International Journal of Health Care Quality Assurance

Managing healthcare information: analyzing trust

Eva Söderström Nomie Eriksson Rose-Mharie Åhlfeldt
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Eva Söderström Nomie Eriksson Rose-Mharie Åhlfeldt , (2016),"Managing healthcare information:
analyzing trust", International Journal of Health Care Quality Assurance, Vol. 29 Iss 7 pp. 786 - 800
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IJHCQA
29,7
786
Received 13 November 2015
Revised 29 April 2016
Accepted 15 May 2016
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International Journal of Health
Care Quality Assurance
Vol. 29 No. 7, 2016
pp. 786-800
© Emerald Group Publishing Limited
0952-6862
DOI 10.1108/IJHCQA-11-2015-0136
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0952-6862.htm
Managing healthcare
information: analyzing trust
Eva Söderström
School of Informatics, University of Skövde, Skövde, Sweden
Nomie Eriksson
School of Business, University of Skövde, Skövde, Sweden, and
Rose-Mharie Åhlfeldt
School of Informatics, University of Skövde, Skövde, Sweden
Abstract
Purpose – The purpose of this paper is to analyze two case studies with a trust matrix tool, to identify
trust issues related to electronic health records.
Design/methodology/approach – A qualitative research approach is applied using two case studies.
The data analysis of these studies generated a problem list, which was mapped to a trust matrix.
Findings – Results demonstrate flaws in current practices and point to achieving balance between
organizational, person and technology trust perspectives. The analysis revealed three challenge areas,
to: achieve higher trust in patient-focussed healthcare; improve communication between patients and
healthcare professionals; and establish clear terminology. By taking trust into account, a more holistic
perspective on healthcare can be achieved, where trust can be obtained and optimized.
Research limitations/implications – A trust matrix is tested and shown to identify trust problems
on different levels and relating to trusting beliefs. Future research should elaborate and more fully
address issues within three identified challenge areas.
Practical implications – The trust matrix’s usefulness as a tool for organizations to analyze trust
problems and issues is demonstrated.
Originality/value – Healthcare trust issues are captured to a greater extent and from previously
unchartered perspectives.
Keywords Medical records, Trust, Health and safety, Public health service, Patient safety,
Electronic healthcare records, Trust matrix
Paper type Research paper
Introduction and primary objectives
Trust is like the air we breathe. When it is present, nobody really notices. But when it is
absent, everybody notices (Warren E. Buffett, in: Sandlund, 2002). Trust is defined as
people’s willingness to invest time, money and other valuables, such as personal
information into a system or organization (Oza et al., 2006; Li et al., 2006; Van Maele and
Van Houtte, 2012). Trust has become a focal point for research on adapting new
technologies (Dubelaar et al., 2005), particularly within healthcare organizations when
discussing collecting digital patient-related information and management. Trust has
been discussed in many areas, such as communication, leadership, management,
negotiation, game theory, performance appraisal and labor-management relations.
Despite interest in trust, it remains difficult to study, since a working definition is
problematic owing non-specific trust referents, which leads to confusion in analysis
levels (Mayer et al., 1995). In healthcare, trust is imperative. Patients must trust
clinicians and their ability to make correct judgments. Clinicians must trust patients
and the information they provide about their health. Research has shown that human
trust, as a prerequisite for exchanging personal information, can be addressed through
 technological capacities that secure information (Ruppel, 2004). When it comes to Managing
providing sensitive information, humans may put their trust in devices or objects healthcare
(Walter et al., 2004) rather than in people, since inanimate objects are things we can
control. In healthcare, trust is essential since the entire arrangement is about human
information
relations (Ozawa and Sripad, 2013). In this context, electronic healthcare records (EHR),
in which trust can be a focus, include physician notes, laboratory results, care notes,
etc., which hold information about the patient’s diagnosis, treatment and care. In the 787
EHR literature, patient safety has often been discussed from a medical perspective,
centering on information management, rather than taking information safety’s full
complexity into account (Sandlund, 2002; Dubelaar et al., 2005). This is, however, not
the only problematic issue. The cultural, process, personnel and technical issues related
to EHR are also highly relevant. The patients’ right to privacy is not in focus in the way
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it needs to be because healthcare staff concentrate on information management needs

and requirements by healthcare providers. To develop better information management
processes and increase effectiveness, more focus should be placed on developing trust
between patients and healthcare organizations. To do this, trust complexity must be
examined. In this study, trust complexity is explained using two case studies, which
aim to identify needs and challenges for achieving a more complete and holistic
approach. The case studies were conducted in Sweden, but the issues are international
and relevant beyond Swedish borders.

Documenting patient information

Activities related to patient care usually involve multiple steps (registration,
consultations, treatment and referrals to other care providers), and each step
introduces further complexity into EHR management (Eriksson, 2014; Åhlfeldt and
Söderström, 2010; Pollard et al., 2013). These steps are often labeled the patient process
and information gathered during this process is often stored digitally in EHRs.
Several authors note that the patient process perspective has pointed out how many
steps are non-productive, because different information collection methods are used
between units or the desire from personnel to perform all investigations by themselves
( Jaako et al., 2006; Lluch, 2011).

Patient safety
Healthcare’s goal, according to Swedish law, is to provide good health and care on
equal terms for all citizens (SFS, 1982). This care should be provided with respect for all
humans’ equal value and for the individual’s dignity. These values form the basis of
systematic quality work within healthcare and serve as prerequisites for meeting
patient safety requirements, patient satisfaction and cost efficiency (Åhlfeldt and
Söderström, 2010; Ministry of Social Affairs, 2010; Magrabi et al., 2013). To provide and
obtain healthcare and ensure patient safety, trust levels must be high both between
patient and healthcare professionals and professions, internally and externally. Patient
safety is defined by the National Board of Health and Welfare as “protection against
healthcare injuries,” which is clarified as actions against risks, accidents and negative
events. A healthcare injury is defined as suffering, discomfort, physical or
psychological injury, illness or death caused by healthcare and which is not an
inevitable consequence of the patient’s condition (SOSFS, 2005, p. 4). Studies report that
20 percent of health-related injuries are caused by information management
deficiencies or are IT related. According to the patient safety investigation law
 IJHCQA (SOU, 2008), patient safety is interpreted as a cross-disciplinary knowledge area; e.g.,
29,7 between technology, medicine and sociology. It is a quality dimension comprising
dynamic interplay between several factors, not least human ones, which in themselves
are changeable over time. Patient safety is also affected by current attitudes; i.e., patient
safety culture. Both the World Health Organization and the European Council publish
recommendations aimed at increasing patient safety (SOU, 2008). Most suggestions
788 concern how to work strategically to prevent healthcare injuries; e.g., via political
directions, a cohesive and complete patient safety strategy and event management
systems. Patient safety investigations also point to the difficulty of having detailed
statistical information, since no evidence-based measures are available.
The investigation demands more research in this area. Patient safety literature is
also focussed on preventing healthcare injuries and primarily those that are purely
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physical or medicinal. There is, however, little understanding and insight about injuries
related to patient suffering and respect for the individual. Furthermore, there is little
research on how to secure information to increase patient safety, even though statistics
show that weak or flawed information causes healthcare injuries (National Board of
Health and Welfare, 2008, 2009).

Trust
Trust definitions are based on sociological perspectives (Oza et al., 2006; Li et al., 2006;
Van Maele and Van Houtte, 2012), but definitions are also associated with technology
(Kim et al., 2005). Often when trust is discussed in information technology research, it is
the technical aspects that are in focus. Perhaps one reason is that online trading
partners tend not to trust people (Ratnasingham, 1999). While trust assumes that
separate principals extend trust to each other, this does not mean that expectations are
the same for all. Expectations derive from concrete experiences tied to the past, person
or societal structures (SOSFS, 2005). Trust is a multidimensional construct with two
interrelated components: trusting beliefs (competence, benevolence and vendor
integrity) and trusting intentions (willingness to depend) (McKnight et al., 2002). Trust
can also be viewed, discussed and analyzed from different levels.

Trusting beliefs
Trusting beliefs; i.e., ability, benevolence and integrity, denote the extent to which one
principal believes that another principal is willing and able to act in the trusting party’s
best interest (Gray et al., 2006). Trusting beliefs are one central component in how trust
is defined, and is hence commonly referred to as trust (Murphy and Blessinger, 2003;
Nakayachi and Watabe, 2005; Hernández-Ortega, 2011):
• ability: includes skills, competencies and/or characteristics that enable either
party to exert influence within some specific expertise domain (Murphy and
Blessinger, 2003; White and Hyuan, 2012);
• benevolence: the extent to which either party believes that the other acts in a
positive manner, or will do good to the other party(ies) regarding their
interactions, excluding egocentric considerations or profit motives (Pavlou, 2002;
Lumsden and MacKay, 2006; Park et al., 2013); and
• integrity: either party’s perception of the others’ devotion to generally accepted
principles (Murphy and Blessinger, 2003; Kim et al., 2013).
Trusting beliefs are related, but separable and together explain most complexity.
 Trust levels Managing
One problematic issue with trust research is that trust is treated and defined in different healthcare
ways (Mayer et al., 1995). In addition to discussing trust from a sociological perspective
(organization and person), technology can also apply. Trust research defines trust in more
information
or less the same way, but application differs. Trust is a basic organizational function
ingredient and underlies sharing vital systems knowledge (Kasper-Fuehrer and
Ashkanasy, 2001). It is a governance mechanism necessary for conflict resolution, 789
intra-organizational goal setting and creating shared values, to enable employees to work
more productively and effectively (Pavlou, 2002; Kasper-Fuehrer and Ashkanasy, 2001;
Wang and Emurian, 2005; Chathoth et al., 2011). In the healthcare setting, this refers to
trust in an organization itself, that it will have procedures, norms and services that enable
patients to feel safe, be in good care and ultimately recover. An individual’s trust in
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hospitals and healthcare systems may also affect his/her service use (Ozawa and
Sripad, 2013). Even though organizational trust often is discussed as concerning the
organization and its employees (Chathoth et al., 2011), the healthcare setting also
must include the patients’ trust in the organization. Next, there is interpersonal trust:
the extent to which a person is confident in and willing to act on another’s words,
actions and decisions (Kanawattanachai and Yoo, 2002), thus increasing vulnerability to
others’ actions (Kim et al., 2005; Jiang et al., 2013). Interpersonal trust thus concerns trust
between individuals and their actions. Lastly, technological trust is the individual’s
trust in technology and its reliability. It relates to a belief that the underlying
technology infrastructure and website control mechanisms facilitate the transactions
(Lumsden and MacKay, 2006). It is important to analyze technology-related trust,
because it will condition the individual’s behavior when using technology
(Hernández-Ortega, 2011).

The trust matrix

This study uses a trust matrix. Söderström (2010) used an extensive literature review of
trust and combined the trust levels (rows) and trusting beliefs (columns) into a trust
matrix. The author investigated trust and criticizes how current research defines trust
from the people perspective, but treats it from commonly the technology perspective.
The matrix (Table I) is used as a tool for discussing and classifying trust-related
problems in the healthcare setting. The matrix top level includes organizational trust,
which covers trust in common goals, shared values, procedures, norms, etc. On the
personal level, referring to trust between people, trust general definitions apply.
Trust at the technology level concerns people placing trust in the technology.

Trusting belief:
Trusting belief: ability benevolence Trusting belief: integrity

Trust level: Collective skills, core Collaboration partners Commitment to contracts

organization competences, equipment want benefits for us and agreements
Trust level: Skills, competences, Good behavior Devotion to principles Table I.
person characteristics The trust matrix:
Trust level: Technology purpose and Technology will respond Technology will function contrasting trusting
technology capabilities to commands according to rules beliefs and
Source: Söderström (2010) trust levels
 IJHCQA Methodology
29,7 This study’s research design is a qualitative cross-case analysis. Case studies are
primarily used to develop new theories, using inductive logic and utilizing methods to
collect primarily qualitative data from which relevant theories are drawn (Goldkuhl,
2008). This design is appropriate for studying an emerging phenomenon and is
primarily used when the primary intention is to understand why and how (Yin, 1994).
790 A case study does not have to cover an entire organization; rather it focusses on a
particular event or a feature. Two case studies are used to explore EHR trust
complexity. Material from two cases was compared and contrasted using cross-case
analysis, which is used to identify emerging patterns (Barratt et al., 2011). Case 1
followed EHR implementation, where patient information could be read by all those
involved throughout a patient process. Perceptions were compared to demonstrate
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health professionals’ trust in EHR in relation to the traditional paper journal system.
Case 2 investigates how patients perceive communication and patient information
management work out in reality. This study was expected to show potential problems
with patient trust in what is communicated by healthcare staff.

Case design
The qualitative research approach focusses on participant perception. In case 1,
physicians, nurses and others who participate in implementing EHR in a Swedish
regional hospital comprised the study population. A questionnaire was distributed to
personnel from each unit where the EHR was introduced. The survey focussed on
knowledge of applicable laws and guidelines, information and availability, quality,
training, user friendliness, safety, time, efficiency, procedures and processes.
The questionnaire was tested in a pilot study among emergency department
personnel. Ten nurses answered the questionnaire and no changes were required.
Opinions were compared between the EHR and the traditional paper-based record. Case 2
embodies the vision that healthcare providers should have access to effective and
collaborating information systems supporting process-oriented care where the patient is
explicitly involved as an active process co-creator. The project also aimed to develop a
prototypical process support to show a new, process-oriented working within healthcare,
where the patients’ active participation and effective communication between actors are
central (Åhlfeldt et al., 2013).

Sampling procedure and data collection

In case 1, personnel from the internal medicine clinic were included (561 people).
They were working as physicians, nurses, assistant nurses, physiotherapists and
occupational therapists. All used the EHR, rather than the traditional paper
journal system. Data were collected via a quantitative survey using a questionnaire.
The survey was conducted by research and development hospital staff.
An introduction letter and two reminders were sent. All participants were promised
anonymity. In case 2, two researchers were participant observers in the medical
consultation and conversation between patients and physicians. Patients were asked if
they wanted to be involved in an in-depth interview to attain deeper understanding of
the patient’s experience from the patient-physician meeting. As a result, seven
interviews were carried out in the patients’ homes, which explored how patients
experienced the information exchange in healthcare organizations and how they
perceived their health status to be affected by its nature. The patients’ contributions
were voluntary (Krasniqi et al., 2011).
 Data analysis Managing
In case 1, the survey focussed on: laws and guidelines, information and availability, healthcare
quality, training and knowledge, user friendliness, safety, time, efficiency,
procedures and processes. Opinions were requested via free-text responses.
information
Totally, mainly and partly agree responses about EHR and traditional paper-based
records were analyzed. In case 2, approximately two-hour interviews were recorded
and transcribed in their entirety, and coded into trust problems. By analyzing the two 791
cases, trust-related problems could be derived from each case. The two lists were
merged and analyzed, and potential groups identified. Problems concerning similar
aspects were connected. Based on cross-case analysis, nine problem groups were
identified and labeled:
(1) Availability (AVAI), which concerns physical accessibility and strategies that
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have been determined and documented. Patient information may also be

divided into local, regional, national and international information. The
information carrier can be digital or human.
(2) Competence (COMC) concerns knowledge about laws, rules, directives,
documentation needs, information retrieval skills and knowledge
about available decision supports. There is currently no role in
healthcare with an overall responsibility for patients and the patient
process. It is currently up to the patient to maintain an overall picture of
their health situation.
(3) Completeness (COMP) refers to all patient or personnel need for information and
treatments registerable in the EHR or given as information to the patient.
(4) Privacy (PRIV) concerns protecting patient privacy, which means both
protecting the patient’s information and respecting him/her.
(5) Responsiveness (RESP) concerns feedback to patients to make them feel that
they are listened to and taken seriously.
(6) Rules and regulations (RUAR) concerns administrative routines for
documenting healthcare information. There is a strong relationship to
competence, but while competence concerns the information template, rules
and regulation focus on how to work with the template.
(7) Storage (STOR) concerns how to store documented healthcare information; e.g.,
physician’s and nurse’s journals, etc.
(8) Understandability (UNDE) concerns keeping terminology clear and concise; e.g.,
in templates. In some cases, it is about language toward patients, in others,
different healthcare staff.
(9) Usability (USAB) concerns user friendliness deals with security awareness; e.g.,
that single users need to logout after their session has ended.

After identification and labeling, the next step was to take the grouped
problems generated in the two case studies and map them to the trust matrix
to identify: what trust problems relate to what trust level; and where most trust-related
problems exist. Each problem was reviewed based on its strongest relation and to
what trusting belief could be identified. Based on these results, needs and challenges
were identified.
 IJHCQA EHR trust problems
29,7 Regarding trust problems related to EHR, contrasting trusting beliefs and trust
levels (Table I) are used as the main analytical model. Tables II and III structure the
problems, first individually and then using cross-case analysis. For simplicity,
Table I is referred to as the trust matrix.

792
Trust problems (questions shortened) EHR vs paper journal

Other caregivers’ information is EHR made it easier to find information, 63.4% (HS-1)
inaccessible in EHR
Multiple decision makers about treatments EHR have always documented treatments and goals,
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goal is unavailable 31.9% (HS-2)

Computers are unavailable at the There are always access to computers, 88.7% (HS-3)
departments
Insufficient training in EHR Many have good knowledge in EHR documentation,
documentation 81.4% (HS-4)
Insufficient patient information related to Focus on own professional groups, 81.5% (HS-5)
from other professional groups
Lack of templates to treatment routines Easier when templates are available, 66.4% (HS-6)
and documentations
Shortage to follow local rules and EHR users have good knowledge about rules and
regulations regulations, 69.8% (HS-7)
Shortage to use prescribed routines to Few use and apply written prescribed instruments, 36.3%
preventive risk factors in healthcare (HS-8)
Patient information is incomplete Most get the necessary information about the patients,
84.5% (HS-9)
Incomplete document in the record by fear Few are document in fear to be report to the National
to be reported in court Board of Health and Welfare (NBHW), 24.0% (HS-10)
Incomplete information about patients’ EHR are an information source to patients, 45.1% (HS-11)
diagnosis and treatment
Patient record is not followed the patients EHR gives an unbroken patient record, 70.5% (HS-12)
process
Disclosure about patient information EHR gives protection of patient privacy, 61.6% (HS-13)
Patients have not access to the EHR logs Patients have the right to know who has read their EHR,
88.0% (HS-14)
Lack of standardized documentation EHR gives written routines about how to document,
routines 66.0% (HS-15)
Repeated information can be documented There is redundant documentation in the EHR, 66.5%
in different places in EHR (HS-16)
Incomprehensible documentation in EHR The terminology is clear and distinct, 80.1% (HS-17)
Laws and regulations are neglected to EHRs make it easier than before to follow laws and
follow in HER regulations, 55.8% (HS-18)
Personnel fail to check previous usable Personnel always investigate whether planned already is
documentation documented, 54.0% (HS-19)
The “log-in” procedure is slow in EHR EHR log-in is rapid, 85.3% (HS-20)
The structure in EHR is hard to EHR structures is easy to understand, 68.9% (HS-21)
Table II. understand
Trust problems in Personnel avoid to “log off” when leave the Personnel always log off when they leave the computer,
patients’ record – computer 83.7% (HS-22)
EHR compared with EHR is difficult to use compared with the EHR make it easier to work, 73.1% (HS-23)
traditional paper paper-based record
record Note: Results from the questionnaire study
 Trust problems
Availability will be affected owing to long
waiting times to care and treatment
Lack of availability according to the patient’s
responsibility to communicate with different
healthcare units can affect patient safety
Incomplete information to the patient about the The patients do not receive adequate information
patient’s overall health status
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Result
Managing
healthcare
Guaranteed right to healthcare is in place but information
accessibility to healthcare must be more efficient
(FI-1)
Patients are forced to act as information carriers
since IT systems in healthcare often do not
communicate across operational and organizational 793
boundaries (FI-2)
about their health. Patient finds information
insufficient and/or not suited to the patient’s ability
and capacity to absorb information (FI-3)

Most patients experience an incompleteness Unclear answers and information is insufficient for
regarding the management of their information patients when waiting for treatment or responses
from a sample (FI-4)
Patients believe that they have the responsibility Collaboration between patients, doctors, specialists
to be the pushing actor in the care process and external actors are complex and hard (FI-5)
Patients lack information about relevant It is the healthcare professional’s responsibility to
medicines and previous contacts to get patient ensure that patients are informed (FI-6)
safety, participation and influence in the care
process
Patients sometimes feel that doctors do not take Improve the patient-physician relationship in order
their health-related problems seriously to strengthen the patient role (FI-7)
Current healthcare systems are organized in a Healthcare staff must focus on their main goals and
way that assumes that patients are active and organize their processes and systems with the
driving their own processes, which can make patient process in focus (FI-8)
patients feel abandoned and forgotten
Most patients perceive that they must accept Healthcare staff must accept patients as active
what they are offered, or decline convenient contributors (FI-9)
appointments Table III.
Patients in a vulnerable position are currently To increase participation, the information must be Trust problems in
expected to remember everything they are told perceived correctly (FI-10) the FHIS project

Hospital EHR study

The hospital director in a middle-sized hospital in west Sweden decided to implement
EHRs (only the text-based module). A project team was established to introduce all
activities. During implementation, personnel from the internal medicine clinic answered
the questionnaire. The survey investigated their opinions about EHR compared with
traditional paper-based journal. The switch from a paper system to electronic records’
purpose was to increase access to patient information, improve documentation quality
and reduce patient visits. Table II presents the main results (the index HS-x presents an
identifier using a case name abbreviation and sequential number).

Future information systems in healthcare study

The Future Healthcare Information Systems project focussed on providing, studying and
evaluating effective and collaborating information systems supporting a process-oriented
care. To address an efficient business, IT systems must collaborate from a holistic view
point. The results showed how processes on different levels could collaborate to address
gains/positive effects in different ways. Increased quality for better decision support,
optimized individual care activity, optimized business, are examples. The project was
 IJHCQA limited to primarily focus on patient meetings and related processes. Table III presents
29,7 the main results related to trust problems from the patient study. The result is a thematic
compilation from patient interviews (the index FI-x, is an identifier using an abbreviated
case name and sequential number).

Analysis and results

794 The trust-related problems identified in two case studies were analyzed and
categorized as belonging to nine groups (listed earlier), which are applied to two real-life
cases, described above, and problems analyzed using these categories.

Trust problem analysis

Trust-related problems from the two real-life cases have been identified. To trace the
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problems back to their origin, each was given an identifier using an abbreviation for the
case name and sequential appearance (number). From the resulting list, problems were
grouped according to the nine categories described earlier (Table IV). To simplify
identification when performing the analysis against the trust matrix, each problem has

Number Comments Trust matrix ID

HS-1 EHR provides better accessibility AVAI1

HS-2 Available treatment goals AVAI2
HS-3 Computer availability AVAI3
FI-1 Availability (healthcare guarantee not working) AVAI4
FI-2 Patients as information carriers AVAI5
HS-4 Adequate knowledge of laws and regulations COMC1
HS-5 Documentation within the profession COMC2
HS-6 Template easy to find COMC3
HS-7 Knowledge about rules and regulations COMC4
HS-8 Available decision support COMC5
HS-9 Necessary information in the EHR COMP1
HS-10 Documentation caused by fear of being reported COMP2
HS-11 Good information source for the patient COMP3
HS-12 Unbroken patient documentation – follow the patient process COMP4
FI-3 Health status information shortage COMP5
FI-4 Necessary information COMP6
FI-5 Missing holistic view COMP7
FI-6 Collaboration and information management COMP8
HS-13 Patient privacy protection PRIV1
HS-14 The patient’s knowledge of who has read the EHR PRIV2
FI-7 Doctors listen and take problems seriously RESP1
FI-8 Must be healthy to be sick RESP2
FI-9 Participation and influence over one’s own process RESP3
HS-15 Procedures on how to document RUAR1
HS-16 Redundant (double) documentation STOR1
FI-10 What did the doctor say? STOR2
HS-17 The terminology is clear and precise UNDE1
HS-18 Easy to follow laws and regulations USAB1
HS-19 Self-monitoring of redundant (double) documentation USAB2
Table IV. HS-20 Fast to sign on USAB3
Trust problem HS-21 Understandable structure USAB4
categorization and HS-22 Logout from the EHR USAB5
analysis HS-23 EHR as work tools USAB6
 been given an identifier using a four-character ID drawn from the respective categories, Managing
coupled with a sequential numbering within each category. healthcare
Among 33 trust problems, five are related to availability, five to competence, eight to
completeness, two to privacy, three to responsiveness, one to rules and regulations, two
information
to storage, one to understandability and six to usability. These problems are analyzed
against the trust matrix (Table V).
795
Trust problems and the trust matrix
The main focus on trust problems is related to the EHR and to investigate results from
a trust perspective, which can be done by using the trust matrix (Table I) as yet another
filter. It helps to show how different problem types map onto various trust aspects
(Table V). Analysis was conducted by studying each problem description carefully and
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placing it within the most appropriate matrix square.

Trust problems and ability

Ability includes skills and competencies. The matrix shows that the category leading to
the most problems is technology. There is little doubt in the staff ability to document
patient information, but the problems expressed in the case studies mainly come from
staff themselves. In the patient process, physicians have the dominating role asking
questions and the patient has more or less only provided answers. There are now calls
to replace this communication dynamic with a patient-physician perspective, where
patients place higher demands on both professionals and organizations. In this model,
where patients have more information about their health, professionals will be required
to access this updated information. Trust technology problems, to a great extent,
concern patients as information carriers when information cannot be transferred
electronically. Systems availability is another factor affecting trust, as it is essential to
ensure that information is available when needed.

Ability Benevolence Integrity

Organization
Competence (COMC2) Completeness (COMP3, Competence (COMC), Responsiveness
COMP4, COMP7, COMP8) (RESP3)
Responsiveness (RESP2) Rules and Regulations (RUAR1)
Storage (STOR2), Understandability
(UNDE1), Usability (USAB1)
Person
Competence (COMC1, Completeness (COMP2, Availability (AVAI2, AVAI4)
COMC3, COMC4) COMP5, COMP6) Privacy (PRIV2)
Responsiveness (RESP1)
Technology
Availability (AVAI1, AVAI5) Usability (USAB3, USAB5) Availability (AVAI3) Table V.
Completeness (COMP1) Privacy (PRIV1) Trust matrix
Storage (STOR1) analysis: EHR-
Usability (USAB2, USAB4, related trust
USAB6) problems
 IJHCQA Trust problems and benevolence
29,7 Benevolence addresses the expectations that others act in a positive manner.
Technology must include all information, stored in such a way that it is safe and
non-redundant, and repeated. Healthcare records need to be logical and well structured,
making them easy to use by both healthcare providers and patients. In contrast to
abilities, technologies comprise a much smaller issue in benevolence problems.
796 Here, issues primarily concern the speed with which systems can be entered and exited.
In this sense, these problems concern whether or not EHR can be trusted to operate
quickly; i.e., the systems acting in patient’s favor. On a person or process and
organizational level, problems are almost solely related to record completeness.
Healthcare personnel and patients find it difficult to trust that information contained in
the EHR is complete. Personnel face another problem, since some may document too
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much about a patient, fearing being reprimanded by national health governance

officers. Personnel are responsible for ensuring that the information they document is
correct, including correctly documenting treatment or diagnosis, which may result in
personnel feeling that they have to document everything and not to lose or forget
anything. Hence, they may document more patient information than is necessary, out of
fear. This means the focus is more on documentation itself and on protecting oneself
rather than on documenting what is relevant and beneficial. If the relevant information
has been included, it increases trust that physicians listen and take the patient’s
problems seriously. At the organizational level, it becomes clear that an absent holistic
view is a general problem. In particular, staff may not view EHRs as good information
sources for their patients.

Trust problems and integrity

Integrity refers to devotion to generally accepted honesty and ethical behavior
principles. We found that there were trust issues at the person level concerning, for
example, trust in personnel having adequate knowledge about rules and regulations,
and acting accordingly. We identified staff as important information agents, that they
are proficient in documenting and knowing how to access relevant information. Issues
involving trust problems and integrity also relate to transferring patient information
between caregivers in different organizations, which places high demands on the
information structure and understandability. Like benevolence, most trust problems
related to integrity reside at the person and/or organizational levels, while only a few
problems can be directly related to technology. Unlike benevolence, however, the
problem categorization for trust is mixed with the integrity column while most
benevolence problems relate to completeness. Starting with technology problems,
computer availability is key to accessing, changing, handling and managing
patient-related information. If personnel do not document in privacy, then they have
a problem. Security mechanisms must be in place or there will be a trust issue –
whether or not the right people access the information. While having the technical
opportunity to access EHRs, healthcare personnel are only allowed to access records
for patients for whom they are responsible. Consequently, there have been cases where
staff has been fired for accessing and reading confidential patients records; e.g., when
famous people have died, or information about a staff member’s neighbor. At a person
level, problems concern unavailable information and healthcare goals, which are
needed to provide quality healthcare. Furthermore, human aspects come into play; i.e.,
patients have little insight into whom within the healthcare organization is accessing
their information. At a managerial level, decision support may cause trust problems.
 Likewise, how and to what extent patients can be included in and have influence over Managing
their care processes are issues that cause strategic concerns. Common standards for the healthcare
entire organization are needed, which address patient inclusion and to documentation
procedures, information to provide to patients concerning what was said during
information
appointments, clear and concise terminology, and to ensure that laws and regulations
are clear and easy to follow.
797
Holistic analysis
Looking at the analysis in Table V, problems connected with ability relate to technology
in most cases. Hence, there seems to be little trust that technology and systems can do
what they are expected to do, or that they can fulfill the purpose for which they were
created. As described in the two cases, respondents are mainly healthcare personnel,
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which indicates that they lack trust in the systems. They also report hearing about other
actors lacking trust such as patients and colleagues. Of the physicians who responded,
there was a fairly large group that sees computer support as a necessary evil.
The opposite situation arises for integrity-related problems, where most problems are
found at the organization level. This indicates a perception that healthcare managers do
not consistently make rules and regulations understandable, nor apply these rules and
regulations consistently throughout the organization. Benevolence-related problems are
fairly evenly spread among the levels, with a slightly higher emphasis on the person and
organization. Healthcare managers could use this information strategically and perform
corrective actions to increase trust and reduce problems.

Discussion
This study presents three pillars, or trusting beliefs, upon which trust in the EHR, from
a patient and a professional’s perspective, rests. Two real-life cases were presented
from which several problems were identified and compared. These problems were
structured as nine categories for further analysis, using a previously untested trust
matrix as a tool for analyzing trust problems and issues. By focussing on different trust
levels and facets, more trust-related problems were captured. Trust is too complex for
single-tracked analyses and a tool such as the matrix is therefore essential for
identifying and managing as many trust problems as possible. The matrix’s strength is
that it can help identify how trust problems relating to ability pertain more to
technology, while integrity-related problems are more frequent at the organizational
level. With this knowledge, better strategies for managing and preventing trust
problems can be developed. Based on our findings, three main challenges for future
research have been identified, to:
(1) achieve higher trust in patient-focussed healthcare; e.g., by identifying
strategies for managing and preventing trust problems;
(2) improve communication between patients and healthcare professionals; and
(3) establish clear terminology, for instance expressions related to patient
empowerment.
The trust matrix can provide a valuable tool to improve the balance between hard and
soft aspects. The threat today against supporting patient focus and trust is that
foundational values for both staff and patients are damaged, which result in the
problems we described. If a patient does not trust a clinician, then she/he will not disclose
all the relevant information needed to get a full comprehensive information overview.
 IJHCQA Healthcare optimization will not be obtained, which in turn results in increased costs.
29,7 Patients who do not trust the care they get will go to other providers, thus requiring
additional healthcare resources and repeating the processes again. Building trust
requires allocating more time for the doctor-patient meeting, to give a chance for a more
complete informational overview and information exchange. Standardization and
information flows are basic needs to both optimize and obtain trust.
798 Our study has limitations. First, the research is based on Swedish conditions,
meaning that further research is needed in other geographical contexts especially for
comparability and generalizability. Second, the study focussed on only two cases and
future work must apply the matrix to more cases and to other settings besides
healthcare. Results are probably still generalizable, since our aim was to identify needs
and challenges for achieving a more complete and holistic approach. These needs and
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challenges should be elaborated in the future with the aim to devise a strategy for
handling them.

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Corresponding author
Eva Söderström can be contacted at: eva.soderstrom@his.se

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