli & Tan, 2016).
The extensive scholarly exploration of literatures in relation to the adoption,
implementation of EHR systems as it impacts on patient’ safety, makes the author of
the work to understand that the healthcare setting is a repository of intensive health
information/activities which produces data in large quantities. In essence, these
associated data that are collected in various settings and systems could result in
data quality attributed to incoherent or contradictory information or a complete data
miss (…..). On the other hand, quality improvement (QI) encompasses the
systematic advancement of standardized and efficient work environments (xxxx;
xxxxx; xxxxx). This documentation process forms the basis of analyzing problems
and identifying the part of healthcare work dynamics that needs improvement and
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such improvement that could bring therapeutic effects not only to the to the patients,
but to the generality of the users.
However, there is need for continuity andr for an existing communication protocol or
format to be standardized, as this will allow for adequate understanding of shared
information ‘by and for’ the stakeholders. In essence, it is essential to develop and
adopt a recognized national and international EHR adoption, implementation pattern
as well as software interoperability to enhance EHR quality, care provision quality
and patient safety (). In addition, there have been various attempts by IT developers,
Policymakers and other stakeholders address the numerous barriers impacting on
EHR adoption, implementation, and interoperability. As such, majority of the
stakeholders had worked hard to improve standardization of associated EHR health
data (……).
(Delgado, et al., 2016; Detro et al., 2016; Osborne et al., 2017; Jabbar et al., 2017;
Voltz, 2014). (Delgado, 2016; Detro et al., 2016; Jabbar, Ullah, Khalid, Khan, & Han,
2017).
Chapter 3: Research Methods and design

Research Methodology:
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There are numerous approaches being currently used by researchers, but the mixed
methods are mostly used as it provides a comprehensive or accurate understanding
of the subject or problem that the research is being conducted upon Consequently,
mixed method is being adopted for this research work as it necessitates the use of
quantitative and qualitative methods (Edmonds, & Kennedy, 2016; Bowen, Rose, &
Pilkington, 2017; Patkar, 2018). The quantitative research method includes
observational studies or clinical trials which then go on to produce numerical data.
Similarly, qualitative methods tend to produce non-numerical data with the use of
methods like semi-structured interviews (Ghauri, Grønhaug & Strange, 2020; Kumar,
2019; Morse, 2016). In essence, the adoption of mixed method for this research
helps in enhancing the research by offering measuring and understanding options,
as well as providing the opportunity of validating the research as data are now being
collected through in-depth interviews within the National Health Service (NHS) with
the UK (Bowen, Rose & Pilkington, 2017; Daniel & Harland, 2017; Edmonds &
Kennedy, 2016). Conversely, the tools such as questionnaires and interview
(unstructured and semi-structured) is currently being used for data collection for this
research (Machado & Davim, 2020; Morse, 2016).
Research methods
For the collation of adequate information, a mixed-methods approach that combines

both qualitative and quantitative methodologies was adopted. The quantitative data
collation method was vital for recording research outcomes, while the qualitative
method was also essential in identifying the participants’ experiences in using the
system (). Thus, considering the purpose and the nature of this study, the qualitative
research method approach was applied in gathering the needed data /information
through the use of semi-structured and structured interviews as well as the open-
ended web questionnaires for exploring the impacts of the adoption, implementation
of EHR on patient safety and security. For the understanding of the impacts of the
adoption, implementation and interoperability of EHR system requires having
detailed information regarding the specifics of the system in use or being
implemented. The type of system functionality needed for the EHR system and who
uses this system for adoption, implementation accomplishments are focussed on
during the interviews and in the questions within the questionnaires. Thus, using the
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qualitative approach enable for thorough and rich information to be collated and
compared.
Research Design:
The mixed method which involves collection, analysis and infusion of both qualitative
and quantitative data has been used during this research work in view of
understanding the research problems. It was considered that using one or the other
(i.e. Quantitative or Qualitative) alone might not be sufficient enough to garner the
needed information to understand how the use of EHR impacts on the care provision
in terms of safety and security. For instance, using the quantitative methods had
allowed the use of numerical data in isolating variable in determining the relationship
and magnitudes of data collected, while using qualitative method helped in
developing a holistic knowledge grounded on constructivism ().
However, the use of mixed method helps the author of this work to build on
pragmatic ground as it involves the use variables and analysis units adequate in
answering and having a good understanding of the research questions. Thus, while
designing the mixed method, prioritisation, integration and implementation were
considered and this necessitates the use of the sequential exploratory mixed
methods design comprising of two separate phases. During the first phase, numeric
data were collected, while the second phase involves graphical analysis of the data.
2.2 Research Approach and Study Design

The research approach and design for this study involves the use of qualitative and
quantitative research methods for data extraction and collection from responses to
each of the research questions. The qualitative data collections were done with the use of
structured and semi-structured standardized open-ended interviews questions. The face to
face interviews were conducted among the unskilled staff and patients/service user. On the
other hand, the web questionnaires with standardized closed-ended questions were
constructed with the link sent out to the proposed participants. However, in order to have a
concise understanding of the impact of the adoption, implementation and interoperability of
EHR on information security and patient safety, interviews were also conducted amongst 8
randomly selected IT & Healthcare professionals working regularly with the EHR system. It
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was from there that a decision was made by the author of this work on who will be targeted
population that questionnaire would be sent to.
medical personnel and information systems personnel the research team should be directors
of health information management since they are the core individuals using the electronic
health record systems.
Sampling Method
The population or the sample size used in this project work includes the healthcare,
professionals, IT professionals and the other essential stakeholders who possesses
some experiences with the use of information system and also with a good
understanding of how the EHR technology works, especially in terms of conducting
the following for their service users; booking online appointment, accessing medical
information, prescriptions request and refilling, etc., and towards supporting the
operation of healthcare organizations in view of numerous processes in patients
encounter. The contact with respondents to participate in the survey were done via
the phone and personal one to one contact through the researcher’s personal
acquaintances and then approached persons were implored to speak with their
colleagues to seek their intention to participate and for the questionnaire be sent.
Thus, while the doctors/physicians, the nurses constitute the professionals, the
patients, the NHS IT structures and other service users (i.e. Patients and their family)
constitutes other stakeholders. The online survey software provider (Google Forms
Questionnaire link ) was used in tracking the numerous numbers of times that the
questionnaires were accessed. 195 people initially signified their intentions in
partaking in the study, but only 72 people with good years of experience in working
within the healthcare settings eventually took part as participants in the research.
The responses were collated from a semi-structured interview and questionnaires
(which include web and paper printed questionnaires) respectively. The adoption, the
implementation and interoperability of the EHR were explored using the availability,
protection, and integrity principles. The healthcare professionals (16 Doctors, 28
Nurses and 14 IT supporting staff) and 16 services users (patients) from a NHS
foundation Trust (from both Mental Health and Physical heath settings) were the
participants used in this study.
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Research Appropriateness
Confidentiality and consents were given highest priority and attention to maintain a
high level of ethical standard all through the course of this research work. Thus,
initial visit was made to the nominated hospital and during which the purpose of the
research work and the format the interview will take place was highlighted. Following
this, the interview questions were sent out ahead of the interview to ascertain
whether the supposed respondent(s) want to still participate in the research work
and to also affirm whether they want to use their real name or just an alphabet or
pseudonyms. This allows the author to be able to select or get the respondents that
are willing to participate in the study. After, the interview, the transcript was read
back to each participant to affirm their responses or what was written down was
there chosen response and whether each participant has been cited properly.
Data Organization, Themes, and patterns generation
The questionnaire used for this study was presented via a well-known and
trustworthy online survey Software (Google Forms Questionnaire Link The
questionnaire was designed, published and distributed via this survey software
secure servers. The designed questionnaire comprised of five pages, not including
the attestation page (See Appendix I). The first and introductory page was used to
introduce the work to the respondents, while the 2 nd to the last page constituted the
pages where the questions were asked. The Questionnaire was also structured into
two groups, the first is for the end users (Healthcare and social professionals, the
patients and other service users), while the second is for the IT or implementation
group. In each of this group, the questions were asked relating to the respondents
understanding of EHR, the anticipated or expected goals for using or implementing
EHR, the overall benefits and obstacle for using EHR, and the overall impact on
service provision and patient safety. A Therefore the responses from the
questionnaires and interviews were then clustered to form dataset and use in
analysing the eventual results as shown further in the course of this work.
Hypotheses Testing
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The Hypothesis regarding overall EHR adoption, implementation and interoperability

were tested. The first hypothesis tested was to that there a poor relationship and
interactions between the healthcare professionals and the patient with the adoption,
implementation of the EHR when compared with the use paper documentation.
Additionally, the second hypothesis is the thought and feeling that the adoption,
implementation of EHR has improved communication amongst the healthcare
professionals when compared to the period of paper documentation. Conversely, it
was also hypothesized that younger healthcare professional under the age of 50
years would find the adoption, implementation and interoperability not only
interactive, but beneficial than those healthcare professionals above the age of 50
years when compared to paper documentation. Thus, there is enormous and
diverse of opinions in view of adoption, implementation, and interoperability of EHR.
There is also diverse stance about patients’ satisfaction with healthcare professional
with the adoption, implementation of EHR without thinking that they are just sitting
their surfing the internet.
Although the data analysis was done using numerous steps, but this research
statistical tests confidence level will be rated at 95% (α = .05), The descriptive
statistic method was adopted in analysing the responses from to individual question
from the questionnaire and the result then clustered into Tables and graphs. In
addition, the hypotheses were analysed as follows:
Hypothesis 1: There is inhibition of EHRs acceptance on the part of healthcare

professionals as a result of lack of authorization controls and security concerns. This
first hypothesis was analysed in this study with the use of correlation analysis
(Pearson). Thus, the questions relating to the impact of EHR implementation on the
patient safety and information security were analysed with a categorical independent
Variable in view of how the adoption of EHR improves the quality of work being
performed by the healthcare professional and leading to improved patient care.
Hypothesis 2: This hypothesis relates to the identifiable barriers that could impact
on EHR’s effective implementation. The cost of implementing the EHR as being too
expensive was considered in relation to its inhibition of the effective implementation
of the EHR. Thus the EHR system implementation or adoption cost was also
classified as one of the variables in responses analysis.
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Hypothesis 3: This is the hypothesis that relates how the users perceived the
adoption of newer technologies like the EHR. The continuous variable was adopted
to analyse the responses to the question about how the implementation of the EHR
system enhances the workflow efficiency and quality.
Hypothesis 4: The hypothesis relates to how the EHRs system protects the
patient’s privacy in comparison with paper oriented medical record keeping. The
continuous variable was used in analysing the response relating to questions relating
how secure and trustworthy the EHRs system Vis a Vis how it promotes
confidentiality.
Hypothesis 5: This hypothesis relates to how inadequate EHR system knowledge

and inadequate computer literacy skills could inhibit its efficient implementation by
healthcare professionals. The analysis of the second hypothesis was also completed
with the use of correlation analysis in answering question about perception and
knowledge users have about EHR. The responses were then classified with a
continuous variable.
Ethics issues, Informed Consent and Confidentiality
In undertaking this research work, the first thing that was considered relates to
ethical concerns which needed to be addressed all through the research work. Thus,
for data collection procedure to be initiated the respondents were provided with
opportunity to make informed consent and also provided with information on how
confidentiality and privacy would be sustained in the course of the study and after
the study. Therefore, all applicable legal and ethical guidelines were observed during
the study. Initially the project proposal was submitted to University of West London
and on getting approval the author then went ahead to conduct this research work.
Chapter 4: Findings and Analysis
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The purpose of this study is to examine the impacts of EHR system adoption,
implementation and interoperability on patients’ safety and information security. The
study entails the examination of the existing relationship between EHR system
interoperability levels (i.e. structural, foundational, semantic) levels and
implementation impacts on quality outcome. The findings from the research work
were analysed using the descriptive and analytical analysis.
Descriptive Statistical Analysis

The analysis of the data were produced and summarised using the hypothesis
testing method in examining various sets of variables culminating into the impacts of
EHR adoption, implementation and interoperability. The hypothesis were tested
using the bivariate analysis method so as to ensure that there are connections
between the variables deduced from the data that was generated and analysed.
Therefore, there was the need for the hypothesis test results to be interpreted for
claim for p-value generation.
the statistical analysis method has been used in this research work as it allows for
the data to be adequately interpreted considering the various relationships existing
between the considered variables. On identifying the objectives of the research, the
first step is data collection and this was then followed by data cleaning so as to
improve the data quality of the data that has been collected. This was then followed
by the application of the stat data combination of outcome variable were analysed.
Descriptive analysis was used in analyzing the data that was is one of the types of
analysis in research which is used in analyzing the data and in establishing the
unknown existing relationships, as well as in discovering the new connections that
would enhance future studies. In essence this descriptive data collection was used in
describing the key attributes relating to measuring data trends, comparisons conduct
and validating the prevailing condition.
is the process of using statistical techniques to describe or summarize a set of data.
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Validity:
In validating this research work, the researcher adopted the Content validity and
Criterion-related validity. The content was used to assess how well the identified
variables matches with the other content domains that are being measured (i.e.
information security and patient safety). In addition, the Criterion-related validity was
also used to determine the degree of relationship between this research in relation to
previous one. Conversely, using the Criterion Validity will help the author of this work
to have an indication as to If there is a high correlation, this gives a good indication
that your test is measuring what it intends to measure Therefore, these two methods
allowed for predictability of future outcomes. In essence, the use of content and
criterion related validity methods allows for the predictive validity to be infused into
the data analysis to create nomological network. Meanwhile, the adoption of this
approach entails a detailed description of the entire construct and allows for the
assessment of the content validity.
Analysis
Many of the respondents (n = 68) in this study were of the view that the EHR as a
system offers an ease of access to patient information. The EHR system has been
regarded by these respondents as a repository for storing enormous volumes of
information that are used by the healthcare professionals for electronic data
monitoring on illnesses and diagnosis, drug prescription and for tracing and tracking
test results. The respondents further highlighted that the adoption, implementation
and interoperability of EHR systems makes efficient transferred of information from a
facility or system to another possible. In addition, the ease of access to patient’s data
either by the patients, the professionals and authorised stakeholders makes process
not only efficient, but also cost effective.
However, according to the information gathered from the respondents during the
course of this research, the adoption, implementation of any electronic technology
could lead to technical barriers (this includes inadequate technical knowhow and the
time needed to acquire the skill), attitudinal (this comprises of inadequate research
and knowledge about EHR, the impacts of EHR adoption and usage, overall
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uneasiness regarding the associated change and also the philosophical and
psychological opposition to the to the implementation of the EHR system, situational
(This refers to the time requires for the EHR implementation and usage, the
investment initial returns and the exorbitant health IT systems cost), physical or
cognitive barriers (this relates to lack of adaptability and usability of the EHR
systems attributable inadequate computer skills) and legal (this includes legal
implication and complications and other medical malpractices that could culminate
into legal lawsuits). All these barriers are linked with couple of identified problems
which are highlighted and broadly discussed later in this report.
Results
In the course of the conducting the interviews, some NHS staff (n = 32) elucidated
their perception and experiences about the EHR system and how this impacts on
patient safety. As such, some challenges that were stated emphatically outweighed
the accruable benefit of adopting the EHR system. Additionally a concerted effort
was made in the course of this interview to balance the two, but it became clear this
challenges impacts more on patient safety than the apparent benefits.
Therefore, some key themes then emerged following the analysis perceived risks
and these are as highlighted below:
EHR system and Social factors

The EHR system introduction was stressed by many of the study participant to be
allied with the potential increased in inputting error, as a result of staff being not used
to using the system and then become more prone to making mistakes. These
respondents considered inputting errors to most occur when new professional and
junior staffs started using the system shortly after an upgrade has been done on the
EHR system, which might necessitate the need to re-learn. In addition, staff with
lower computer literacy level stressed that their inadequate typing skills make them
more susceptible to making inputting errors. In addition, anxiety, nervousness the
prospect of showing the slow typing attributes and, lack of confidence with use of the
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EHR system in presence of patients and ones colleagues could lead to inefficient
and effective use of the system. The apprehensions surrounding inputting errors
were exacerbated by the potential implications that entering incorrect information
onto the EHR system could have unimaginable impact information security and
patient safety. For instance, a situation whereby it inputted that a patient has
received a certain treatment as opposed to not receiving could indirectly impact on
the patient length of stay in hospital, the type of subsequent treatment to be provided
or might even lead to fatal consequence. Additionally, if inputting errors are not
realised and corrected on time, it might have a potentiality for medical and legal
consequences.
In the course of the study, the participants highlighted the perception and concerns
of most NHS staffs in relation to the associated risks of EHR system implementation
which were linked to technical and social factors. Similarly, the system design and
human factors considered to be the contributing factor to the identified risks Vis a Vis
missing or misplaced patient information and inputting or computation errors. In
addition, the adoption of socio-technical perspective allows for in-depth insight into
the limitations, constraints and potential harms associated with the EHR system
were identified in the course of this study. Thus the findings from this study correlate
with previous studies on Health Information Studies and also add to the emerging
evidence that EHR adoption, implementation and interoperability has potential risks
on patients’ safety.
EHR system and Technical factors

The respondents highlighted that technical issues that have always has significant
impacts on information securities and patient safety. These problems revolves round
inadequate computer facilities (i.e. insufficient computers) and associated time spent
waiting for availability of computer and then the logging in procedures which was
also linked to unavailability of adequate supports where the system locked the user
out. The study participants stressed how this could impact on work flow and patients
safety in general (increase in the discharge time and clinic waiting times), especially
where patient health deterioration is at stake, while they are trying to locate and
access an available computer and associated logging issue. Some of the highly
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skilled health professionals also highlighted the associated problems with inflexible
data entry methods around diagram drawing and documentations of operative
procedures. Therefore, the patients information are usually presented in a
standardised method which while desirable, could sometimes results to misplacing
the details and nuances of patients care needs and procedures.
Many of the participants also stressed that EHR system’s data entry methods mainly
incorporate the use of tick boxes and drop down which tends promote associated
inputting errors risk, especially where it makes it inevitable for the clinicians with time
constraints to have a wrong box ticked. Similarly, some of these participants
indicated that the inability to rectify inputting mistakes do also elevates the
associated problems as staff would have the only option of waiting till support is
available from colleagues, the super-user(s) or other tech support team in order to
be able to correct such error(s), most especially when such error happens at the
weekend or out of office hours.
Statistics
There was a total number of 72 respondents in the study and their responses were
aggregated and recorder in the table (see Appendix 2 ).
Research Questions
1. Has the adoption, implementation and interoperability of EHRs enhanced the

quality care provision or promotes patients’ safety?
2. Are usability issues also a factor contributing to the failure of EHR
implementation?
3. Will time be saved, and health services delivery efficiency improved with
adoption, implementation and interoperability of EHR?
4. What are the barriers preventing comprehensive adoption, implementation
and interoperability of the EHR system from being accepted on a larger
scale?
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Chapter 5: Conclusions and Recommendations

Summary of Findings
In conducting the research work, information was gathered through an in-depth
interview and Questionnaire administration process. The descriptive and Statistical
analysis were used in evaluating the impact of adoption, implementation and
interoperability of the EHR on information security and patients safety alongside its
identified barriers and challenges (Feldman, 2018). As part of data gathering, these
two analytic tools were used in analysis is an effective manner to derive emerging
themes from the respondents provided responses’ findings (Perry & Krippendorff,
2013; Stemler, 2015). Meanwhile, it was gathered during the data collation that t he
efficient adoption, implementation of the EHR system requires adequate
understanding of the users’ objectives and perspectives before deciding on the
structures, functionalities and investment, as this is also fundamental to the success
of the EHR as one of the NHS project, (and this buttress the arguments of Yin,
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2017, Xxxxx, xxxxx). As such, the adoption, implementation of the EHR system
solutions in Healthcare organizations is with the aim of improving organizational
operations vis a vis information security and patients safety.
Discussion
The adoption, implementation and interoperability of the EHR have brought with it a
digital medical data explosion in various forms in recent years, but the existing
evidence linking EHR system adoption, implementation and interoperability to better
care is mixed. The EHR system has brought major changes to the capturing and the
use of healthcare information towards improving patients’ care. It has provided a
theoretical opportunity for large-scale data integration and analyses in relations to
different patient attributes such as person identifiable information, types of diseases,
available treatment, prognosis and progression, outcomes and lots more. In
essence, the effective and efficient adoption, implementation and interoperability of
the EHR system comes with numerous benefits which includes but not limited to the
(a) enriched clinical decisions making resulting from active collaboration, (b)
decrease in costs, and (c) increase in research opportunities and decrease in
disease progression by harnessing the EHR power towards improving care provision
and a method for creating value.
Meanwhile, the results derived from this study come in form of a mixed story. About
90% of the respondents were able to use EHR system effectively and efficient in a
way that support perpetual quality improvement, 75% of the patients reported that
they also able to engage with the EHR (using the system for information access,
online data viewing, data downloading etc.). In addition, some of these respondents
reported that some specific valuable functions has not yet been widely adopted and
thus poses a risk to the patient. The provision of access for the patients into their
health records is linked to existing posited benefits with healthcare quality concepts
of effectiveness, efficiency, patient or person centered care and safety. However, the
successful adoption, implementation and interoperability of the EHR system within
the NHS in the UK could be linked with both technical and social factors which
hitherto have led to some limited interoperability of the EHR and this tends to create
inadequate data across numerous healthcare systems. In essence, despite the
developing body of evidence on the accruable benefits of the patients’ usability of the
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EHR system, there still exist some considerable gaps between the projected and
established benefits of adoption, implementation and interoperability of the EHR
system.
Conversely, this research work concentrated explicitly on the impacts of the

adoption, implementation and interoperability of the EHR system on information
security and patient safety. The analysis of data that was gathered during this study
highlights the need for more work to be done towards enhancing the delivery of a
high-value care as a result of system leverage from the use of the EHR system.
Although the UK government is with the target of ensuring that EHR system is
comprehensively introduced and in use across England by the end of this year 2020
to encompass the collation of relevant patient’s electronic record which embraces
some information about care preferences, lifestyle (diet & exercise), medical history
etc. It is obvious that the UK government wants the EHR system to be implemented
in a way that will allow for effective interoperability between its stakeholders. The
findings from this study suggest that there has been a great national investment in
the EHR system for comprehensible interoperability amongst the social and
healthcare providers for reorganized and realisation of the set objectives in its real-
time. The findings from this study highlights that adoption, implementation or
interoperability of the EHR even with its success does not eliminate related concerns
(Information security and patient safety) and there is need for procedures to be put in
place for monitoring and remediating any associated problem relating to the
adoption, implementation and interoperability of the EHR. However, there is also the
need to understanding the emerging themes as highlighted below.
EHR and Patient Confidentiality

Many of the participants (n = 34 ) highlighted that one of the main fears surrounding
the adoption, implementation and Interoperability of the EHR systems has to do with
patient confidentiality. They stressed that despite the system been used with the
good intents, there are still associated problems in relation to patients’ personal
information being exposed to unauthorized use. In essence, as the patients’ medical
records are becoming computerized, there is susceptibility of such information being
accessed by the wrong personnel and
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Inadequate skills mix, Culture and professional/Peer perspective:
About 10% (n = 7) of the participants stressed that the introduction and acceptance
of any information technological innovation is mostly dependent on available training,
the workplace culture and the apparent benefits that is accruable to such technology.
In healthcare settings, nurses are mostly responsible for the integration of numerous
information sources as well as coordination of resources towards effective and
therapeutics engagements with patients on daily basis. Therefore, inadequate or lack
of training and/or adequate preparation in view of the use of EHR system could
impact on the care being provided, especially when it comes to retrieving necessary
information by such nurses or healthcare without at least basic background in
information technology. It was further highlighted that the adoption or the
implementation of a new technology for the prevailing workload with adequate
training could impacts on information security and associated service provision.
The relevance of the influence of peers and the organization toward the adoption of
IT cannot be overlooked or underestimated. Nurses more readily accept new
technology if it is perceived to be a fit with nursing practice, improves patient
outcomes, and decreases the workload of the nurse. Nurses are the largest
discipline in healthcare and present with unique information needs. Therefore, it is
crucial to obtain a nursing perspective when
implementing an IT system in order to promote the acceptance and integration of the
system The acceptance of new technology can depend on the interaction and social
dynamics of coworkers and the culture of the organization
Once nurses acquire the skills to work with IT, the ability to influence systems that
deliver safe effective patient care will be invaluable
Information exchange & Work Flow arounds:
According to the collated data from the participants, it is highly essential for accurate
information to be shared as this was stressed to enhance high-quality care provision.
The EHR system presents an explicit avenue for communication and the sharing of
personalised electronic health data. Thus, the EHRs has emerged as becoming a
medium for quick sharing of records such diagnostic data not only between
healthcare and medical professionals, but also amongst different hospitals and
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providers with the potentiality of considerably improving the quality of healthcare

provision as well as reducing patient mortality (). The participants in the study
highlighted that the latest version of the EHR design and functionalities provided the
users data sharing ability across numerous evaluated applications and able to be
used in undertaking other tasks. However, some of these participants despite
enumerating the importance of the EHR in information exchange or sharing in terms
of improving outcomes, the lack of EHR system unified standard and functionalities
across various settings and among various providers could lead to an increase
communication error risk that could impact negatively on the patients.
Standards optimization & Data Ownership:
Standard optimization involves the use of collaborative actions such as research,

legislation, auditing and decision-making for accomplishing interoperability and
enhancement of personalized care process. It is worth mentioning that all the
participants agreed that there is need for standards to be optimized as it is vital to
the realisation of effective interoperability and in the course of the collation of the
responses and these were classified into three distinct clusters (a) technical is
augmented by security standards and information exchange privacy., (b) semantic:
this encompasses the use of shared data standards content that promotes sharing of
contents amongst various healthcare organizations and their supporting entities, and
(c) functional: the shared business rules and health information best practices.
Additionally, it was also stressed by majority (80%) (n = 55) of the participants that
healthcare facilities and hospitals have numerous workstations, specialist medical
and mobile equipment that runs numerous services with embedded functional
software and systems which are either backed up in on their physical premises and
in cloud-based environments. The participants reiterated the need for proper action
to be taken towards appropriate upholding of data ownership/stewardship with the
use of information governance guidelines. Many of the participants stressed that
virus and malware are malicious and the upsurge in interoperability had made it a
requirement for security strategy / patches upgrade to be made by the healthcare
professionals so as to improve the quality of care provision.
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Government Regulatory Amenability:
The respondents (78%) opinionated that regulations have impact on the way data
are being handled in healthcare settings, especially within the NHS. It was stated
that there is high need for compliance with regulation and this dictates the quantity of
data entry requirement that has to be met by the clinicians or healthcare personnel
which are sometimes above and beyond the necessary or needed for patient care or
interventions (…). On the positive side, the respondents see these regulations as a
benchmark for the EHR developers towards EHR's system designs and updates in
view of maintaining system certification. Meanwhile, these respondents were of the
view that there are existing government highlighting the requirement or mechanism
that will be used in identifying or quantifying the EHR user experience across the
numerous installations. In addition, these participants felt government regulations
have gone a long way in protecting patient privacy and safeguarding patients’
personal information in the face of ever evolving technology.
These respondents responses made the author to understand three identifiable

principles which includes (1) Accountability: which is operation process that focusses
on data access with controlling features implemented towards ensuring essential
data are not altered without authorisation, (2) Compliance: which revolves the
healthcare organization's ability to conform with all regulatory requirements, (3)
Availability: which emphases the need to ensure there is accessibility to whenever
needed, (4) Transparency: which highlights the need for apt use of patients
information and processes in compliance with organizational and government
regulatory policy in relation to the proper appropriate use of information.
Technology advancement and enhancements:
According to some of the participants (70%, n = 48 ) with good background in IT, the
ever evolving technological development necessitates the use of advanced
algorithms, a combination of data sets, and powerful computing which offers a newer
approach and perspectives into patient’s care. On the other hand, about 65% of
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participants irrespective of their IT backgrounds were of the opinions that health

data/information are being recorded and organized in line with a single establish
standard that allows the healthcare professionals and other related healthcare
providers an ease of access to accurate and up-to-date patient information as at
when needed. However, the group of respondents with good IT background stressed
that companies like Amazon, Microsoft, Oracle and Google provides the essential
support for many of these healthcare settings in terms of artificial intelligence, cloud
computing and system interoperability. Thus, the use of numerous emerging
applications enhances the improvement of data collection associated with the EHR
system. Thus, it was generally stressed that there exist a universal objectives
amongst these health providers to meritoriously provide healthcare data and in the
process offer an improved health outcomes at lesser costs.
Insufficient Staff Training and inadequate stakeholder engagement:
Most of the participants (10%, n = 7 ) were of the opinion that professional training
and certification are essential part of EHR implementation and interoperability
success. They reiterated that it is important to have a scheme through which a
training curriculum would be introduced for professionals and hospitals staff for
towards learning the basics of interoperability, care, transitions, diagnosis and
mapping, family and patient engagement which will go a long way in quality
improvement and as promoting the Interoperability initiatives. These participants or
respondents mostly agreed that a certified user of EHR in any organization will
guarantees the effective use of the EHR system functionalities and security
perimeters towards achieving efficient interoperability. Additionally, about 70% of
these respondents highlighted that that the NHS are found not to be adequately
financially committed to technological infrastructure or support their personnel, and
were of the view that these deficiencies actually frustrates their staff. These issues
impacting on implementation and interoperability of EHR were broadly categorised
by the respondents as insufficient computers and poor systems integration,
inadequate wireless connectivity slow Internet access. Thus, it was stressed that
rectifying these problems would afford the EHR users the confidence on
confidentiality, information systems quality and security.
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Process automation, Quality improvement and value-based care:
Quality improvement was generally acknowledged by 78% of the participants as one

of the greatest advantages of the adoption, implementation and interoperability of the
EHR system, in view of its contribution to the improvement of clinical outcomes and
patient safety through its numerous functionalities by allowing the organisation and
displaying of data in a meaningful and structured ways. These participants with their
responses stressed that the EHR systems with its interoperability creates the
possibility of improving patient care outcomes as well as boosting better clinical
decision making through transfer of essential information into the organisational
workflow. About 75 % (n =51 ) participants detailed the broad range of EHR
system’s functions that includes but not limited to gathering, managing and sharing
of digital health information that could be exploited by the healthcare professionals in
supporting medical decision-making and operations.
However, 78% of the participants further stressed that the clinical decision support
tool was perhaps the most accentuated mechanism associated with the EHR system
that contributes to the improvement of clinical information and communication
management. Additionally, these participants further stated that the EHR system with
its decision support algorithms helps in identifying and preventing medical errors, in
coordinating other interventions, as well as help in promoting the reduction patient
morbidity and mortality. Thus, this attributes of the EHR was reported by the
participants to supports the implementation of guidelines as set by the NHS England
for the minimization of deviations from best practices, improvement of diagnosis and
treatment, and also allows for improvement of information management. In essence,
the EHR system creates an avenue for information management improvement in
care attributes areas, such as checking of drug interactions, for drug related
allergies, drug dose errors etc., which is considered by the participants as being
paramount in capturing organising of this data to enable the advancement and
improvement of treatment decisions.
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Meanwhile, about 80% (n = 55) of the participants were of the view that the adoption,
implementation and interoperability of the EHR system has somehow led to
automation of some existing processes, and this has resulted into improvement in
chronic care management, general medical practices and clinical care outcomes.
This was also stated to have enabled communication and the system integration
across the NHS organizations, and reduction of fragmentation amongst the different
care providers. On the other, the EHR was highlighted as being at the core of
patient’s care, with the process starting from the retrieval of records from provider
database in relation to individual patient past encounters which is then use as a
platform for information gathering and access, diagnosis collaboration, decision
support. Hence, the EHR system has become an essential tool for the improvement
of coordination of numerous of the care providers’ activities towards reducing errors
and enhancing medical decision making, especially when patient care intervention
revolves round the use of several professionals or large numbers of transitions.
Similarly, the adoption, implementation of the EHR is beneficial as it helps in
addressing the emergent crisis in healthcare such as time management issue,
medication errors, inability to monitor treatment plan adherence as well as in
adequate appointment tracking which were peculiar to paper documentation (….).
EHR and its support for observational and epidemiologic research:

About 20% (n = 23) of the participants claimed that there are some existing
limitations to with the EHR system in relation to conducting potential clinical
research, even though routine medical data being collected and this tends to
substantially overlap with research data collected. In essence, the available data
from the EHR system have been greatly being in used towards supporting
observational research studies, either as separate data or as connection to other
administrative data sets or other primary research data. In addition, the EHR system
data could be used in support of assortments of epidemiological research in relations
to numerous disease or illnesses, drug utilization, safety and other health services
researches.
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Considering the above, many of the respondent (70%, n = 48), stressed that there
has been major investment by major stakeholder towards the
adoption/implementation and interoperability of the EHR, and this had led to
improvement in patient safety and clinical outcomes through a variety of
mechanisms. Therefore, the respondents stressed the need for EHR systems to
have capability of communicating and interacting with each other in order to promote
an accurate, efficient, and meaningful clinical data exchange.
Conclusion
There have been series of issues with potential implications for patient safety
identified from participants’ responses during the findings results collation and
analysis in relation to subject of this study. However, many of the study participants
stressed the need for the EHR system to be effective and effectively adopted or
implemented as it would be one of the greatest achievements of the information
technology in producing predominant results within healthcare domain. The
organisation of patients’ information within the EHR system in interoperable, easily
manageable and highly effective manners has enhances the facilitation of easy
retrieval and access to such information by the healthcare workers and other
professionals irrespective of the treatment access point. In essence, they postulated
that the EHR system and its associated technology has some numerous advantages
which includes but not limited to diagnostic information and disease symptoms
recording and monitoring, keeping and maintaining of medical account etc.
Therefore, from the analysis of respondents’ responses it was deduced that the
introduction of the EHRs system has led to increase efficiency, has enhances the
high streamlining of the clinician’s workflow, provided the opportunities to improve
patient care, and also created ease of identifying and recruiting eligible healthcare
providers and patients for clinical research.
Limitations of findings
Some of the strengths derived from this project relates to the willingness of
respondents to participate in study and the simplicity surrounding the organisation of
the study. However, there some limitations encountered in the course of this study
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and which the author believes impacts on the general outcome of the study. Firstly,
the time frame that was employed in the study was relatively short, while the
information that was embedded in the questionnaire and interview schedule was not
that overwhelming in nature. In addition, the study was conducted within a NHS
Trust, but amongst staffs from two separate units of the Trust and thus limiting the
outreach of the EHR users. As such, these issues, that had, may not necessarily be
experienced by other trusts implementing different electronic systems. However, it is
likely that many of these factors would be transferable to other similar large hospital
trusts and other clinical specialties. Equally, the fundamental mechanisms underlying
the EHR system adoption, implementation and its interoperability amongst different
units or hospital could not be assessed. Therefore, while the result from this study
contributes and add to the awareness regarding the impact accruable to EHR
system adoption implementation and interoperability on information security and
patient safety, it could be affirmed to that the study will translate to having definite
knowledge across all the NHS settings.
Recommendations
The EHR system has been very encouraging, and the acquisition of more knowledge
by the users will continuously transform the system for efficient improvement in the
patients’ safety and information security. It is worth mentioning that the emergent
technological expulsion has unprecedented produced analytic capabilities within the
system, but there is also the need to continue to guide the system jealously and then
put adequate procedures in place for the management of clients’ privacy and
information security. In addition, there is need for a more focused and rigorous
research to be conducted in fulfillment of the set objectives for effective adoption
implementation and interoperability of the EHR system especially in relation to the
delivery of optimized patient care. Similarly, the author of this piece of work also
recommends that future study could be extended to include how the EHR system
adoption, implementation and interoperability impacts on information security and
patients’ safety in the in the private sectors or hospitals. Accordingly, there exist
some expectations from the Healthcare professionals in relation to the EHR system
tools becoming more user-friendly, reliable and sophisticated. It is essential for any
38 | P a g e
healthcare related IT products to interoperable in a way that the end users are
extensively engaged in the design process. As such, future research should
endeavor to engage or investigate the needs of the end users in view of a systematic
design that comprehensively understand the EHR system strengths and limitations
for knowledge maximization.
As such, the effective and efficient EHR system adoption, implementation and
interoperability should be a goal among many healthcare stake holders irrespective
whether they belongs to the public or private sectors.
39 | P a g e
Chapter 6: References, Appendices and Tables
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Appendices
Appendix 1:
Research Information
Research Title: The impact of the adoption, implementation and interoperability of

Electronic Health Records (EHR) on security and patient safety.
Research Objectives
The researcher’s name is Yomi, a student of University of West London and you are being
invited to take part in a research work towards a partial fulfilment of Master’s degree in
Health Informatics. As the above topic implied, the author is trying to understand the
Reason for taking part in the research work
In view of your background and your continuous interaction with/ usage of the Electronic
Health Record (HER), you have been selected to help provide an insight into the impact of
EHR into the explore the effect of EHRs on patient safety
Your involvement in the study
Participating in the research would involve helping to complete a questionnaire and this
could also be followed up by Telephone interview to discuss your personal experience(s)
with the adoption, implementation of EHR. However, the interview will be arranged at your
convenient time and this could last between 20 – 30minutes and would be recorded based
on your consent. In essence, you are also free to withdraw your consent and participation at
any point in time and request for your information not to be recorded and without this
impacting on your professional liability or your aspect of care or support.
Meanwhile, all collected data will be treated with strict confidentiality and your participation
will not be identified in any form whatsoever.
Researcher’s Contact: University of West London, Department of …….., Email:

21419990@study.ucl.ac.uk. Phone: 07920198010.
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Interview Questionnaire
To: User of EHR
Date:
 Section 1: Individual Information
1. Gender: Male: Female: Non-binary:
2. What is your professional role or title (e.g Physician, Psychiatrist, Nurse etc.)?
…………………………………………………………………………………………………
 Section 2: EHR related
1. What do you understand by EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
2. Do you believe EHR is best suited for you or your role?
Yes No
3. What are the reasons why you are implementing or using EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
4. What are your specific goals in relation to the implementation of EHR?
…………………………………………………………………………………………………
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…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
5. What are your long-time goals and expectation for implementing or using EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
6. How do you get to know about EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
7. Have you previously worked on an EHR system?

Yes No
8. Do you believe EHR has the potential of automating health care jobs thereby
causing job loss for health care employees?
Yes No
9. Do you believe EHR is necessary?

Yes No
10. how expensive is the implementation of EHR to you?

Moderate Expensive Very Expensive
48 | P a g e
11. Are you out sourcing the implementation of EHR?

Yes No
12. Do you have an ICT unit?

Yes No
13. Rate your ICT skills Knowledge

70 - 100
60 - 69
40 -59
1 - 39
14. Do you believe manual data entry of patient records should be obsolete?
Yes No
15. Would you recommend the implementation of EHR?

Yes No
16. How secure is the EHR system?

Moderate Not Secured Very Secured
17. Do you believe in having a centralised network of patient records?

Yes No
18. What is your preparation status in relation in implementing EHR?

100-70% 69-50% 50-40% 40-10%
19. Describe your action plan in implementation of HER
a. Do you have predefined milestones?
Yes No
b. What is your timeline for implementation of EHR?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
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20. What do you think would be the key challenge to implementation of EHR?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
21. Who is taking credit for the success/or failure of the project?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
22. Describe the areas where you think adaptation or changes would need to be
made (e.g. Confidentiality, data input, prescription refills, lab results, tracking
referrals and data, etc)?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
23. Can you describe the anticipated effect of the EHR health provision?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
To: Members of the IT & implementation team
Date:
1. Gender: Male Female Non-binary
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2. What is your professional role or title (e.g Physician, Psychiatrist, Nurse etc.)?
………………………………………………………………………………………………
1. What do you understand by EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
2. What are the aims of implementing EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
3. Do you think EHR would help in facilitating your end goal?
Yes No
4. What method would you adopt in implementing EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
5. Would you have any predefined milestones?
Yes No
6. What are your specific goals in relation to the implementation of EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
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…………………………………………………………………………………………………
…………………………………………………………………………………………………
7. Do you think this project would be a success?
Yes No
8. What are your thoughts on the failure of the project, would it be devastating to
your organization?
Yes No
Thoughts:
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………………
9. Do you intend outsourcing resources during the implementation?
Yes No
10. Would front line workers be involved in the implementation?
Yes No
After completion of EHR
11. How would you classify the implementation taken steps?

…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
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12. Were you able to achieve the goals set before the implementation?
Yes No
13. If No above, please enumerate what changed below
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………………
14. What area during the implementation do you encountered the most problem in?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………………...
15. What are your recommendations to prospective people that are willing to
implement EHR?
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Appendix 2:
Tables:
Response rated Response

in percentage in number
(%) count
Age between 18 – 49 years 75% 54
Age from the age of 50 years and 20% 14
above
No response or prefer not to say 5% 4
Number of answered questions 38
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Number of skipped Questions. 0
GRAPHICAL ANALYSIS
AGE
GENDER
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What is your preparation status in relation in implementing EHR
Q1 Has the implementation or adoption of EHRs enhanced the quality care provision
or promotes patients’ safety?
Table constructed on based on the related questionnaire questions.
Yes No
(%) (%)
Were you able to implement the EHR software into 65 25
the team?
Were the goals set before the implementation 80 20

begun met?
Has the implementation increased the team 90 10

productivity?
Do you believe in having a centralised network of 45 55

patient records
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70
60
50
40
30
20
10
0
Yes (%) No (%)
Were you able to implement the EHR software into the team?
80
70
60
50
40
30
20
10
0
Yes (%) No (%)
Were the goals set before the implementation begun met?
60
50
40
30
20
10
0
Do you believe in having a centralised network of patient records
Personnel Skills Resources Other

Issue Deficiency Issues (%)
(%) (%) (%)
If No above, what caused the breaking 70 20 8 2.5
point in the implementation?
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If No above, what caused the breaking point in the implementation?
70
60
50
40
30
20
10
Personnel Skill Other

(%) (%) (%)
If no above, what area is still inhibiting the 70 20 10
efficiency of the team after implementation of
EHR?
70
60
50
40
30
20
10
0
Personnel in %
Others in %
Skill in %
If no above, what area is still inhibiting the efficiency of the team after implementation of EHR?
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Prescription Data Lab Tracking

(%) Protection Results referrals
(%) (%) (%)
What area is the most positively 40 30 20 10
affected after implementation of EHR?
40
35
30
25
20
15
10
5
0
Lab result in
Data Protectiom in
Tracking referrals in
Prescription in
%
%
What area is the most positively affected after implementation of EHR?
Q2 Are usability issues also a factor contributing to the failure of EHR

implementation?
Yes No
(%) (%)
Do you have experience in using an EHR 70 30
software?
Do you have any programming skills? 70 30
Do you have an ICT unit ? 80 20
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70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you have experience in using an EHR software?
70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you have any programming skills?
80
70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you have an ICT unit ?
Very Low Low Moderate High Very

(%) (%) (%) (%) High
(%)
How would you rate your knowledge 10 20 30 20 20
of EHR software?
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30
25
20
15
10
0
Low in %
How would you rate your knowledge of EHR software?
70 -100 60 - 69 40 - 59 10 - 39
(%) (%) (%) (%)
Rate your ICT skills Knowledge 40 20 30 10
40
35
30
25
20
15
10
0
70 -100 (%) 60 - 69 (%) 40 - 59 (%) 10 - 39 (%)
Rate your ICT skills Knowledge
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Q3 Will time be saved, and health services delivery efficiency improved with
adoption, implementation, and interoperability of EHR?
Yes No
(%) (%)
Do you think EHR would help in facilitating your 30 70
organization vision?
Do you think this project would be a success? 30 70
Do you believe that the EHR software is safe enough? 75 25
Are you computer literate? 80 20

Do you believe manual data entry of patient records 65 35
should be obsolete
70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you think EHR would help in facilitating your organization vision?
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70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you think this project would be a success?
80
70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you believe that the EHR software is safe enough?
80
70
60
50
40
30
20
10
0
Yes (%) No (%)
Are you computer literate?
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70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you believe manual data entry of patient records should be obsolete
Prescription Data Lab Tracking

(%) Protection results referrals
(%) (%) (%)
Describe the areas where you think 25 50 15 10
adaptation or changes would need to be
made (e.g. Confidentiality, data input,
prescription refills, lab results, tracking
referrals and data, etc.)?
50
45
40
35
30
25
20
15
10
5
0
Describe the areas where you think adaptation or changes would need to be made?
Disrupt Flow Stop Work Have little Can’t say

of work flow to no
(%) totally effect (%)
(%) (%)
If the software develops a bug, 10 40 30 20
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how do you think that would

affect patient care?
40
35
30
25
20
15
10
5
0
Disrupt Stop Work Have little Can’t say
Flow of flow totally to no effect (%)
work (%) (%) (%)
If the software develops a bug, how do you think that would affect patient care?
Q4. What are the barriers preventing comprehensive adoption, implementation and
interoperability of the EHR system from being accepted on a larger scale?
Administration Logistics Personnel

(%) (%) (%)
What area during the 70 20 10
implementation do you
encountered the most problem in?
64 | P a g e
70
60
50
40
30
20
10
0 Administration in
Personal in %
Logistics in %
%
What area during the implementation do you encountered the most problem in?
Increase Increase Get Train

Administration Logistics genuine staff on
allocation (%) allocation EHR effective
(%) software use of
(%) EHR (%)
What are your recommendations 40 30 20 10
to prospective people that are
willing to implement EHR?
65 | P a g e
40
35
30
25
20
15
10
5
0
What are your recommendations to prospective people that are willing to implement EHR?
Yes No
(%) (%)
Do you think EHR would help in facilitating your end goal 70 30
Were you able to achieve the goals set before the 70 30
implementation?
What are your thoughts on the failure of the project, 30 70

would it be devastating to your organization?
70
60
50
40
30
20
10
0
Yes (%) No (%)
Do you think EHR would help in facilitating your end goal
66 | P a g e
70
60
50
40
30
20
10
0
Yes (%) No (%)
Were you able to achieve the goals set before the implementation?
70
60
50
40
30
20
10
0
Yes (%) No (%)
What are your thoughts on the failure of the project, would it be devastating to your organization?
67 | P a g e
68 | P a g e

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Research Methods Thesis 21419990

The impacts of Electronic Health Records

Msc. Health Informatics

My indebtedness and special thanks go to my supervisor Dr Laden Husamaldin for

The recommendations made from conducting this research is to support in creating

Chapter 2: Literature Search and Review

Chapter 3: Research Methods and design

a. Research Methods and design………………...……...............................................7

Chapter 4: Findings and Analysis

a. Analysis and Results......................................................................................10

Chapter 5: Conclusions and Recommendations

Chapter 6: References, Appendices and Tables

Chapter 1: Introduction and background

Meanwhile, communication and information technologies advancement had

about healthcare improvement and positive patient outcome. In addition, the

1. Has the implementation or adoption of EHRs enhanced the quality care

Chapter 2: Literature Search and Review

The utilised database

EHR's adoption, implementation associated principles.

Conversely, it is pertinent for organizations to establish the roles, responsibilities and

Result and findings

The EHRs sustainability in clinical research was regarded to be dependent on the

Chapter 3: Research Methods and design

For the collation of adequate information, a mixed-methods approach that combines

2.2 Research Approach and Study Design

Data Organization, Themes, and patterns generation

The Hypothesis regarding overall EHR adoption, implementation and interoperability

Hypothesis 1: There is inhibition of EHRs acceptance on the part of healthcare

Hypothesis 5: This hypothesis relates to how inadequate EHR system knowledge

Ethics issues, Informed Consent and Confidentiality

Chapter 4: Findings and Analysis

Descriptive Statistical Analysis

is the process of using statistical techniques to describe or summarize a set of data.

EHR system and Social factors

EHR system and Technical factors

1. Has the adoption, implementation and interoperability of EHRs enhanced the

Chapter 5: Conclusions and Recommendations

Conversely, this research work concentrated explicitly on the impacts of the

EHR and Patient Confidentiality

Inadequate skills mix, Culture and professional/Peer perspective:

Information exchange & Work Flow arounds:

providers with the potentiality of considerably improving the quality of healthcare

Standards optimization & Data Ownership:

Standard optimization involves the use of collaborative actions such as research,

Government Regulatory Amenability:

These respondents responses made the author to understand three identifiable

Technology advancement and enhancements:

participants irrespective of their IT backgrounds were of the opinions that health

Insufficient Staff Training and inadequate stakeholder engagement:

Process automation, Quality improvement and value-based care:

Quality improvement was generally acknowledged by 78% of the participants as one

EHR and its support for observational and epidemiologic research:

Chapter 6: References, Appendices and Tables

Adler-Milstein J, DesRoches CM, Kralovec P, Foster G,Worzala C, et al. 2015.

American Health Information Management Association (AHIMA). (2015). Information

Bachmann, B. (2017). Research data collection and analysis framework. In Ethical

Blijleven, V. et al., (2017) Workarounds emerging from electronic health record

Bullard, K. (2016). Cost-effective staffing for an ehr implementation. Nursing

Campanella P, Lovato E, Marone C, Fallacara L,Mancuso A, et al. 2016. The impact

Charles, D. et al., (2015). Interoperability among U.S. non-federal acute care

Cram, W. A., Proudfoot, J. G., & D’Arcy, J. (2017). Organizational information

Daniel, B. and Harland, T., (2017) Higher education research methodology: A step-

Delgado, D. et al., (2016) Effects of health information technology on patient