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FAMILY PRACTICE PHYSICIANS’ ACCEPTANCE AND USE OF A REPLACEMENT
ELECTRONIC MEDICAL RECORD SYSTEM: INSTRUMENTAL CASE STUDY
by
Diana Cointa Berich Brieva
Copyright 2020
A Dissertation Presented in Partial Fulfillment
of the Requirements for the Degree
Doctor of Health Administration
University of Phoenix
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ABSTRACT
Transitioning or upgrading electronic medical record (EMR) systems have unique and
significant challenges than moving from paper charts to electronic charts. Physicians’
perceptions of EMR systems affect the rate of adoption and use. The purpose of this
qualitative instrumental case study was to explore the decision- making process of family
practice physicians transitioning to a replacement EMR system at a multi-specialty
ambulatory clinic located in a metropolitan area of Northeastern Indiana. This study sought
to understand how family practice physicians form their decision to accept and use a
replacement EMR system, how the family practice physicians overcame the barriers and
challenges associated with transitioning EMR systems, and how did family practice
physicians feel emotionally during the transition. Semi-structured interviews of 8 family
practice physicians explored the decision-making process to accept and use a new EMR
system. NVivo for Windows computer software was used to assist with the analysis of semi-
structured interviews, questionnaires, and artifacts to identify themes. Three themes and 8
subthemes emerged from the data analysis. Key recommendations from the study include
highlighting how the new system will improve the quality of care of patients, develop a
multidisciplinary quality training program, and be prepared to address with the physicians the
emotional impact inherent in transitions. The study findings may be important to health care
leaders, policymakers, and health information technology designers and implementors in
understanding how family practice physicians decide to accept and use future technology.
iii
DEDICATION
This dissertation is dedicated first and foremost to my Lord and Savior, Jesus Christ,
through him all things are possible. To my family and friends who have supported me
throughout my journey; their love and support were the fuel that kept me going. To my fur
baby, Zoe, thank you for your unconditional love, kisses, and snuggles even when I did not
always give you the attention you wanted.
iv
ACKNOWLEDGEMENTS
I do not have the words to express my gratitude to my dissertation chair, Dr.
Joann Kovacich, who stuck with me during this long journey. Dr. Kovacich provided me
invaluable feedback and encouragement that carried me to the finish line. Dr. Kovacich
also introduced me to the research world where I had the opportunity to have a poster
presentation at an international research conference. I was so impressed with that
experience that I attended another qualitative research conference where I had the
opportunity to attend workshops with Johnny Saldana, something I would have never
done on my own. Thank you Dr. Kovacich for sharing the opportunity of the conferences
and exposing me to the research world, a genuinely nice and supportive network. I also
want to thank my dissertation committee members, Drs. Kroposki and Nandy, for their
time and valuable feedback.
v
TABLE OF CONTENTS
Contents: .......................................................................................................... Pages
List of Tables .......................................................................................................... X
List of Figures ....................................................................................................... XI
Chapter 1: Introduction ...........................................................................................1

Background of the Problem ............................................................................2
Problem Statement ..........................................................................................4
Purpose of the Study .......................................................................................5
Population and Sample ..................................................................................6
Significance of the Study ................................................................................8
Significance of the Study to Leadership .........................................................9
Nature of the Study .........................................................................................9
Overview of the Research Method ........................................................10
Overview of Design Appropriateness ..................................................11
Research Questions .......................................................................................14
Theoretical Framework .................................................................................15
Definition of Terms.......................................................................................19
Assumptions, Limitations, and Delimitations...............................................20
Assumptions........................................................................................20
Limitations ..........................................................................................21
Delimitations .......................................................................................22
Chapter Summary .........................................................................................22
Chapter 2: Review of the Literature.......................................................................24

Title Searches, Articles, Research Documents, and Journals .......................25
Historical Content .........................................................................................26
Brief History of Early EMR Systers ...................................................26
Current Content.............................................................................................28
Acceptance (Adoption) .......................................................................28
Use ......................................................................................................39
Challenges ...........................................................................................40
Drivers/Facilitators .............................................................................42
vi
Barrier .................................................................................................43
Physician Perceptions .........................................................................44
Leadership ...........................................................................................45
Theoretical Framework Literature ................................................................45
Technology Acceptance Model (TAM) ..............................................45
Unified Theory of Acceptance and Use Of Technology (UTAUT) ..47
William Bridges' Transition Model ...................................................51
Methodology Literature ................................................................................52
Qualitative Research .........................................................................52
Quantitative Research .......................................................................53
Mixed Methods Research .................................................................54
Research Design............................................................................................54
Phenomenology.................................................................................55
Grounded Theory ..............................................................................55
Ethnographic Research .....................................................................56
Case Study ........................................................................................57
Conclusion ....................................................................................................58
Chapter Summary .........................................................................................59
Chapter 3 : Method ................................................................................................61
Research Method and Design Appropriateness...........................................62
Research Questions .....................................................................................63
Population and Sample ................................................................................64
Population.........................................................................................64
Sample ..............................................................................................64
Recruitment ......................................................................................65
Informed Consent/Confidentiality ...............................................................66
Informed Consent .............................................................................66
Confidentiality ..................................................................................68
Geographic Location ...................................................................................69
Instrumentation ............................................................................................69
Field Test ....................................................................................................70
Trustworthiness ...........................................................................................70
Transferability ..................................................................................70
vii
Credibility.........................................................................................71
Confirmability/Dependability .........................................................72
Researcher's Acknowledgement of Biases ..................................................73
Data Collection ............................................................................................74
Interviews .......................................................................................75
Participant Observation ..................................................................77
Archival Data .................................................................................78
Data Analysis ..............................................................................................78
Summary .....................................................................................................80
Chapter 4: Analysis and Results ............................................................................81
Research Question .......................................................................................81
Data Collection ............................................................................................81
Demographics ..............................................................................................85
Data Analysis ..............................................................................................86
Step 1. Assigning attributes. ....................................................88
Step 2. Listing and preliminary grouping ................................88
Step 3. Reduction and elimination ..........................................90
Findings .......................................................................................................90
Theme 1: Accepting and using an EMR means continuity of care .90
Theme 2: Overcoming Barriers and Challenges means addressing 95
Subtheme 1: The challenge of importing old records ............95
Subtheme 2: Findings records in the new system ...................97
Subtheme 3: Lack of consistency in training ..........................99
Subtheme 4: Timing of go-live..............................................103
Subtheme 5: Lack of support ................................................104
Subtheme 6: Workarounds ...................................................106
Subtheme 7: Physicians' Recommendations for future ........107
Theme 3: Transitioning is an Emotional Experience ...................108
Subtheme 1: Decreased compensation .................................110
Summary ...................................................................................................112
Chapter 5: Conclusions and Recommendations ..................................................114
Research Question ...................................................................................114
Disscussion of Findings ...........................................................................115
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Theme 1: Accepting and Using An EMR Means Continuity of Care116
Theme 2: Overcoming Barrier And Challenges Means of Address ..117
Subtheme 1: The challenge of importing old records ...............118
Subtheme 2: Finding records in the new system .......................118
Subtheme 3: Lack of consistency in training ............................119
Subtheme 4: Timing of go-live ..................................................119
Subtheme 5: Lack of support.....................................................120
Subtheme 6: Workarounds ........................................................120
Subtheme 7: Physicians' recommendations for future .............121
Theme 3: Transitioning is an Emotional Experience......................122
Subtheme 1: Decreased compensation ....................................123
Limitations ...............................................................................................123
Recommendations for Leadership and Practitioners ...............................124
Recommendations for Future Research ...................................................126
Chapter Summary ....................................................................................127
References ............................................................................................................129
Appendix A: Premises, Recruitment, and Name (PRN) Use Permission ...........144
Appendix B: Recruitment Protocol ......................................................................146
Appendix C: Informed Consent ...........................................................................148
Appendix D: Interview Guide..............................................................................151
Appendix E: Demographic Survey ......................................................................155
Appendix F: Observation Guide ..........................................................................156
Appendix G: Data Access and Use Permission ...................................................159
Appendix H: Coding Interviews ..........................................................................161
ix
LIST OF TABLES
Table 1: Demographic Survey Results...................................................................85
Table 2: Recommendations to Leaders........................................................... 125
x
LIST OF FIGURES
Figure 1 Unified Theory of Acceptance and Use of Technology (UTAUT).........16
Figure 2 The Seven-Step Coding Process..............................................................86
xi
Chapter 1
Introduction
Transitioning from an older legacy electronic health record (EHR) system to a
more comprehensive EHR system will become more common as the first generation of
EHRs are becoming dated (Saleem et al., 2018). Black Book Rankings has named 2013
“The Year of the Great EHR Switch,” (Schaeffer, 2013). The global ambulatory EHR
market is projected to grow from $3.92 billion in 2016 to $5.20 billion by 2021
(MarketsandMarkets, 2018). As ambulatory care settings rushed to adopt an EMR system
to take advantage of financial incentives and avoid financial penalties from the Centers
for Medicare and Medicaid Services (CMS), many of the EMR systems fell short of
expectations.
This study was an opportunity to gain a better understanding of the decision-
making process of family practice physicians regarding the acceptance and use of a new
EMR system after having used an EMR system for more than five years. Researchers
have found that the rate of physician acceptance and ultimately adoption and use of an
EMR can be accelerated by vendors and health care organizations understanding
physician perceptions and tailoring education to those perceptions (Lakbala & Dindarloo,
2014). Information from this study may be helpful to health care leaders, EMR system
implementers, and policymakers transitioning to or upgrading an EMR system. Health
care providers are the primary users of EHRs and their perceptions of the benefits of
these systems are important and may influence successful integrations of EHR systems
(Krousel-Wood et al., 2017). Lessons from a system transition may also be useful to
health systems that are considering a system upgrade or a switch to a new system
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(Saleem et al., 2018).
Chapter 1 included the background of the problem, the statement of the problem,
the purpose of conducting the study, the significance of the problem, and the significance
of the study to leadership. The chapter also included the nature of the study, an overview
of the research method, design appropriateness, research question, and theoretical
framework for this study. The end of the chapter defined terms, described assumptions
made, described the scope and limitations of the study, showed delimitations, and
concluded with a chapter summary.
Background of the Problem
The American Reinvestment & Recovery Act (ARRA) of 2009 created the Health
Information Technology for Economic and Clinical Health (HITECH) Act of 2009 to
support the concept of electronic health records (EHRs) and meaningful use. Meaningful
use is defined as the use of certified EHR technology in a meaningful way; making sure
that the EHR certified technology provides an electronic exchange of health information
to improve the quality of care through interconnections (CDC, 2012). Meaningful use is
an incentive program created to encourage widespread EHR adoption by easing the
financial burden associated with system implementation (CDC, 2012). Meaningful use is
a staged approach divided into three stages beginning 2011 (data capture and sharing),
2013 (advanced clinical processes), and 2015 (improved outcomes). The incentive
payments range from $44,000 over 5 years for Medicare providers to $63,700 over 6
years for Medicaid providers (CDC, 2012).
Since the passing of the HITECH Act of 2009, the rate of adoption has been
steadily increasing. In 2012 71.8% of office-based physicians reported using any type of
2
EHR system, an increase of 34.8% from 2007 (Hsiao et al., 2014). In 2012 23.5% of
office-based physicians had an EHR that was categorized as fully functioning compared
to 3.8% in 2007 (Hsiao et al., 2014). Healthit.gov (2015) reported that in 2015 54% of all
office-based physicians have a fully functioning EHR system and are successfully
meeting the meaningful use measures. In April 2018 overall physician office adoption
reached 69.6% (IQVIA, 2018).
The percentage of providers who had a positive perception of EHR systems has
significantly decreased over time in areas of overall satisfaction, productivity, better
patient care, clinical decision making, access to patient information, monitoring patients,
more time with patients, coordination of care, computer access, adequate resources, and
satisfaction with ease of use (Krousel-Wood et al., 2017). Researchers reported that 70%
of physicians stated that implementing an EHR was not worth the transition even with the
government incentives (Andresen et al., 2017). A survey of eligible providers (EP)
participating in the MU incentive program perceived that the MU program diverted the
focus from patient care to reporting requirements by imposing greater compliance
requirements (Weeks et al., 2014). Some eligible providers dropped out of the MU
program after the first year, when the majority of the money was available, as they did
not find the requirements worth the incentive money available (Weeks et al., 2014).
The factors related to primary care physicians’ acceptance and use of EMRs are
complex. As more studies are conducted on the topic, the results should help health care
leaders, policymakers, and EMR system implementers a better understanding of the
complexities and why they exist. The longer it takes to understand these complexities and
how to manage them the longer it will take to manage the health care costs in the United
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States. The scope and effort transitioning between EMR systems are similar to the
transition from paper to an EMR system (Penrod, 2017). This research added to the
literature by addressing gaps in the literature in understanding physicians’ decision to
accept and use a new EMR when transitioning between EMR systems.
Problem Statement
The general problem is, despite previous EMR use, transitioning to a different
EMR system or upgrading the current system has unique and significant challenges that
differ from transitioning from paper records (Edsall & Adler, 2015). Edsall and Adler
(2015) found that the number one challenge in switching EMR systems was the time
investment followed by productivity loss, difficulty learning the new system, cost to
switch systems, data loss in the conversion, difficulty using the new system, and lastly
the loss of functions of the old system. Understanding those differences are important
because as technology, industry, and policies change, systems need to be upgraded or
replaced (Edsall & Adler, 2015). The ability of an EMR system to capture, analyze, and
report data is critical as the current payment models move from fee-for-service to value-
based (Martin, 2017).
The specific problem is that physicians’ perceptions of EMR systems affect the
rate of adoption and use (Lakbala & Dindarloo, 2014). This impacts reimbursement under
the Quality Payment Program (QPP) where adjustments of up to plus or minus 9% for
Medicare recipients are applied to eligible clinicians (Quality Payment Program, n.d.).
Understanding the key decision-making factors of family practice physicians related to
EMR acceptance and use could be used to better develop and plan future EMR transitions
to help expedite acceptance and use. The benefits gained from an EMR system are only
4
accomplished by getting the greatest number of physicians using an EMR system
(Lakbala & Dindarloo, 2014). This increases exponentially with prolonged use of the
system (King et al., 2014). Adoption of the EMR by family practice physicians has
steadily increased over the years to 75% in 2015 (ONC, 2016); however, health care
organizations and the health care system cannot afford for this adoption rate to decrease
when physicians transition to a new EMR system.
Edsall and Adler (2015) reported that an EMR system switch will slow operations
and productivity down for the first three to four months, they recommend preparing as if
you are implementing an EMR system for the first time, the process is that disruptive.
Lakbala and Dindarloo (2014) found that knowing how physicians perceive an EMR
gives leadership and vendors the necessary tools to be able to train and accelerate the rate
of adoption. This study addressed the gaps in the literature on the decision-making
process of family practice physicians in ambulatory care settings transitioning an EMR
system and the emotional impact of such a transition. The study results may help health
care leaders and policymakers better understand some of the potential drivers and
challenges of EMR acceptance and use when transitioning or
upgrading EMR systems.
Purpose of the Study
The purpose of this qualitative instrumental case study was to explore the
decision- making process of family practice physicians transitioning to a replacement
EMR system at a multi-specialty ambulatory clinic located in a metropolitan area of
Northeastern Indiana. The decision-making process focused on the acceptance and use of
a replacement EMR system. The decision-making process also focused on the drivers and
5
challenges faced by family practice physicians during the system transition with a goal of
accelerating acceptance and use of future EMR replacement systems.
Interest has grown for more qualitative research in health informatics (Rahimi et
al., 2008). Qualitative methods in health care research have provided much insight into
health professionals’ perceptions and barriers to changes in health care operations (Al-
Busaidi, 2008). The goal of qualitative research is to understand issues or situations by
“investigating the perspectives and behavior of people” within those situations and the
context of the action (Kaplan & Maxwell, 2005, p.30). Qualitative research methods can
be used to obtain specific details about phenomena such as emotions, feelings, or thought
processes that would be difficult to see using more conventional quantitative research
methods (Strauss & Corbin, 1998).
Yin (2014) identified the elements of a case study as being an empirical inquiry
that investigates a contemporary phenomenon in-depth and with a real-world context. An
instrumental approach to case study research focuses on providing insight into an issue or
issues where the case is acting as a conduit to assist in understanding something else, the
issues (Grandy, 2010). Gaining a better understanding of the decision-making processes
of physicians and using that information to help them navigate in today’s healthcare
environment is a perfect example of the Scholar, Leadership, Practice model of the
University of Phoenix, and what drives this study.
Population and Sample
The population for this study included all physicians transitioning to a
replacement EMR system. The target population, the group of people the researchers
wanted to generalize the findings to, including all family practice physicians transitioning
6
to a replacement EMR system. The accessible population included all 40 family practice
physicians transitioning to a replacement EMR system at a multispecialty group located
in Northeastern Indiana. The sampling strategy used to select participants was purposeful
purposive sampling.
The purpose of purposeful sampling was to select information-rich cases that illuminate
the questions under study (Patton, 1990). Patton (1990) stated that a sampling strategy must be
selected to fit the purpose of the study, available resources, the questions being asked, and the
constraints faced. Mohd Ishak and Abu Bakar (2014) stated purposive sampling is useful for case
study research in three instances when the researcher: 1) wants to select unique cases because
they are especially informative, 2) would like to recruit a difficult-to-reach, specialized
population, and 3) wants to identify the specific types of cases for in-depth research. This
research study fit all three criteria; the case selected was unique because of the recent transition to
a replacement EMR system, physicians under study were a specialized population, and the
specific type of case was family practice physicians because the amount of information they are
tasked with entering into the EMR that are not asked of other physicians because of their
specialty.
Participants included a sample of 8 family practice physicians employed in an
ambulatory care setting. Participants were limited to family practice physicians residing
in the state of Indiana and only included family practice physicians at a specific hospital-
owned multi-specialty practice in a metropolitan area of Northeastern Indiana. All
participants had at least two years’ experience on an EMR to ensure basic computer
skills.
The sample size is not a definitive number in qualitative studies. The sample size
depends on the research question, the purpose of the research study, what is useful, what
7
will be credible, semi-structured interviews, observations, and documents reviewed were
limited to the point of saturation. Data saturation occurs when no new insights occur from
collecting one more piece of data (Hanson et al., 2011). The purpose of qualitative
studies is to provide a rich, contextualized understanding of human experience by
studying a particular case not to generalize findings to a larger population like
quantitative studies so the sample size is less important (Robinson, 2014).
The information gained from this study may be used to form strategies to expedite
the adoption of future replacement EMRs. The family practice physicians are in a multi-
specialty practice which is part of a larger network system. The decision to replace the
EMR system was not made with the input of the physicians. The adoption of the system
is not optional. The network is part of an Accountable Care Organization (ACO) and the
EMR is a tool used to validate quality measures.
Significance of the Study
The study findings may be important to health care leaders, policymakers, and
health information technology designers and implementors in understanding how family
practice physicians decide to accept and use future technology. No known knowledge
exists on how to best design, implement, and use HIT (Rippen et al., 2013). Slabodkin
(2015) stated a 2014 report from KLAS reported that 27% of ambulatory practices were
considering changing EMR systems. Factors driving the need to switch EHR systems
include mergers and acquisitions, a practice’s growth, dissatisfaction with the systems,
inefficient workflows, and lack of reporting capabilities (Kosiorek, 2014; Andresen et al.,
2017). The current EMR systems are not robust enough to meet future advances in health
care which are driving the need to switch from legacy EMR systems to more
8
comprehensive EMR systems (Saleem et al., 2018).
Significance of the Study to Leadership
Innovative technologies in health care are already being designed and physicians
will need to adapt quickly to this changing environment as the expectations of care are
also changing. The accelerating rate of commercial EMR implementations, aided by
Federal government investments, has widened the scope of researchers trying to decide
the most efficient way to use HIT (Atkins & Cullen, 2013). The transition from one EHR
system to another will become more common as the first-generation systems are
becoming outdated (Saleem et al., 2018).
Ellis (2014) reported that it took his practice four months for patient volumes to
return to the same levels as before the change. Patient safety issues will likely emerge and
organizations need to be prepared (Saleem et al., 2018). Health care organizations should
expect to see a decrease in physician satisfaction after an EMR system transition which
could last up to two years (Saleem et al., 2018). As business leaders gain a better
understanding of how family practice physicians decide to accept and use a replacement
EMR system and a better understanding of some of the drivers and challenges faced with
such a transition, the gap may close between the clinical care world of the physician and
the business world of leadership.
Nature of the Study
The purpose of this instrumental case study was to explore the decision- making
process of family practice physicians to accept and use a replacement EMR system and to
better understand some of the drivers and challenges faced with such a transition. The
study results may help health care leaders and policymakers better understand some of
9
the potential drivers and challenges of EMR acceptance and use when transitioning
between EMR systems. Understanding of EMR acceptance and usage drivers and
challenges could be incorporated in developing training programs that may expedite
acceptance and use of future system implementations.
Overview of the Research Method
A qualitative method was appropriate for this study since the aim of this
qualitative instrumental case study was to understand how family practice physicians
decide to accept and use a replacement EMR system to better prepare for future EMR
changes. Yin (2011) stated that qualitative studies have five features: to study the
meaning of people’s lives under real-world conditions, to represent the views and
perspectives of participants, to evaluate the contextual conditions within which people
live, to contribute insights into new or existing concepts that may help explain human
behavior, and to enable the use of multiple sources of evidence rather than relying on just
one.
Qualitative researchers are interested in understanding the meaning people have
constructed from their perspectives, how individuals make sense of their world and
experiences (Merriam, 1998a). In qualitative research, the researcher is the primary
instrument for data collection and analysis typically involving fieldwork and inductive
research strategies (Merriam, 1998a). Since qualitative studies usually focus on process,
meaning, and understanding the final product is richly descriptive in words and pictures
as opposed to numbers typically found in quantitative studies (Merriam, 1998a).
Since the aim of this qualitative instrumental case study was to understand how
family practice physicians decide to accept and use a replacement EMR system, a
10
qualitative study would be a more appropriate method for this research. Qualitative
research questions seek patterns of anticipated as well as unanticipated relationships
whereas quantitative research questions seek relationships between a small number of
variables (Stake, 1995). Bogdan and Taylor (1975) stated that qualitative research
methods enable researchers to explore concepts that would have otherwise been missed
using different approaches. Concepts such as beauty, pain, faith, suffering, frustration,
hope, and love can be studied in their real-world context as they are experienced and
defined by people. A quantitative study would be able to quantify by stating how many
users and non-users or how many accepted or not but the study would not be able to
explain the physicians’ motivations behind the action or inaction to understand their
decision-making process.
Overview of the Design Appropriateness
Case studies allow researchers to focus on a unit of analysis while retaining a
holistic and real-world view (Yin, 2014). A case can be an individual or a group or can be
simple or complex (Suryani, 2008). Some examples of an individual case might be a
child, an adult, a student, a teacher, a person’s experience, or a phase in life (Suryani,
2008). A case study is ideal when researching contemporary events where the
participants’ behaviors cannot be manipulated (Yin, 2014).
The goal of case study research may be exploratory to define questions or
hypotheses, descriptive to depict a phenomenon within its context, or explanatory to
identify a cause-and-effect relationship (Curry et al., 2009). Case study research can also
be intrinsic, the case is of primary interest, instrumental, the case provides an
understanding of something else, and collective, studying many cases at the time (Stake,
11
1995). An instrumental case study was an appropriate design for this study since the
purpose of this qualitative instrumental case study will be to explore the decision- making
process of family practice physicians transitioning to a replacement EMR system at a
multi-specialty ambulatory clinic located in a metropolitan area of Northeastern Indiana.
The decision-making process focused on the acceptance and use of the
replacement EMR system and the drivers and challenges faced by family practice
physicians during the transition with a goal of accelerating acceptance and the use of
future EMR replacement systems. Concepts such as acceptance, use, drivers, and barriers
were explored as they are experienced and defined by the study participants through
semi-structured interviews. The case (physicians) was used to help better understand
something other than the case, potential drivers, and challenges of replacement EMR
systems.
Other qualitative designs were considered for this study. Phenomenology seeks to
describe what an experience means to the people who had the experience and can provide
a detailed account of that experience (Schram, 2006). Ethnography is the study of
peoples’ culture and rituals where the researcher is a participant-observer who lives
among the study participants to try to see the world from their perspective (Shank, 2006).
Grounded theory uses procedures to generate theory describing a phenomenon and is
grounded in the views from study participants (Curry et al., 2009). The purpose of this
study was to explore the decision-making process of family practice physicians to accept
and use a replacement EMR system and understand some of the drivers and challenges
faced with such a transition; therefore, none of the other qualitative designs considered
were appropriate for this study.
12
Case study research was the preferred method over other qualitative studies when
the main research questions are how or why, the researcher has little control over the
participants’ behavior, and the study is looking at a contemporary phenomenon (Yin,
2014). Stake (1995) explains that a case is studied when the case is of very special
interest. Merriam (1998) describes a case study as an intensive, holistic description and
analysis of a bounded phenomenon. The phenomena could be a program, an institution, a
person, a process, or even a social unit making a case study the most appropriate method
for this study.
Commonly used data collection methods for qualitative case study research
includes documents, archival records, interviews, direct observation, participant-
observation, and physical artifacts (Yin, 2014). Yin (2014) shared that individual sources
of evidence are not recommended for case study research; researchers need to use
multiple sources of evidence, triangulation, which is a strength of case study research and
improves the overall quality of the study. Knowing how much data to collect is described
as being similar to the law of diminishing returns; there is no way to be sure you have
found all pertinent information but the patterns of repetition make it unlikely that more
investigation will produce any new information, saturation (Shank, 2006). Rigor in
qualitative research comes from the researcher’s presence, the interaction between
research and participants, the triangulation of data, the interpretation of participants’
perceptions, and thick description (Merriam, 1998a).
Data was gathered using, semi-structured interviews, participant observations, and
organizational documents such as meeting minutes, training plans, and training agendas
regarding the EMR transition from the organization. Semi-structured open-ended
13
interviews were used to obtain an in-depth understanding of the participants’ decision-
making process to accept and use the replacement EMR system. Stake (1995) shared that
the two principal uses of case study research are to obtain the description and
interpretations of others as each person has their reality and interviewing is an avenue to
multiple realities. The interview questions were field-tested by a group of 5 multi-
specialty physicians not participating in the study who just experienced the transition to a
new EMR system so they will have great insight.
Participant observation was used to collect environmental and organizational data
at each participant’s clinic and to help corroborate self-reported acceptance and use
claims by the participants. Archival data such as meeting minutes, training plans, and
training agendas were used to describe organizational support during the system
transition. Questionnaires were used to collect demographic information on the
participants.
Research Question
The central question was:
Q1: How did family practice physicians form their decision to accept and use a
replacement EMR system?
Two sub-questions used to explore additional factors inherent in transitioning between
EMR systems:
S1: How did family practice physicians overcome barriers and challenges
associated with transitioning EMR systems?
S2: How did family practice physicians feel emotionally during the transition.?
Understanding the providers’ decision-making process to accept and use a
14
replacement EMR system, how they overcame barriers and challenges with such a
change, and how they felt emotionally during the process may be important to health care
leaders, policymakers, and health information technology designers and implementors in
understanding how family practice physicians decide to accept and use future technology
and at which stage of the transition.
Theoretical Framework
The theoretical framework to guide this study was the Unified Theory of
Acceptance and Use of Technology (UTAUT) and William Bridges’ Transition Model.
Technology acceptance models or theories are usually used in studies to identify the how
and why of individual behaviors in acceptance and use of new technology (Trimmer et
al., 2009; Dulle & Minishi-Majanja, 2011). Venkatesh et al. (2003) incorporated eight
prominent theoretical models of adoption and acceptance of technology (Fig. 1). The
result of the study was the development of a new model, UTAUT; which can identify as
much as 70 percent of the variation of intention to use technology (Venkatesh et al.,
2003).
Unified Theory of Acceptance and Use of Technology (UTAUT)
Yin (2014) stated that the use of theory in case study research is an important aid
in defining the appropriate research design and data to be collected for the study. The
UTAUT framework identified direct determinants of acceptance and usage behavior to
include performance expectancy, effort expectancy, social influence, and facilitating
conditions (Venkatesh et al., 2003; Wright & Marvel, 2012). UTAUT incorporates
perceived usefulness and perceived ease of use into the effort expectancy, and subjective
norm into the social influence (Holden & Karsh, 2010).
15
UTAUT is believed to be a more robust model than other technology acceptance
models (TAM) in evaluating and predicting acceptance (Taiwo & Downe, 2013).
UTAUT proposes variables that directly influence the outcome variables of Behavioral
Intent and Usage of Technology (Trimmer et al., 2009). These variables are mediated by
one or more of a set of demographic variables (gender, age, experience, and voluntariness
of use) (Trimmer et al., 2009).
Figure 1
Unified Theory of Acceptance and Use of Technology (UTAUT) Model
Note: Adapted from “Going Beyond Intention: Integrating Behavioral Expectation into
the Unified Theory of Acceptance and Use of Technology,” by L. Maruping, H. Bala, V.
Venkatesh, and S. Brown, 2017, Journal of the Association for Information Science and
Technology, 68(3), p. 627.
16
According to the UTAUT model, performance expectancy, effort expectancy, and
social influence constructs are the strongest predictors of adoption/acceptance whereas
behavioral intention and facilitating factors are the strongest predictors of use (Venkatesh
et al., 2003). Behavioral expectation was introduced into the original UTAUT model to
address the uncertainty that could not be adequately addressed in the behavioral intention
construct (Venkatesh et al., 2008). The central question was how do family practice
physicians form their decision to accept and use a replacement EMR system? A
subquestion was how did they overcome barriers and challenges associated with
transitioning EMR systems? Using semi-structured interviews provided insights into the
perceptions of family physicians and to see how they align with the UTAUT constructs.
William Bridges’ Transition Model
The William Bridges’ Transition Model was used to help understand the level of
transition each participant was in. The Transition Model has three phases in which one
passes during times of transition: the ending, the neutral zone, and the beginning. The
model starts by letting go of the old ways, travels through a neutral zone, and ends with a
new way of doing things. Transitions are psychological events whereas changes are
situational events (Bridges & Bridges, 2016).
Phase 1 is called the Ending. Bridges and Bridges (2016) stated that it is not the
change that people resist, it is the losses and endings they experienced and the transition
that is being resisted. Some of the emotions associated with the endings phase include
anger, sadness, frightened, depression, and confusion. Bridges and Bridges (2016) have
found that many times organizations confuse bad morale with the signs of grieving which
include: denial, anger, bargaining, anxiety, sadness, disorientation, and depression.
17
Phase 2 is called the Neutral Zone. The neutral zone is a period of flux where
people’s anxiety rises and motivation decreases, a feeling of disconnectedness and self-
doubting, resentful and self-protecting, and people’s energies are drained from working
on coping mechanisms (Bridges & Bridges, 2016). During this phase, people miss more
work than normal, at best productivity falls but at worst medical claims and disability
increase, older weaknesses from the past emerge, people are overloaded, mixed signals
are sent because systems are in flux and unreliable, priorities get confused, information
gets miscommunicated, important tasks go undone, discord arises, teamwork and loyalty
to the organization are undermined, vulnerability to outside threat increases because tired
people respond slowly to such threats, but it is a great time for innovation (Bridges &
Bridges, 2016).
Phase 3 is called New Beginnings. New Beginnings occur after people come out
of the neutral zone and are ready to make an emotional commitment to do things in a new
way and they see themselves as new people (Bridges & Bridges, 2016). The timing of
New Beginnings is driven by the transition process; however, they can be encouraged,
supported, and reinforced. Getting people through the transition process is important if
the change is to work as planned (Bridges & Bridges, 2016).
Understanding what phase of the transition process a participant is in, may shed
some light on their decision to accept and use a replacement EMR system. The
psychological impact transitions have on people was worth exploring in this study.
Bridges and Bridges (2016) puts the responsibility on leadership to help guide staff
through these phases of transitions. This information may be helpful to leadership and
could be applied to any transition an organization is facing.
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Definition of Terms
This section is to clarify the meaning of some key terms used throughout this
study.
Behavioral Intention – “An individual’s conscientiously formulated plan to
perform a behavior” (Maruping et al., 2017, p. 625).
Effort Expectancy – the degree of ease in using an information technology
system (Venkatesh et al., 2003).
Electronic Medical Records (EMR) – an electronic record of health-related
information on an individual that can be created, gathered, managed, and consulted by
authorized clinicians and staff within one health care organization (Healthcare
Informatics, 2008).
Facilitating Conditions – the degree to which an individual believes that the
organization has the infrastructure in place to support the use of the new system
(Venkatesh et al., 2003, p. 447).
Health Information Technology (HIT) - is a broad term for technologies that
store, share, and analyze health information. HIT includes electronic health records
(EHR), personal health records (PHRs), and e-prescribing (HealthIT.gov, 2013).
Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009 -- The American Recovery and Reinvestment Act of 2009
provides opportunities for the Department of Health and Human Services (DHHS) and
the States to improve the nation’s health care through HIT and promoting MU of EHRs
via incentives. Funds will be distributed through Medicare and Medicaid incentive
programs to those who use the system in a meaningful way, as outlined in the program
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(CMS.gov, 2009).
Institute of Medicine (IOM) – The Institute of Medicine (IOM) was established
in 1970 as the health arm of the National Academy of Sciences (NAS). President
Abraham Lincoln signed a congressional charter in 1863 which was the catalyst for the
NAS. The NAS was created to operate outside the government to advise the nation when
needed. The NAS added the National Academy of Engineering (NAE) in 1964 to
complete their needs. On July 1, 2015, the NAS voted to change the name from the
Institute of Medicine to the National Academy of Medicine which joins the NAE and
NAS in advising the United States on matters of science, technology, and medicine (The
National Academies of Science-Engineering-Medicine, 2015).
Perceptions – a process where individuals organize and interpret their sensory
impressions to give meaning to their environment. People’s behavior is on what reality is,
not on reality itself (Robbins & Judge, 2013).
Performance Expectancy – the degree to which an individual believes that using
a particular technology will assist in improved job performance (Venkatesh et al., 2003).
Social Influence – the degree to which the individual perceives important people
believe that the individual should use the system (Venkatesh et al., 2003).
User Acceptance – “the demonstrable willingness within a user group to employ
information technology for the tasks it is designed to support” (Dillon, 2001).
Assumptions, Limitations, and Delimitations
Assumptions
The first assumption was that the participants will answer truthfully. Participation
in this research was voluntary so there was no reason to assume that the participants were
20
not truthful. The second assumption was that the participants were willing to share their
perceptions of the EMR system. The third assumption was that findings from this
research may be important to health care leaders and policymakers in understanding how
the use of future technological advances will be perceived to project their rate of
adoption. The final assumption was that semi-structured interviews are the most effective
way to collect data on perceptions.
Limitations
Some limitations of qualitative research included a lack of generalizability. The
research findings are so in-depth they refer to the specific participant population.
Subjectivity was another limitation of qualitative research where the researcher has some
influence on the findings of the study. Bias can be reduced but never eliminated because
of the nature of qualitative research. Bias is made explicit in qualitative research designs
(Watkins & Gioia, 2015).
The present study was limited in several ways. First, the generalizability of the
research findings was limited by the fact that only one type of EMR was referenced in
one type of organizational context. Second, this research included only family practice
physicians despite the importance of knowing there are other health care professionals’
who hold beliefs about EMRs. Thirdly, the study included EMR users in the ambulatory
care setting and did not include EMR users in the hospital. Fourth, the case was selected
based on the maximization of information gained and accessibility; case studies are not
sampling research (Stake, 1995). Fifth, this study only focused on perceptions of family
practice physicians working in the United States, though adoption is a global problem. A
final limitation was that this design does not allow for inference of cause.
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Delimitations
The focus of this study was to explore perceptions of family practice physicians in
a multi-specialty ambulatory clinic located in a metropolitan area of Northeastern
Indiana. Participants were limited to family practice physicians practicing in Indiana who
have had at least two years of experience on an EMR system. Participants were limited to
one specific location in Northeastern Indiana. The participants were all from the same
multi-specialty group. The population included only those working in an ambulatory care
setting.
The study had a small sample size and was conducted over a month. Semi-
structured interviews were conducted at the physician’s office or virtually using Google
Meets. The results of the study may be different using a larger sample, or conducted at a
different period of time, and if conducted at a different location. The results will not be
transferable to other physicians working in different settings, in different parts of the
country. Additionally, using a different research method and design may result in
different findings. The epistemological orientation of this instrumental case study was
that of a constructivist and results may be different with a different orientation.
Chapter Summary
the replacement EMR system and the drivers and challenges faced by family practice
physicians during the transition with a goal of accelerating acceptance and the use of
22
future EMR replacement systems. The general problem was, despite previous EMR use,
transitioning to a different EMR system or upgrading the current system has unique and
significant challenges that differ from transitioning from paper records (Abramson et al.,
2012).
The specific problem was that physicians’ perceptions of EMR systems affect the
rate of adoption (Ajami & Bagheri-Tadi, 2013). The theoretical framework used to guide
this study was the Unified Theory of Acceptance and Use of Technology (UTAUT) and
Bridges Transition Model which supported the research questions and method. The
constructs of UTAUT and the Bridges Transition Model were used to help guide the
interview questions to help understand how family practice physicians decide to accept
and use a replacement EMR system to better prepare for future EMR changes.
Chapter 1 provided a background discussion of the problem and purpose
statements, the significance of the study, the nature of the study, the research question,
and the theoretical framework that frames the research study. Sections that were also
included were definitions of terms, assumptions of the researcher, scope and limitations
of the study, and researcher-imposed delimitations of the study to put the study in
context. Chapter 2 is the literature review where several pieces of literature about
physicians’ perceptions of EMRs were compared and contrasted to bring validation for
the need for this study. The review included seminal research as well as current articles to
better understand the gaps that currently exist in understanding the phenomenon of this
study.
23
Chapter 2
Literature Review
physicians during the transition with a goal of accelerating acceptance and use of future
EMR replacement systems. Reviewing prior research studies on evaluating family
practice physicians’ perceptions of EMRs including barriers and facilitating factors, were
necessary for understanding the key factors that influence their decisions. Evaluating
what research methods have been used to investigate family practice physician
perceptions of EMRs in an ambulatory setting helped identify key variables or measures
as well as the advantages and disadvantages of each method. Reviewing what central
theories have been used to explain family practice physicians’ perceptions of the EMR in
an ambulatory setting was necessary for understanding what theories already exist, any
relationships between them, and by what means existing theory has been investigated to
identify gaps that exist.
The focus of this chapter was to provide insight into the barriers and challenges
influencing EMR adoption and use and to examine how underlying theoretical models are
used to assess EMR use by family practice physicians. Gaining a better understanding of
providers’ perceptions of the EMR may give information technology implementers and
leadership insights to achieve expeditious adoption, reduce healthcare costs, and to have
24
improved the sharing of medical information. Chapter 1 provided some background
information on the importance of an expeditious adoption rate and some of the challenges
leadership, policymakers, and physicians have had implementing EMRs. It has been
estimated that more than $81 billion in health care costs will be saved annually with the
widespread adoption of health information technology (HIT) (Gee & Newman, 2013).
Yet, there is a lack of consideration on how to best design, implement, and use HIT
(Rippen et al., 2013).
Title Searches, Articles, Research Documents, and Journals
The resources for the literature review were from online databases at the
University of Phoenix and Google Scholar. The databases used were EBSCOhost and
ProQuest with the filtering set to peer-reviewed journals. Approximately 1,014 scholarly
sources were reviewed for this study. The search terms included: family practice
physicians EMR, family practice physicians’ perceptions of EMR, physicians’ perception
of EMR, electronic medical records (EMR), EMR adoption, EMR implementation, EMR
use, health information technology (HIT), qualitative research, case study research,
diffusion of innovation, TAM, UTAUT, and William Bridges’ Transition Model.
The majority of the articles included in the literature review were published
within the last three years; however, not every article reviewed applied to the research
study. Resources were stored and managed in the Mendeley software system. Resources
were also imported into NVivo 12 where nodes were created to help manage and sort
through the data. Nodes that were coded included: purpose, gap, theory, sample, method,
findings, future research, and limitations. Word frequencies were run as well as word
clouds to help identify recurrent themes.
25
Historical Content
Brief History of Early EMR Systems
The study of health information technology, including EMRs, is a fairly new
phenomenon. The earliest reference to an EMR appeared in publications in the 1950s and
the earliest peer-reviewed journals in medical informatics published in the United States
started in 1967 (Collen, 1986). The first definition of medical informatics appeared in the
preliminary announcements for the 1977 Third World Conference on Medical
Informatics in Tokyo where the chairman defined the term as the application of computer
technology to all fields of medicine (Collen, 1986).
The early development and evolution of medical informatics in the United States
were mostly supported by government grants and contracts (Collen, 1986). The first
EMR designed for ambulatory care as an out-of-the-box application was the COSTAR
(Computer Stored Ambulatory Record) system version 5 (Barnett et al., 1982). The
COSTAR system was originally developed in the late 1960s by the Laboratory of
Computer Science at Massachusetts General Hospital (MGH) in collaboration with the
Harvard Community Health Plan (HCHP), a prepaid group practice established in 1969
and located in Boston. The HCHP version of COSTAR, COSTAR 4, is a system that had
been used successfully but customized for the operations of HCHP and therefore not
suitable for other organizations without modifications (Barnett et al., 1982). Barnett et al.
(1982) wrote that the need for computer technology in ambulatory settings is “becoming
acute” (p.8). They also wrote that many practices have started using computer technology
in their practices but it was being used for billing purposes and not for patient care
(Barnett et al., 1982). COSTAR 5 was developed to satisfy the clinical needs Barnett et
26
al. (1982) saw missing in ambulatory care practices.
Implementation of COSTAR 5 included a phased implementation approach
(Barnett, et al., 1982). Some of the implementation issues cited were the lack of
knowledge between the system engineers and the needs of the end-users (Barnett et al.,
1982). The minimal amount of training available to the end-users was another problem
identified in the implementation of COSTAR 5 (Barnett et al., 1982). Barnett et al. (1982)
identified that physicians are specifically attuned to on-the-job training and would benefit
by having a resource person available to answer any questions or solve any issues, and
identified that the cost of the system could be a barrier. Good local leadership is essential
to implementation according to Barrett et al. (1982). The University of Utah Department
of Biophysics and Bioengineering, which was established in 1963, designed and
implemented a hospital-based computer system that utilized medical decision logic, the
HELP system. The HELP system was implemented at the LDS Hospital in Salt Lake
City, Utah which started in 1975 and used a phased-in approach which ended in August
1981 (Pryor et al., 1982). The researchers requested an independent evaluation of the
HELP system and found that overall end users were happy with the system. The most
favorable responses revealed from the evaluation were regarding what the physicians
expected and received from the system, from those who used the system. Some future
recommendations were for upgrades to the HELP system included addition to the medical
decision-making module, increase the speed of the system, and putting the HELP system
in the doctor’s office (Pryor et al., 1982).
The COSTAR 5 and the HELP systems were early EMRs that showed promise
but, yet widespread adoption was aborted even after a phased implementation. These two
27
implementations did provide leadership, policymakers, and system implementers
feedback on what worked well in their implementations and what were some of the
challenges and barriers to adoption. Some of the challenges included lack of at-the-elbow
support, system design, and slow computer speeds. Yet more than thirty years later we
are still discussing some of the same barriers to EMR adoption.
Current Content
Acceptance (Adoption)
Researchers sought to gain a better understanding of the factors affecting
physician acceptance of EHR systems (Steininger & Stiglbauer, 2015). A nationwide
survey of Austrian doctors in private practice was conducted in 2010 with 204 useful
questionnaires returned.
The results of the study revealed that attitude was a significant predictor of use, perceived
usefulness had a significant positive effect on the intention to use as well as attitude
towards the system, and the external factors; social influence, health information
technology experience, and privacy concerns, had a significant positive effect on the
intention to use (Steininger & Stiglbauer, 2015).
The researchers were able to confirm from these results that resident doctors with
experience in similar computer systems found the system useful and beneficial, were
more comfortable about collecting and sharing health data, and were more likely to use
the system as soon as it was implemented. A significant concern of the physicians the
safety and security of the data from third parties with malicious intent (Steininger &
Stiglbauer, 2015). This information will be very important to this study as the participants
have had experience using EHRs in the past and it will be interesting to see if the results
28
are the same. The Austrian residents were on a national EHR system it will be interesting
to see if the results of this study differ or if EHR adoption is contagious among healthcare
providers.
Gan (2015) suggests that EHR adoption is contagious among health care
providers; however, the contagion effect is dependent on the fit between the
characteristics of the system and the health care provider. Gan (2015) uses both task
technology fit (TTF) theory and social contagion theory as a framework for the study. A
survey of 51 Health Organization Management students with practical experience in
health care using EHR systems was conducted. A research model was developed with the
constructs of TTF, social contagion, organizational valence to EHR, and intention to
adopt, and data were analyzed using partial least squares (PLS).
The researcher found a positive association between an organization’s perception
of fit between the EHR system and clinical activities and the organization’s valence
(feeling) towards the EHR system. The organizational valence will be higher when strong
(positive) social contagion (behavior) presents, and the organization's valence toward the
EHR system is positively associated with intention to use the system (Gan, 2015). The
terminology was a little misleading, in health care, a provider is typically a physician,
nurse practitioner, physician assistant, midwife, or certified registered nurse anesthetist,
but in this study, the researcher used students who had experience in health care and with
EHRs; the sample selection would have been more meaningful if actual providers or
organizational leaders participated. Gan (2015) was able to validate the data, but the
results may not be as meaningful as they could have been had physicians been used.
Gagnon et al. (2014) conducted a study to identify the main determinants of
29
physician acceptance of an EHR in Canada. The basis for the theoretical framework was
the Theory of Acceptance Model (TAM). Understanding the limitations of the model and
using recommendations from previous research, the researchers extended TAM to
include computer self-efficacy and demonstrability of the results and integrated that
model into a psychosocial model with constructs from the Theory of Interpersonal
Behavior (TIB) and additional constructs of resistance to change and information about
the change, ending with 4 theoretical models to test behavioral intention to use. The
sample consisted of 150 physicians who were members of the Quebec Medical
Association (QMA) and had valid email addresses on file (Gagnon et al., 2014).
The researchers first conducted descriptive analyses, computed Pearson
correlations between constructs, performed path analysis to test for direct and indirect
effects of both TAM models, and performed a multivariate linear regression (Gagnon et
al., 2014). The findings surmise that TAM explained 44% of the variance in physician’s
intention to use the system, Perceived Usefulness (PU), and Perceived Ease of Use
(PEoU) explained a significant portion of the behavioral Intention to Use (BIU). PEoU,
modified by computer self-efficacy, is a strong and significant determinant of physicians’
intention to use EHR and influenced their PU. Computer self-efficacy was found to have
a significant overall effect on BIU; training physicians on computers would improve their
overall PEoU (Gagnon et al., 2014).
Normative factors were found to be the most important factors in determining
physician use. Professional Norm (PN) was the second determinant of physician’s BIU;
the more physicians associate EHR use as behavior for a physician the more likely they
are to use the system. The third most important determinant was Social Norm (SN) which
30
predicts that EHR acceptance by physicians can be strongly influenced by their peers;
recommending physician champions and super users to increase acceptance (Gagnon et
al., 2014).
Looking at sociodemographic and professional characteristics, researchers found
that PU and SN has a higher effect on BIU for general practitioner under 50 years of age.
Physicians 50 years old and older with no EHR experience, PEoU had more impact on
BIU. PN on BIU is stronger for women and RD has more influence on BIU among
general practitioners. Strategies need to be built for new users based on individual
characteristics such as age and gender (Gagnon et al., 2014). This was a very complex
study that had several constructs and identified many associations to influence BIU. The
factors identified from this study will be useful when trying to adopt a new EHR system
into practice.
The study evidenced the main determinants of physician acceptance of an EHR
system in Canada. Illustrations of determinants of acceptance that need to be considered
when physicians are introduced to an EHR system suggest individual user characteristics
need to be considered. This paper advances the idea that a standard implementation
strategy may not be effective. The approach of this study failed to address longitudinal
acceptance behavior as it was simply a snapshot in time.
Johnson et al. (2014) also used TAM but added two new constructs,
institutionalized use, and developmental pattern to test actual longitudinal acceptance
behavior. Institutionalized use is described as the technology being used as part of the
end user's everyday work; only then can the benefits of technology be realized. The
second construct of the developmental pattern was defined as a way to model the process
31
from the introduction of the innovation to actual institutionalized use. The sample was 44
internal medicine residents working at a hospital ambulatory primary care clinic for 11
months in 2002 where the use of the system was strongly encouraged but not mandatory,
user’s acceptance behavior stabilized after 10 months. Data was collected by several
questionnaire surveys to access the perceptional constructs, Cork’s instrument was used
to assess computer literacy and the general optimism toward the use of information
technology, and IBM Satisfaction Questionnaire was used to assess the satisfaction with
the innovation being tested (Johnson et al., 2014).
The results revealed that when examining developmental trends, light users stayed
at a 33% utilization rate during the 10 months, the medium user started strong at 70 %
and after 10 months were at 33%, and heavy users started at about 50% and finished at
100% by the end of the 10 months. Stepwise regression was applied to the data to test the
hypotheses and found that Perceived usefulness (PU) did not have a significant influence
on usage measures nor did PU nor perceived ease of use (PEoU) correlate with initial use
which is contrary to the TAM findings; however, PEoU had a significant positive impact
on self-reported usage and user satisfaction. The findings extrapolated that computer
knowledge harmed user satisfaction, institutionalized use is positively related to general
enthusiasm about the system where neither PU nor PEoU had an impact on this measure
nor did PU or PEoU impact usage group membership. Johnson et al. (2014) concluded
that the probability of one following a specific developmental trajectory was based on
computer knowledge and computer optimism (Johnson et al., 2014).
Reviewing the antecedents of PU and PEoU, PEoU had a significant positive
influence over PU, computer knowledge (CK) negatively impacts PU, and general
32
optimism is a significant determinant of PU. PEoU has one significant antecedent which
is computer experience and computer experience was found to positively influence PEoU
(Johnson et al., 2014). The findings evidenced that computer knowledge may shed some
light on the shortcomings of computer systems influencing the negative impact of
satisfaction. Contrary to the findings of Gagnon et al. (2014) where PU and PEoU were
factors of BIU; PU and PEoU were not found to be factors influencing actual use.
This longitudinal study clarified user behavior after a period of use. The
information will be helpful in better understanding long term use and the importance of
general optimism in keeping users engaged for a long time. The results of this study are
very important to EHR developers in understanding the users of their products and the
expectations of savvy computer users. One factor not yet explored was the organizational
environment and its impact on EHR adoption.
Sherer et al. (2016) wanted to explain how institutional forces affect EHR
adoption in ambulatory physician practices. Sherer et al. (2016) used the institutional
theory as the theoretical framework for their study. The institutional theory posits that an
institution’s environment is stronger at influencing the development of structures than
market pressure. An institution’s environment consists of the cultural belief system,
normative frameworks, and regulatory frameworks that provide meaning and stability
within their industry. Institutional forces such as mimetic (imitate), normative
(community), and coercive forces (competition and regulation) can influence an
organization's environment (Sherer et al., 2016).
Data was collected from two different surveys, the 2008 Health Tracking Survey
and the 2012 National Electronic Health Records Survey which were sent to practicing
33
physicians asking questions about demographics, practice characteristics, and use of
information technology. Approximately 9,200 total respondents from both surveys were
included in the sample. The decision to adopt was modeled, from knowledge to use, at
the organizational level, in ambulatory practice, and as a function of coercive, normative,
and mimetic forces. Using descriptive statistics, the percentage of adoption doubled
between 2008 and 2012, the ordered logit model results were mixed supporting the 2008
data but did not support the 2012 data for the hypothesis that stated physicians subjected
to higher mimetic forces are more likely to adopt but it did support the hypothesis that
physicians subjected to higher normative forces are likely to adopt EHRs, but the
coercive forces were mixed; supporting Medicare but not supporting Medicaid (Sherer et
al., 2016).
Demographic data was found to influence the decision to adopt, older physicians
and smaller independent practices were less likely to adopt and organizations are more
likely to adopt compared to independent physician groups. The results of this study
confirmed some of the information already known such as the increased adoption rate
and the influence of demographic information on use but capturing the impact of the
HITEC Act of 2009 under coercive forces was a new approach. The varying results
between the two programs are described as having more participants in one program over
the other, plausible, and easily determined. The Medicaid program is directed more
toward the pediatric population and did not implement such a significant penalty for not
meeting the program goals; participation could have been less since participation is
limited to one or the other program but not both (Sherer et al., 2016). Other
organizational forces impacting adoption were the EMR’s impact on patient flow.
34
Bushelle-Edghill et al. (2017) conducted a pre-implementation (one year prior)
time and motion study and a post-implementation study (immediately after and one year
later) to see what changes may have occurred in their pediatric clinic. A total of 2,448
patient visits were collected from all three timeframes, 4 workflow steps were reviewed:
1) check-in to the front desk, 2) check-in to triage, 3) triage to the room and 4) room to
check-out. Time from check-in to front desk decreased after implementation and was
sustained, time from check-in to triage quickly decreased after implementation but
stabilized after a year, the time from triage to room increased significantly from 4.5 mins
to 12.5 mins a year after implementation, room to check out also increased significantly
from 35 mins to 41 min; which is time spent with the provider including shots and check-
out process. The total patient time increased from 56 mins to 81 mins down to 64 mins a
year later. The researchers found that training before implementation and technology
support after implementation will help to realize the benefits of the system (Bushelle-
Edghill et al., 2017).
A common theme found in the EMR acceptance and adoption literature was an
attitude (Gan, 2015; Johnson et al., 2014; Steininger & Stiglbauer, 2015). Bushelle-
Edghill et al. (2017) findings regarding increased time for both patients and providers
may be a contributing factor to the decision to accept and adopt a new EMR system.
Likely, attitude will also be a factor discussed by the physicians in the study. The
discussions may provide more insights for developers, system implementors, and
organizations for future implementations or system optimizations.
Expanding on the findings of Bushelle-Edghill et al. (2017), Nambisan (2014)
examined the impact of peer support and online forums for EMR adoptions. Social
35
contagion and social cohesion theory were used as the theoretical framework. Social
contagion states that when people encounter others who have adopted a particular
innovation there will be a tendency to adopt. Social cohesion theory describes the social
interaction between an adopter and a laggard and if empathic conversations transpire the
laggard will likely adopt the innovation.
Nambisan (2014) collected data from survey questionnaires of 153 respondents.
Questionnaires were sent to members of local physician associations, national-level
healthcare professional associations, local networks, and online physician forums;
Medical Group Management Association (MGMA) supplied most of the responses. The
demographics of the respondents are 108 practices adopted EMR and 45 practices had
not, 63 respondents were from small practices, 77 from medium practices, and 11 from
large groups. The majority of the respondents, 81.9 %, were from primary care providers
(Nambisan, 2014).
Using regression analysis to test the study’s hypothesis, all 5 hypotheses were
supported. The first hypothesis stated that opportunities to interact with other physicians
or office-based practice owners regarding EMR selection had a positive impact on
adoption. The second hypothesis stated that participating in online forums that supported
peer-level interaction about the EMR was positively related to adoption. The third
hypothesis stated that peer support from physicians within your specialty regarding the
selection of EMR or a vendor can positively influence EMR adoption. The fourth
hypothesis stated that peer support was more influential in EMR adoption than financial
incentives. Finally, the fifth hypothesis stated that economic penalties will have more of
an impact on the adoption that incentives (Nambisan, 2014).
36
Nambisan’s (2014) findings are like those of Sherer et al. (2016) who found that
financial penalties have a positive impact on EMR adoption. In addition, Bushelle-
Edghill et al. (2017) found that support after implementation will help with efficiencies.
The HITECH Act of 2009 has spent millions of dollars in incentives to increase the
adoption rate and the data from these two studies revealed that penalties were the most
important driver. However, this approach may be problematic in areas of the country
where broadband is limited.
Whitacre and Williams (2015) investigated the link between broadband
availability and EMR adoption in Oklahoma. Data were used from a survey conducted by
SK&A Office-based Providers Database in 2011. There were 2,743 physician office
respondents. The survey asked questions about the type of practice, the number of
physicians, patient volume, type of providers, whether Medicare and Medicaid were
accepted, whether they are affiliated with a health system, whether they were owned by a
hospital, whether they had an EMR and if so what features were they using, and the
location was based on the street level address (Whitacre & Williams, 2015).
The research findings reviled that rural practices were typically primary care, solo
practices, low patient volumes, and were staffed by non-physician providers. When
comparing urban to rural practice EMR adoption rates, Whitacre and Williams (2015)
found that rural practices had a significantly higher adoption rate especially in obstetrics
and gynecology, solo physicians, psychiatry, and low patient volume, and where
Medicare was not accepted. However, ophthalmology practices and practices owned by a
hospital had a higher urban adoption rate (Whitacre & Williams, 2015). After the
researchers analyzed the characteristics of the practices, they started analyzing the
37
availability of broadband access.
Whitacre and Williams (2015) used the National Broadband Map (NBM) from
2010 and compared that to the addresses of all the practices to see the number of
broadband providers as well as upload and download speeds (Whitacre & Williams,
2015). The findings exposed that urban areas did have greater download speeds, only two
rural practices were shown to not have broadband available, adoption rates seemed higher
for areas with many broadband providers available; however, the greatest adoption rates
were found in areas that had the slowest upload and download speeds. Whitacre and
Williams (2015) then used regression analysis to identify the characteristics that most
influenced adoption in urban areas. They found that obstetrics/gynecology, psychiatry,
and solo practices are less likely to adopt EMRs in urban areas. They also found that
large practices with a larger number of physicians increased the odds of adoption, as well
as higher patient volume, the acceptance of Medicare, an affiliation with a health
network, hospital ownership, employing a DO, and employing non-physician providers;
however, these relationships did not show significant differences between urban and rural
practices (Whitacre & Williams, 2015).
Broadband availability did not show to be a determinant of EMR adoption. The
researchers could not find a relationship between practice level EMR adoption and
broadband availability (Whitacre & Williams, 2015). Whitacre and Williams (2015)
suggested that future efforts to increase EMR adoption should focus on targeting specific
categories of physicians as they found obstetrics and gynecology to be low EMR adopters
in urban areas ). Identification of characteristics of EMR adaptors and new research on
the impact of broadband availability expanded the literature on EMR adoption. Though
38
this study was to be conducted in an urban setting, wireless connectivity was found to be
an issue with some of the physicians.
Use
Raymond et al. (2015) conducted a study to understand the factors that lead to
greater performance outcomes from EMR systems in primary care. A research model was
developed and tested based on the concept of extended EMR use. Extended use of an
EMR system by family practice physicians was found to improve performance benefits.
Performance benefits include quality of care, efficiencies, operational performance,
economic performance, and social performance (Raymond et al., 2015). Raymond et al
(2015) also found increased physicians’ satisfaction with the EMR system lead to
increased performance benefits for the physicians and the practice. The study also found,
when physicians find the EMR system easy to use they are usually satisfied with the
system, and physicians will use the EMR system when more useful features are offered.
A finding that was not as strong as the previous findings were that physicians use the
EMR system more extensively when they perceive use to be free of effort. What could
not be confirmed was the association between EMR use and user satisfaction (Raymond
et al., 2015).
Stein et al. (2015) examined the role of emotions had a role in how Information
technology (IT) use patterns emerged. The study also found that affective responses from
IT stimulus can be categorized into four classes; 1) loss emotions (anger, frustration), 2)
achievement emotions (satisfaction, pleasure), 3) deterrence emotions (worry, fear), and
4) challenge emotions (excitement). In addition, Stein et al. (2015) defined five different
types of affective characteristics (cues): 1) IT instrumentation, 2) interactions with others,
39
3) involvement in change, 4)) identity work, and 5) IT symbolism. Five patterns of use
were also identified: 1) exercising discretion, 2) being a good citizen, 3) gaming the
system, 4) personalizing, and 5) opting out.
Stein et al. (2015) concluded that users respond emotionally to cues present in an
IT stimulus event. The type of response depends on the nature and content of the cues
and their interactions. People respond to their emotions with either clear adaptation
strategies or vacillating strategies (Stein et al., 2015). These coping behaviors and
strategies are reflected in IT use patterns. Tracing use patterns back to responses and cues
to prompt emotions allows researchers to better understand how and why users make
their IT choice (Stein et al., 2015). Adding to the literature, the current study included
William Bridges’ transition Model to gain more in-depth insights into the emotional
response of the participants and how they are managed during the EMR transition
process. A better understanding of emotional responses will provide organizations more
information to better prepare users for the change.
Challenges
Paré et al. (2014) conducted a Delphi study to see why so many primary medical
care practices in Canada had not adopted an EMR system. The study surveyed 431
physicians without an EMR system and asked them to mark why their practice had not
yet implemented an EMR system. Paré et al. (2014) learned that barriers were both
intrinsic (behavioral and knowledge-based) and extrinsic (economic and technological-
based). Paré et al. (2014) called for more research given their study’s findings that many
medical practices faced no barriers to adoption while others differed greatly as to types of
barriers. A limitation of the study was the potential of survey bias from relying on
40
perceptions of a single-family practice physician to characterize the medical practice
(Paré et al., 2014). The findings of Pare et al. (2014) are similar to Whitacre and Williams
(2015) where technology was found to be a challenge to EMR adoption and use.
An Andalusian case study using statistical descriptive analysis of results from an
online survey of 705 physicians who worked in clinics, found three common barriers to
adoption: lack of financing, physician’s lack of computer skills, and security issues for
telemedicine. A limitation of this study and internet-based surveys is the possibility of
underrepresentation of those who are not using an EMR system (Villalba-Mora et al.,
2015). The Andalusian health system is a public integrated system managed and
governed by the Andalusian Public Health System (SSPA). Andalusia is located in
Southern Spain and accounts for 17.8% of the Spanish population or about 8 million
citizens. The SSPA has made the integration of HIT a priority and part of the Andalusian
health policy since its foundation in 2000 (Villalba-Mora et al., 2015).
The SSPA managed the implementation of Diraya in primary and specialty care
practices which included EHR, electronic prescribing, and appointments made to a call
center or online. This program started in 2004 and covered more than 94% of the
population by January 2010. The stability of the Andalusian governmental leadership of
some 30 years provided a strong commitment to a policy allowing for the reorganization
of services and new governance mechanisms to continue funding these programs’
infrastructure (Villalba-Mora et al., 2015). This study is a perfect example of the
complexities involved in the adoption of HIT. The health system had the support of their
governmental constituents for policies and funding and still encountered barriers to
adoption.
41
Drivers/Facilitators
Jacobs et al. (2015) examined the innovation implementation framework among
physicians using structural equation modeling. The framework postulates that the
consistency and quality of innovation use is a result of organizational implementation
policies and practices (IPP) and individual climate perceptions. Jacobs et al. (2015) found
that ensuring physicians feel supported and perceive they are getting what they need to
effectively implement innovation is more important than having a certain number of staff
available. The findings of Jacobs et al. (2015) are similar to Gagnon et al. (2014) where
the need for the physicians to feel supported was identified and the use of physician
champions was a recommendation to support the need.
Ayanso et al. (2015) examined physicians’ intentions to continue using the EMR
in the post-adoption phase within the framework of expectation-confirmation theory
(ECT) incorporating perceived risk to the model. A field survey of 135 Canadian
physicians who use EMR systems was used to test their hypothesis. Ayanso et al. (2015)
found that physicians are willing to change and adapt to new ways of practicing as long
as the change creates better outcomes for the patients; however, perceived risks reduce
the physician's willingness to continue using or adopting extended features of the system.
McAlearney et al. (2015) saught to improve understanding of the facilitators of
EHR system implementation, focusing on the opportunities to maximize physician
adoption and effective implementation. The frameworks used for this study were Kubler-
Ross’s five stages of grief model and Kotter’s eight-step change management. Data was
collected using interviews and focus groups consisting of 47 physicians and 35
administrative key informants from six U.S. health care organizations. Ten EHR
42
deployment strategies were identified based on the participants’ recommendations: 1)
manage expectations, 2) focus on quality, 3) recruit champions, 4) communicate, 5)
acknowledge the painful transition, 6) provide good training, 7) improve functionality, 8)
acknowledge competing priorities, 9) allow time to adapt to the new system, and 10)
promote a better future (Ann Scheck McAlearney et al., 2015). McAlearney et al. (2015)
used a model to address the emotional experience of EMR implementations as did Stein
et al. (2015) indicating that the emotional implications of the change may have more
impact than what was originally thought.
Research on EMR adoption has provided a better understanding of the
drivers/facilitators for EMR adoption from the physicians faced with the change.
Understanding ways to reduce the stress and anxiety felt by some providers may help
future implementation strategists appeal to the needs of the physicians. The findings from
these studies shed more light on the needs of physicians and how to facilitate the
maximization of physician adoption. The methods used were both qualitative and
quantitative providing a deeper understanding of the physicians' needs.
Barrier
Arndt et al. (2017) conducted a study to assess the amount of time primary care
physicians spent documenting in the EHR both during hours and after hours using system
event logs. The study was a retrospective cohort study of 142 family practice physicians
using the same EMR system for three years. Arndt et al. (2017) found that clinicians
spend 5.9 hours of an 11.4-hour workday in the EHR per 1.0 full-time equivalent, 4.5
hours during clinic hours, and 1.4 hours after clinic hours. Bushelle-Edghill et al. (2017)
had similar results to Arndt et al. (2017) where the amount of time to complete a patient
43
encounter and document the visit post-EMR increased for the providers instead of
decreasing which may contribute to physician burnout.
Shanafelt et al. (2016) evaluated the association between the electronic
environment, clerical burnout, and burnout in US physicians. Physicians across all
specialties throughout the US were surveyed between August and October 2014.
Physicians who used the EHR and computerized physician order entry (CPOE) had low
EHR satisfaction, were less satisfied with the amount of time spent on clerical tasks, and
were at a higher risk of burnout (Bushelle-Edghill et al., 2017; Arndt et al. 2017 ). More
research is needed to learn if the associations observed were causal (Shanafelt et al.,
2016)
Physician Perceptions
Jamoom et al. (2014) compared perspectives of physicians who have and have not
adopted EHRs focusing on three areas: the experienced or expected impact of EHRs on
clinical care, practice efficiency, and operations; barriers to adoption; and the influence of
major policy initiatives that seek to increase EHR adoption. Data was collected from the
2011 National Ambulatory Medical Care Survey (NAMCS) and the NAMCS Physician
Workflow Survey (PWS). The researchers used a quantitative, multivariate logistic
regression model to analyze the data.
The results of the study revealed that a large portion of physicians, regardless of
their adoption status, felt that EHRs had positive impacts on clinical care, practice
efficiency, and finances; cost and loss in productivity were major barriers; and physicians
cite financial penalties and sharing information via health information exchanges (HIE)
as top factors that would influence adoption (Jamoom et al., 2014). The results of the
44
Jamoom et al. (2014) study disagree with the productivity findings of Bushelle-Edghill et
al. (2017) and Arndt et al. (2017) and the coercive forces of penalties found in the Sherer
et al. (2016) study.
Leadership
Transformational leadership uses intellectual stimulation and inspirational
motivation to increase the use of new system features and reduce legacy system habits
(Venkatesh et al., 2016). Two other characteristics of transformational leadership include
charisma, and individualized consideration (Yurov & Potter, 2006). Transformational
leadership was added to the UTAUT model to try to mitigate old habits from the legacy
EMR system which may hinder the learning and use of the new EMR system (Venkatesh
et al., 2016). Venkatesh et al. (2016) posit that transformational leadership positively
affects the learning curve slope.
Yurov and Potter (2006) included leadership in technology acceptance models
specifically in post-adoption technology use. They found that employees are more
motivated to contribute information about a new computer system features if the manager
offers challenging tasks about learning new technology features. Transformational
leadership is a leadership model that works best in post computer implementation and
within the UTAUT framework. This is important to this study as the UTAUT framework
will be used for this study.
Theoretical Framework Literature
Technology Acceptance Model (TAM)
The Technology and Acceptance Model was first introduced in1986 as a doctoral
dissertation by Fred Davis, a student at Massachusetts Institute of Technology (MIT).
45
The theoretical framework for the model was based on the Theory of Reasoned Action
(TRA), an intention model that has been successful in predicting and explaining behavior
over a variety of different settings (Davis et al., 1989). TAM uses TRA to find linkages
between two constructs: perceived usefulness and perceived ease of use and users’
attitudes, intentions, and actual computer adoption behavior. According to TRA, the
performance of a particular behavior is determined by behavioral intention which is
influenced by a person’s attitude and subjective norms about the particular behavior
(Davis et al., 1989). TAM is an adaptation of TRA used to model user acceptance of
information systems (Davis et al., 1989).
TAM posits that perceived usefulness and perceived ease of use are primary
determinants for acceptance and use behaviors for computer systems. Perceived
usefulness is one’s subjective probability that using the computer system will increase
their job performance. Perceived ease of use is the degree to which the prospective user
expects the computer system to be free of effort (Davis et al., 1989). The main purpose
of TAM is to have a mechanism to trace the impacts of external factors on internal
beliefs. Computer use can be predicted based on one’s intentions, perceived usefulness is
a major determinant of use intention, and perceived ease of use is a secondary
determinant of use intention (Davis et al., 1989).
This information is useful in predicting, explaining, and increasing user
acceptance of computer technology (Davis et al., 1989). One of the limitations of TAM is
that user data are self-reported (Davis et al., 1989). Another limitation is the model’s
inability to factor in external variables and barriers to adoption (Yarbrough & Smith,
2007). Understand physician perceptions of usefulness and ease of use are important
46
factors but so are the barriers and external factors that have made adoption and use such a
complex phenomenon. These limitations are the reasons this model was not a good fit for
this study on its own as barriers were a focus for this study.
Unified Theory of Acceptance and Use of Technology (UTAUT)
The Unified Theory of Acceptance and Use of Technology (UTAUT) model is a
useful tool for management to assess the likelihood of a successful introduction of new
technology by providing insights into the drivers of acceptance and use. The UTAUT
model was developed in 2003 by conducting a meta-analysis of eight prior technology
acceptance models which include: the theory of reasoned action (TRA), technology
acceptance model (TAM), the motivational model (MM), the theory of planned behavior
(TPB), a model combining the technology acceptance model (TAM) and theory of
planned behavior (TPB), the model of PC utilization, the diffusion of innovation theory
(DOI), and the social cognition theory (SCT) (Venkatesh et al., 2003). The constructs
derived from the consolidation of the various models include Performance Expectancy
(PE), Effort Expectancy (EE), Social Influence (SI), Facilitating Conditions (FC),
Behavioral Intention (BI), and Use Behavior (UB). The model included these moderating
factors: gender, age, experience, and voluntariness of use. The UTAUT model can
explain 70 percent of the variance in intention to use new technology (Venkatesh et al.,
2003).
Venkatesh et al. (2003) confirmed that there are three direct determinants of
intention to use (Behavioral Intention) performance expectancy, effort expectancy, and
social influence. Performance Expectancy was found to be the strongest predictor of
intention and is significant in both voluntary and mandatory settings. Effort Expectancy
47
was also found to be a significant predictor of intention in both voluntary and mandatory
settings but becoming less significant with increased and sustained use. Social Influence
was not found to be significant in voluntary settings but was significant in mandatory
settings due to compliance expectations, significance attenuates with sustained use
(Venkatesh et al., 2003).
Two direct determinants of usage behavior (Use Behavior); intention to use
(Behavioral Intention) and facilitating conditions were found. Facilitating Conditions are
predictive of intention only in the absence of Effort Expectancy. The moderating
influences of age, gender, experience, and voluntariness were significant and essential
features of the UTAUT model (Venkatesh et al., 2003).
The results from testing the UTAUT model highlighted the significance of
moderating factors. The findings supported the researchers’ hypothesis that gender and
age moderate performance expectancy on behavioral intention, stronger for men and even
more so for younger men. Another hypothesis supported was that age, gender, and
experience moderate the influence of effort expectancy on behavioral intention; stronger
for women, more so younger women, and happening in the early stages of the experience.
The final moderating hypothesis was that gender, age, voluntariness, and experience were
found to moderate social influence on behavioral intention; stronger for women,
specifically older women in mandatory settings in the early stages of the experience
(Venkatesh et al., 2003). Moderating factors have been shown to have a significant role
in the UTAUT model.
Facilitating conditions are individual users’ beliefs that organizational and
technical infrastructures are in place to support use. The researchers’ hypothesis that
48
facilitating conditions do not have a significate influence on behavioral intention was
supported. The researchers did find that when predicting usage behavior, both behavioral
intention and facilitating conditions were significant, where facilitating conditions were
more important to older users especially with increased use. No significant influence on
behavioral intention was found regarding self-efficacy, computer anxiety, or attitude
toward using technology; however, the behavioral intention was found to have a
significant positive influence on computer usage (Venkatesh et al., 2003). Additional
research helped identify constructs that can add to the prediction of use behavior
(Venkatesh et al., 2003).
Venkatesh et al., (2008) expanded the original UTAUT model (Venkatesh et al.,
2003) to include an additional construct, behavior expectation, and to expand user-
behavior to include three conceptualizations: duration, frequency, and intensity. The
expansion was necessary as there were three known limitations of the behavioral
intention construct: behavioral intention addresses internal personal factors and not
external factors, behavioral intention is unable to predict and explain unforeseen events
that happen between the time the intention is decided and when it is acted upon, and
lastly, behavioral intention is unable to predict behaviors that are not within the
individual's control (Venkatesh et al., 2008). Facilitating conditions have also been found
to have limitations.
Facilitating conditions is a construct used to identify how an individual perceives
their control over a behavior; more generally, their perception of the availability of
resources to mitigate barriers to use. Facilitating conditions can only predict behaviors
when information is complete and certain, facilitating conditions are not a good predictor
49
of behavior when presented with ambiguous or incomplete information (Venkatesh et al.,
2008). Behavioral expectation is a new construct used to combat these limitations.
Behavioral expectation is the subjective probability of behaving based on one’s
cognitive appraisal of behavioral determinants such as behavioral intention and
facilitating factors (Maruping et al., 2017). Behavioral intention is driven by internal
factors and motivation whereas behavioral expectation is driven by external factors,
making it a better predictor of use under conditions of uncertainty. Behavioral intention
was found to be a better predictor of the duration of system use and behavioral
expectation is a better predictor of system frequency and intensity (Maruping et al.,
2017). Venkatesh et al. (2008) found these differences between behavioral intention and
behavioral expectation: behavioral intention was positively influenced by behavioral
expectation, behavioral intention is a better predictor of duration after some time, they
also found that behavioral expectation is better at predicting frequency and intensity of
system use, behavioral intention to use a system increases the more the system is used but
the opposite will happen with behavioral expectation, behavioral expectation had a
significant direct effect on use while facilitating conditions had a significant direct effect
on behavioral expectation, and finally they found that facilitating conditions on
behavioral expectation is moderated by age, gender and experience and would be
stronger on older women who have system experience (Venkatesh et al., 2008). These
additions to the original UTAUT model have made it better at predicting use under
conditions of uncertainty and the ideal tool for this research.
Additional constructs added to the UTAUT model include perceived security, in
the context of home health robots, which were found to have a direct association with
50
behavioral intention, and cultural differences (Alaiad et al., 2014; Lin, 2014, 2017;
Venkatesh & Zhang, 2010). These were found to have a significant influence on
behavioral intention, education level, and academic discipline. Which were moderating
factors that affected behavioral intention and use behavior (Awwad & Al-Majali, 2015).
A longitudinal study was conducted and showed how time and experience influenced the
user's perceptions and behavioral intentions and use (Abualbasal et al., 2016). A
limitation to all of these studies is that the UTAUT model was not replicated in its
entirety, not using constructs and moderating factors from the original model an issue
with many current and past studies (Venkatesh & Zhang, 2010). Overall the UTAUT
model was found to be simple, accurate, and robust at predicting acceptance and use of
technology (Khechine et al., 2016).
William Bridges’ Transition Model
Bridges and Bridges (2016) defined change as situational and transition as
psychological. Transition is a three-phase process people go through when they come to
terms with the details of the new situation that the change brings. Getting people through
change is essential if a change is to work as planned. Transitioning involves three phases:
letting go, the neutral zone, and the new beginning. Bridges and Bridges (2016) states
that because the transition is a process it could be said that transition begins with an
ending and ends with a beginning. Failure to get ready for endings is the largest difficulty
for people in transition.
Transitioning is letting go of something; the next step is understanding what
happens after letting go, the transitioning limbo. The gap between the old and new is
where innovation is most possible and the organization can be most revitalized (Bridges
51
& Bridges, 2016). One of the important roles for leadership during this time is to
articulate what needs to be left behind. The task is twofold; first, get your people through
the transition phase in one piece and then encourage them to be innovative (Bridges &
Bridges, 2016).
Methodology Literature
The purpose of the research is to answer questions and gain new knowledge
(Marczyk et al., 2005). Research can be used to describe, explain, and predict which
make important and valuable contributions to knowledge and how we live our lives
(Marczyk et al., 2005). A researcher’s decision on which method to select should be
based on decisions about why, where, the concerns, and from what perspective (Schram,
2006). The form of the research question determines the appropriate research method to
use (Yin, 2014). There are three research methodologies: qualitative, quantitative, and
mixed methods.
Qualitative Research
The goal of qualitative research is to create concepts that assist in the
understanding of a social phenomenon in a natural setting while focusing on the meaning,
experiences, and views of the participants of the study (Al-Busaidi, 2008). Shank (2006)
defined qualitative research as a form of systematic empirical inquiry into meaning.
Systematic describes the research as planned, ordered, and public. An empirical inquiry is
an inquiry-based on the world of experience. Inquiry into meaning is the development of
a complex picture into the phenomenon or situation using rich, deep, thick, textured,
insightful, and illuminative descriptions of meaning (Shank, 2006).
Qualitative research can be used to obtain specific details about a phenomenon
52
such as feelings, thought processes, and emotions which are hard to obtain through
quantitative research (Strauss & Corbin, 1998). Qualitative research data refers to
people’s lives, lived experiences, behaviors, emotions, feelings, organizational
functioning, social movements, cultural phenomenon, or international interactions. Some
of the data can be quantified such as census data or background information but most of
the analysis is interpretive. The most common qualitative research tools for data
collection include interviews, observations, and analysis of documents (Al-Busaidi,
2008).
Qualitative research does not require variables or causal models, observations and
measurements are not based on random assignment to experimental groups, and
qualitative research does not generate hard evidence like quantitative research (Denzin &
Lincoln, 2008). Qualitative research is a type of research that produces findings without
using statistical procedures or other quantification (Strauss & Corbin, 1998). There are
many reasons to conduct qualitative research such as preference or experience, but the
most valid reason is the nature of the research problem (Strauss & Corbin, 1998).
Quantitative Research
Qualitative research seeks to answer questions on how social experience is
created and given meaning, whereas quantitative research emphasizes the measurement
and analysis of causal relationships between variables. Quantitative researchers are
unable to capture their subject’s perceptions because they rely on more inferential
empirical data methods such as surveys (Schram, 2006). Quantitative researchers report
findings in terms of complex statistical measures or methods such as path, regression, and
log-linear analysis (Denzin & Lincoln, 2008).
53
Quantitative researchers are not interested in rich descriptions because that would
hinder the ability to make generalizations (Denzin & Lincoln, 2008). Quantitative
researchers abstract from the world on an etic science based on probabilities from many
randomly selected cases. Qualitative research is inductive and depends on a purposeful
sampling of participants. Qualitative research is action research that uses observation and
interview methods (Al-Busaidi, 2008). The blending of qualitative and quantitative
methods gives rise to a third method, mixed methods.
Mixed Methods Research
Mixed methods research is defined as a class of research where the researcher
mixes or combines quantitative and qualitative research techniques, methods, approaches,
concepts, or language in a single study to minimize the limitations inherent in each
method (Johnson & Onwuegbuzie, 2004). An important principle of mixed methods
research is that the researcher creates designs that answer the research question instead of
selecting a standard design based on the research question (Johnson & Onwuegbuzie,
2004). Johnson and Onwuegbuzie (2004) recommend using contingency theory when
applying a mixed-methods approach to a study. Contingency theory is the preferable
theory under quantitative, qualitative, and mixed methods approach as it is the
researcher’s responsibility to examine the contingencies and make decisions about the
approach design (Johnson & Onwuegbuzie, 2004).
Research Design
Research design is a logical plan or blueprint of the research study starting with
the research question and ending with conclusions about the questions (Yin, 2014). Yin
(2014) identifies 5 components of a research design: 1) the research question, 2) the
54
research proposition, 3) the units of analysis, 4) the logical linking of the data to the
propositions, and 5) the criteria for interpreting the findings. Schram (2006) stated that
the research design selection process should be based on the researcher’s belief of which
option would best address the research problem, the research question, and the purpose of
the study. Schram (2006) recommended that the decisions about why, where, around
what concerns, and from what perspective the researcher will be conducting the study
should be considered. Ways of looking include observing, asking, and examining what
others have done are similar among the different qualitative designs but ways of seeing
which include underlying intent, guiding concerns, focus, and perspective are not so
similar (Schram, 2006). Several research designs were considered for this study.
Phenomenology
Phenomenology investigates the meaning of the lived experience of a small group
of people related to a phenomenon. Phenomenological researchers focus on what
inexperience means for the person who had lived the experience and provide a
comprehensive description of that experience. Phenomenologist collects data through
long in-depth interviews and critical self -reflection of the researchers. Phenomenology
research does not build theory but offers insights into the world of the study participants
(Schram, 2006).
Grounded Theory
Grounded theory proposes a methodological stance and a set of tools designed to
develop a theory based on the study of social situations rather than being an actual theory.
A distinguishing factor of grounded theory is the specific analytic strategies, not the data
collection methods. Grounded theorists begin analysis as soon as there is data and start
55
coding and theorizing based on the data collected, making this a fluid process as more
data is collected the theorizing made go in a different direction. Most grounded theory
research relies on fieldwork primarily interviewing to generate data that is used to
analyze human behavior and social interactions (Schram, 2006).
Research questions in grounded theory are directed towards an understanding of
how a process or change over time influences participant's perceptions (Schram, 2006).
Grounded theorists regard their theories as qualifiable, modifiable, and open to
negotiation. Grounded theorists ground their theories in data and validate the statements
of the relationship between concepts during the research process. The purpose is to create
new and theoretically expressed understandings and to also ground that theory and data
where theory and data are interpreted in a systematic way (Strauss & Corbin, 1998). The
aim of this study was not to build theory but to understand how family practice
physicians decide to accept and use a replacement EMR system to better prepare for
future EMR changes, so grounded theory would not be an appropriate research design for
this study.
Ethnographic Research
Ethnography was derived from anthropology and qualitative sociology. Culture is
the central concept for ethnographic research design where the interactions and actions of
the group create their social norms. Ethnographers typically study groups, communities,
and organizations by immersing themselves in this setting and using different data
collection methods (Marshall & Rossman, 2011). This research study did not look at the
culture of an organization but the lived experiences of those within the organization;
therefore, ethnography was not an appropriate research design for the study.
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Case Study
A qualitative case study research design is a focused holistic (global) description
and analysis of a bounded phenomenon such as a person, a process, or a social unit
(Merriam, 1998a). A case study design allows the researcher to study a case while
retaining a holistic and real-world perspective (Yin, 2014). A case study design is also
used to gain an in-depth understanding of a situation and meaning to those involved in
the situation. The interest is in the process, context, and discovery of the situation
(Merriam, 1998b).
The scope of a case study research was an empirical inquiry with an in-depth
investigation of a contemporary phenomenon within its real-world context especially
when the boundaries between the phenomenon and context may not obvious (Yin, 2014).
Case study research should be used when how or why explanatory research questions are
asked, the researcher has no control over the behavioral events, and the focus of the study
is on a This study used a qualitative research method to gain a more in-depth
understanding of the phenomena under investigation. Transitioning EMR systems is
becoming more common in the health care industry and comes with its own set of
challenges and barriers. The goal of this study was to understand the decision- making
process of family practice physicians to accept and use a replacement system, the
challenges and barriers physicians faced, and the emotional impact of this change may
help health care leaders and policymakers better understand some of the potential drivers
and challenges of EMR acceptance and use when transitioning or upgrading EMR
systems.
The results of this qualitative instrumental case study will not be generalizable to
57
a larger population but could be generalizable to an organization with similar
characteristics to this case. This study looked at the decision-making process of accepting
and using a replacement EMR system from the family practice physicians’ perspective.
In-depth interviews provided thick descriptions of the physician’s experience, what they
were thinking, and how they were feeling. The qualitative method was the most
appropriate method to answer the research questions posed in this study.
Some limitations of qualitative research include the lack of generalizability. The
research findings are so in-depth they refer to the specific participant population.
Subjectivity is another limitation of qualitative research where the researcher has some
influence on the findings of the study. Bias can be reduced but never eliminated because
of the nature of qualitative research. Bias is made explicit in qualitative research designs
(Watkins & Gioia, 2015).contemporary as opposed to a historical event (Yin, 2014).
Baxter and Jack (2008) stated that when considering how to define the case one needs to
consider the research question. Baxter and Jack (2008) also stated that questions need to
be answered by the researcher to determine the case; what do I want to analyze: an
individual, a program, a process, or the differences between organizations?
Merriam (1998) characterizes qualitative case studies as particularistic,
descriptive, and heuristic. Particularistic because case studies focus on a particular event,
situation, program, or phenomenon. Descriptive because the result of the study is a thick
description of the phenomenon under study. Heuristic because case studies shed light on
the reader’s understanding of the phenomenon under study (Merriam, 1998b). The
decision to use a case study design depends on what the researcher wants to know.
Conclusion
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The literature was able to identify the factors that influenced adoption as well as
the barriers and challenges since the first EMR implementations. Many of the same issues
that were encountered with the implementation of the COSTER5 (Barnett et al., 1982)
and the HELP (Pryor et al., 1982) have continued and are still issues today. There has
also been much learned about factors influencing adoption and use. What was not present
in the literature were the answers to this study’s research questions. The fact that a single
solution has not yet been identified for EMR acceptance and use emphasizes the
complexities of such an endeavor.
Chapter Summary
Several research methods and designs have been used to try to approach the issue
from multiple angles. Surveys have been used to investigate factors influencing EMR
adoption (Steininger & Stiglbauer, 2015; Sherer et al., 2016; Shanafelt et al., 2016;
Jamoom, Paterl, Furukawa, & King, 2014) or test theoretical frameworks (Gan, 2015).
TAM is a theoretical framework that has been used by several researchers (Gagnon et al.,
2014; Johnson, Zheng, & Padman, 2014) and UTAUT has many of the same factors as
TAM. Many of the studies found in the literature are of quantitative methodology so
conducting a qualitative study will add knowledge to the literature.
Chapter 3 discusses the research method and design. Discussions about the
appropriateness of the method and design, the research question, the population, and the
sample are included. The recruitment and informed consent process is outlined.
Confidentiality, geographical location, instrumentation, and field testing are discussed.
Steps to achieve trustworthiness are outlined including transferability, credibility, and
confirmation, and dependability. Acknowledgment of the researcher’s bias, data
59
collection, and data analysis are also discussed.
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Chapter 3
Research Methodology
EMR replacement systems. This study took place in an ambulatory care setting in a large
healthcare system in northeast Indiana to explore factors family practice physicians
believe to be drivers and challenges of acceptance and use when transitioning EMR
systems. In-depth interviews, participant observation, and archival documents were used
to help understand family practice physicians’ decision-making process to accept and use
a replacement EMR system. The results of the study may be useful in understanding the
complexities of family practice physician's acceptance and use of EMR systems and to
potentially expedite the adoption of future upgrades or EMR system changes.
Chapter 3 contains a detailed discussion on method, design, appropriateness of
design, research question, population, sampling, informed consent, confidentiality,
geographic location, personal bias, data collection, instrumentation, data analysis,
trustworthiness, and summary to help explore how family practice physicians perceive
the use of EMRs. Method and design appropriateness were discussed as well as the
population and sample for the participants of the study. Data collection procedures and
rationale for those procedures are also discussed. Field testing of the interview questions
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was addressed in this chapter. The data from the study was then explored and examined
in Chapter 4.
Research Method and Design Appropriateness
Researchers have three research methods to choose from that will best fit the
goals and objectives of their research study qualitative, quantitative, or mixed methods.
The focus of qualitative studies is on the process, meaning, and understanding which
produces data that is richly descriptive (Merriam, 1998). The focus of quantitative
research is to find closure of a particular issue, be able to replicate and reconfirm findings
to have certainty, use data to explain, predict, or control outcomes, and refute competing
explanations of research findings (Schram, 2006). Mixed methods research design is a
combination of both qualitative and quantitative methods. This research study used a
qualitative research framework that was appropriate for the study goal of understanding
how family practice physicians decide to accept and use a replacement EMR system to be
better prepared for future transitions.
Schram (2006) recommended that the decisions about why, where, around what
concerns, and from what perspective the researcher will be conducting the study should
be considered. Qualitative studies look for an in-depth inquiry to understand the
phenomenon of interest from the participant's perspectives, emic (Merriam, 1998). Ways
of looking include observing, asking, and examining what others have done are similar
among the different qualitative designs but ways of seeing which include underlying
intent, guiding concerns, focus, and perspective are not so similar (Schram, 2006).
Several research designs were considered for this study, but a qualitative instrumental
case study seemed to be the perfect fit.
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An instrumental case study is a descriptive tool that was used to explore the
decision-making process of family practice physicians to accept and use a replacement
EMR system. This research study also focused on a single case to learn as much as
possible about the participants overcoming barriers and challenges related to transitioning
between EMR systems within a specific multi-specialty group practice in Northeastern
Indiana. Also, the psychological impact of transitioning EMR systems was explored to
better understand some of the decision-making processes described by the participants.
When looking at other qualitative research designs, an instrumental case study
was the best fit for the purpose of this research study. Phenomenology is used when the
researcher aims to provide meaning that is fundamental to the experience (Schram, 2006),
which was not the purpose of this study. Grounded theory aims to develop a theory that is
derived from and grounded in data or to expand upon or modify existing theory (Schram,
2006), not the purpose of this study. Ethnography studies human groups to understand
how they work together to create a culture (Marshall & Rossman, 2011), not the purpose
of this study.
Research Questions
The central question was:
Q1: How did family practice physicians form their decision to accept and use a
Two sub-questions used to explore additional factors inherent in transitioning between
EMR systems:
S1: How did family practice physicians overcome barriers and challenges
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S2: How did family practice physicians feel emotionally during the transition?
Population and Sample
Population
The population is defined as a group of individuals limited to a geographical
region or institution that has one common characteristic (Martínez-Mesa et al., 2014).
The medical group chosen for this study employs 1,050 people, 158 are physicians, 40
are family practice physicians, and 14 of the 40 are female physicians. The accessible
population included all 40 practicing family practice physicians employed by the medical
group in Northeastern Indiana who are over the age of 21 and where the use of the EMR
system is required, and where the current EMR system was replaced with a new system.
Excluded from the target population were those family practice physicians who are under
the age of 21, have not transitioned EMR systems, are not licensed, or who are not
currently practicing medicine.
Sample
The sampling method that was used for this study was purposeful sampling. The
power of purposeful sampling is in the selection of information-rich cases for in-depth
study (Gentles et al., 2015). Stake (1995) suggests bounding a case by time and activity,
similar to inclusion and exclusion criteria in quantitative studies. Saturation is often used
as a criterion for sample size in qualitative studies (Malterud et al., 2016). Saturation
occurs when no new data, no new themes, no new coding, and the ability to replicate the
study (Fusch & Ness, 2015).
Eight family practice physicians were interviewed to describe the challenges and
barriers associated with transitioning EMR systems and emotional experience. The same
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physicians who were interviewed were also be observed to cross-reference the data
collected in the interview. Minutes from implementation meetings were reviewed to add
depth to the interviews and participant observations. Castellanos (2016) conducted an
instrumental case study and had 15 participants; data saturation occurred at 8 participants.
The multispecialty medical group practice selected as a research site provided an
information-rich environment as they recently transitioned EMR systems and the
experience is fresh in their minds. Each family practice physician is a unique individual
who brings various ideas and perceptions of their experience transitioning EMR systems.
Since the use of the new EMR system was required, selected physicians would be
familiar with the system and its use. The recent transition to a replacement EMR
provided an information-rich environment for this case study. Permission to use the site
was obtained by the practice administrator (Appendix A). The authorized party permitted
the researcher to use the premises to conduct the study. The permission also requested the
researcher to be able to recruit participants from the premises. The permission also
requested authorization to use the name of the premises when publishing the results of the
study. The premises declined the use of their name when publishing the results of the
study but did authorize the researcher to recruit participants from the premises.
Recruitment
A purposive sample consisted of 8 family practice physicians. Physicians were
selected based on age category starting at 21 years old and in categorical increments of
years and gender, important themes in the UTAUT model. The age splits for the study
and demographic survey included: a) 21-34, b) 35-44, c) 45-54, d) 55-64, and e) 65years
and older. Physicians were asked in-depth questions. Interviews were conducted with a
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minimum of 10 family practice physicians or until the point of saturation, saturation point
was reached at 8 participants. Face-to-face interviews were conducted at the participant’s
private office within the clinic or via Google Meets for virtual interviews conducted due
to COVID-19 restrictions. Participant observations were conducted on those participants
interviewed to compare what was said to what is observed. The study was limited to
family practice physicians who practice in a multi-specialty group in Northeastern
Indiana and had prior experience with an EMR system.
Prospective participants were introduced to the study with a phone call to their
office and follow-up email outlining the study with the informed consent attached to see
if they will be willing to participate (Appendix B). Contact information was be obtained
from the company’s employee directory, as permitted. For recruits who agreed to
participate, interviews were scheduled to be held at their office or via Google Meets for
virtual face-to-face interviews at a date and time of their convenience. The interviews
where be limited to one hour but most lasted around 30 minutes.
Informed Consent and Confidentiality
Informed Consent
The informed consent form (Appendix C) was collected from every participant.
Participants interested in being a part of the study were explained the purpose of the
study. Participants were informed that the data collection methods of this study consisted
of semi-structured interviews, participant observations, and archival documents regarding
the EMR transition from the organization. Interviews were scheduled at the participant’s
private office within the clinic and were scheduled for an hour but took about 30 minutes.
Participants were informed about the nature of the research, that participation is
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voluntary, that they can stop participation at any time, participants were provided the
researcher’s contact information to contact with questions about the study and detailed
information about their commitments as participants of the study. Participants were
informed of any foreseeable risks or discomforts as a result of participation in the study,
given a statement that no financial compensation will be made for participation, and
described how the confidentiality of the records identifying the participants will be
maintained.
Informed consent was discussed at the initial phone call when soliciting
participants and discussing their potential participation in the study. Potential participants
who verbally agreed to participate in the study were emailed a copy of the informed
consent to review before their interview. The informed consent was also discussed before
the start of the interview to make sure the participant had not changed their mind or if
they have any questions regarding the consent form. Signed consent was collected from
every participant just before the completion of the demographic survey and the beginning
of the interview. If face-to-face interviews are not possible because of COVID 19
restrictions or comfortability of the participant, informed consents were collected via
email before the virtual Google Meets interview.
A discussion about withdrawing from the study at any time occurred at the initial
phone call and again at the interview site and included as part of the recruitment protocol
(Appendix B) and interview guide (Appendix D) where the participant can notify the
researcher via email of their desire to withdraw from the study. Participants were
informed that the interviews will be audio-recorded, audio and video recorded for virtual
interviews, and hand field notes will be taken. All data collected on participants was
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confidential and will be destroyed by burning the data flash drive after three years.
Informed consents were stored in a fireproof safe in a locked room at the researcher’s
residence and were stored separately from raw data.
Confidentiality
Data was kept secure. Data files were kept on an encrypted flash drive that is
password protected. Data files, paper documents, and notes were kept in a fireproof safe
locked in a room at the researcher’s residence. Informed consents were kept in a separate
fireproof safe from the raw data in a room at the researcher’s residence. Those who
agreed to participate in the study received a copy of the consent form to review before
their interview. A copy of the consent form was presented to the participant at their
scheduled interview for signature before the start of the interview, or via email for virtual
visits. All data will be destroyed after three years by burning.
Recordings were kept in a secure file on an encrypted flash drive. All recordings
will be kept for three years at which time the files will be deleted, reformatted, and the
flash drive burned. Interviews were conducted via web conferencing due to COVID-19,
the interviews were audio and video recorded with the participant's permission and the
participants received a copy of the recorded interview, a feature of Google Meets.
Important data such as facial expressions were void of the face-to-face interview
experience due to the requirement of facial coverings. Web conferencing allowed an
alternate means to have a similar experience to a face-to-face meeting and provided for
facial expressions to be visible. The web conferencing format chosen was Google Meet
which has a recording feature that records the audio and video components of the
interview.
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Every effort was made to protect the privacy and confidentiality of the
participants. Interviews were conducted in the private office within the clinic of the
participants and data will be stored on encrypted flash drives. To provide confidentiality
to the participants the researcher used an archival numbering system and interviews were
conducted outside of regular business hours. All data will be destroyed after three years
by burning the flash drive.
Geographic Location
A Multi-specialty group located in Fort Wayne, IN, was the data collection site.
The sample for this case study was a multi-specialty ambulatory clinic in Northeastern
Indiana where family practice physicians were faced with the decision of whether or not
to accept and use the replacement EMR system that was implemented in the second
quarter of 2019. This location was selected as it is within close proximity to the
researcher. The site was purposeful to the study as they just recently transitioned EMR
systems.
Instrumentation
The researcher is the instrument in qualitative studies (Marshall & Rossman,
2011). Data was collected through semi-structured face-to-face in-depth interviews,
demographic surveys (Appendix E), participant observations, and organizational
documents. A recruitment protocol (Appendix B), interview guide (Appendix D), and an
observation guide (Appendix F) were used to help identify appropriate questions to ask,
specific activities and events to observe, and maintain consistency throughout the data
collection process by adhering to these tools. The documents requested from the
organization were documents regarding the EMR transition, training manual, training
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agenda, minutes from meetings with the EMR vendor.
Field Test
The researcher field-tested the interview protocol and a demographic
questionnaire to evaluate the appropriateness and ambiguity of the questions being asked.
They were tested by presenting them to a group of 5 multi-specialty physicians. The field
test participants are not part of this research study sample population but have already
transitioned to the replacement EMR system. The field test participants provided their
feedback on how best to refine the research questions and questionnaire which was
incorporated; no data was collected which is different from a pilot test.
Trustworthiness
Trustworthiness is a qualitative approach to validity. Trustworthiness is the
degree to which we can depend on and trust the research findings. Trustworthiness
includes the concepts of transferability, credibility, confirmability, and dependability
(Shank, 2006). Qualitative research studies have been viewed as less scientific than
quantitative studies because of the lack of established quality guidelines, those views are
improving as the studies become more trustworthy.
Transferability
Transferability is the degree to which the findings of one study can be transferred
to a different setting or a different population (Shank, 2006). The primary tool for
establishing transferability is in the use of adequate and detailed thick descriptions in
identifying all of the relevant details of the research process (Shank, 2006). Thick
descriptions were obtained through field notes, interviews, observations, and
interpretations during data collection also describing the context, location, and people
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studied, and transparency regarding analysis and trustworthiness.
Credibility
Credibility is the degree of belief in the research findings. Credibility can be
established by prolonged exposure to the research participants to get to know them and
how they act (Shank, 2006). The researcher has worked with many of the physician
participants in the sample as their controller and later as their practice administrator
during the first transition from paper to EMR and is very familiar with their personalities
as they are with the researchers.
Member-checking is a technique used to enhance the credibility of research
results (Birt et al., 2016). Member-checking is a process where interview transcripts are
returned to the participants for review for accuracy and reduce biases from the researcher.
Researchers with a constructivist epistemology allow the participants to add or delete
items from the transcript (Birt et al., 2016) which is the epistemology of the researcher of
this study and will conduct member-checking in the same manner. Transcripts of the
interviews were delivered in a sealed envelope to the participant for review and
modifications. Participants had a week to review and return any changes to the
researcher.
Reflexive journaling is another technique used to establish credibility. The
researcher conducted a reflexive journal throughout the entire research process to help
provide an audit trail of events. The journaling included details on how data were
collected and how decisions were made throughout the data collection and analysis
process (Merriam, 1998). Reflexive journaling was also used to record the researcher’s
experiences, insights, hunches, questions, methodological and analytical concerns during
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the data collection and analysis process.
This study utilized triangulation as a credibility tool by collecting data from
interviews, participant observations, and organizational documents and comparing the
findings. Triangulation is the use of multiple methods or data sources in qualitative
research to develop a comprehensive understanding of the phenomena (Carter et al.,
2014). Findings as a result of interviews, observations, and documents are more
convincing than findings from just one or two of these sources (Hancock & Algozzine,
2011). Triangulation is also important to credibility because the more various data
sources communicate the same findings the more credible they become (Shank, 2006).
Confirmability/Dependability
Confirmability deals with the details of the methodology used. Confirming that
enough detail has been provided to enable an analysis of the data collection process and
analysis of such data. A methodological audit trail addresses the issues of the type and
nature of the raw data, how data was analyzed, and how categories and themes were
formed (Shank, 2006). The researcher kept an audit trail of each detail of the data
collection and analysis of the data to meet the requirements of confirmability and
dependability.
Dependability is the ability to know where the data from a study came from, how
it was collected, and how it was used (Shank, 2006). An audit trail is a key strategy for
ensuring dependability. An audit trail tracks the path between the data collected and how
the data was used (Shank, 2006). An audit trail was maintained for this research study.
The audit trail outlined the decisions made throughout the research process to provide a
rationale for the methodological and interpretive judgments of the researcher (Houghton
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& Keynes, 2013).
Researcher’s Acknowledgement of Biases
The researcher has worked with some of these participants in multiple capacities.
From 1999 – 2007 the research was employed by some of the members of the sample, in
their previous practice, as their controller. The researcher was reunited with some
members of the sample from 2013 -2016 in the capacity of the practice administrator.
During this time, the group was transitioning from paper charts to an EMR.
The researcher is still part of the same parent organization but in a different
capacity and has no influence nor authority over the participants of this study. The
researcher serves as the Chief Quality Officer which is a supportive role and poses no
threat to the potential participants as the researcher is not part of their reporting structure.
The focus of the quality department is on closing gaps in care, making sure patients who
need certain screenings, annual visits, or lab work are identified and reported to the
physicians for follow up. The quality department supports the physician’s offices by
helping the physicians and staff use the EMR so the work they are doing can be captured
for reporting purposes.
Strong relationships have been built over the years and some of the participants
will have no problem sharing information. There are some newer members of the group
who had little interaction with the researcher and others that are new and have not met the
researcher. This is a physician-led organization where elected physicians from the group
sit on the Physician Management Committee (PMC) and vote on all aspects of change
within the organization, clinical and operational.
The researcher reports to the network Chief Quality Officer, not through the
73
medical group. Therefore, there will be minimal risk posed to the participants. A conflict
of interest will not exist since the researcher is not part of the operations team. Interviews
will be audio-recorded and transcribed, member checking will be used to verify the
participant’s words and to reduce potential bias. Participant observation should provide
real-life data as the presence of the researcher in the office will not be unusual. Risk has
been mitigated by obtaining data access and use permission as well as premises,
recruitment, and name permission.
Data Collection
The case was a group of family practice physicians practicing within a
multispecialty medical group in Northeastern Indiana who have recently transitioned to a
new EMR system. The study was conducted after 15 months of transitioning from a
legacy EMR to a replacement system. Data triangulation was achieved by conducting
semi-structured interviews, participant observation, and reviewing organizational
documents such as meeting minutes, training plans, and training agenda documents
regarding the replacement system implementation. The study of the physicians was
instrumental in understanding the EMR transition process which is why an instrumental
case study was appropriate for this study. A demographic survey was used as
demographic data are important elements for the UTAUT model used in this study.
The interviews were conducted at the participant’s private office within the clinic
office or via virtual interviews using the Google Meets platform. The number of
participants is not as important in a qualitative study as it is in a quantitative study and
interviews will continue until the point of data saturation. Data saturation occurs when no
new data or themes are being revealed by the participants and is an indicator of rigor in
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qualitative studies (Morse, 2015). Data saturation occurred after 8 interviews.
The data collected was organized and managed using NVivo software to help
categorize theoretical propositions on the participant’s decision-making process. The
theoretical propositions were useful to assist in gaining a better understanding of family
practice physician’s decision-making process of EMRs so acceptance and use efforts of
replacement EMR systems are more expeditious. This study also explored the
psychological impact of transitioning EMRs systems to better understand the effect on
physicians.
Some of the limitations of case study research are lack of rigor compared to other
studies and lack of generalizability, (Yin, 2014). This study used a qualitative research
method to gain a more in-depth understanding of the phenomena under investigation.
Transitioning EMR systems is becoming more common in the health care industry and
comes with its own set of challenges and barriers. The goal of this study was to
understand the decision- making process of family practice physicians to accept and use a
replacement system, the challenges and barriers physicians faced, and the emotional
impact of this change may help health care leaders and policymakers better understand
some of the potential drivers and challenges of EMR acceptance and use when
transitioning or upgrading EMR systems.
Interviews
Semi-structured face-to-face or virtual via GoogleMeet (due to COVID-19
restrictions) in-depth interviews, demographic surveys, participant observations, and a
review of organizational documents of the EMR transition process provided the depth of
data needed to describe such a complex phenomenon. The study explored perceptions,
75
thoughts, feelings, and emotions as the participants experience the EMR system
transition, providing the richly descriptive data that was needed to answer the research
questions. Semi-structured interviews were conducted at the participant’s private office
within the clinic or virtually via Google Meets where the researcher explored how the
participants made their decision to accept and use the replacement EMR system, how
they overcame the challenges and barriers inherent in transitioning to a new system, and
how they felt emotionally while going through the transition.
Semi-structured interviews work well in case studies (Hancock & Algozzine,
2011). Researchers ask predetermined but open-ended questions to which the responses
provide data to assist in answering the researcher’s study questions. Semi-structured
interviews ask follow-up questions to look deeper into the participant’s issues of interest
(Hancock & Algozzine, 2011). Semi-structured interviews are designed to allow
participants to express themselves openly and freely so they can define the world from
their perspectives (Hancock & Algozzine, 2011).
This research study was conducted using an instrumental case study design where
data was collected through semi-structured interviews which allows the participants to
share their stories. Using semi-structured interviews allowed the researcher to provide
little direction into what was discussed while allowing the participant to share as much or
as little about the questions being asked. Participants were encouraged to answer the
questions truthfully to help provide valuable findings.
Merriam (1989) stated that interviews are necessary when we cannot observe how
people behave, feel, or how they interpret the world. Face-to-face interviews were
conducted at the participant’s private office within the clinic which was both audio-
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recorded, and audio and video recorded when Google Meet was utilized. In addition, the
researcher took handwritten notes within the face-to-face interviews. A recruitment
protocol (Appendix B) and an interview guide (Appendix D) were used for this study.
The researcher provided questions that were semi-structured and within the context of the
theoretical framework.
The interviews were audio-recorded, or audio and video recorded via Google
Meet, with permission. Notes were also taken to record observations at the interview.
Audio records were transcribed using Nuance voice recognition software, Dragon
Anywhere. Participants were asked to review their transcribed interview for accuracy,
member checking. The answers to the research questions were used as data to analyze
information on how family practice physicians form their decision to accept and use a
replacement EMR system.
Participant Observation
Data was also collected through participant observation (Appendix F). This
included observations of how the actions of the physicians compared to what was shared
in the interview. Participant observations were scheduled with the participant just after
the interview; patient exam rooms were not included in the observation. The observation
was specific to how the participant used the system in practice and if actual use
corresponds to responses from the interview to see if what was told in the interview is
what happened in practice. The researcher also looked for “workarounds” implemented,
assessed the organizational and technical infrastructure, and looked for any emotional
responses from the participants while using the EMR.
Careful objective notes about the observations and conversations were made in
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field notes in a field notebook file. Participant observation enabled the researcher to
frame a context around each participant's experience adding more depth to the case.
Access to the facility was granted to the researcher (Exhibit G) so the researcher had
access to these offices and operations. Special attention was given to the timing of the
documentation to see when it occurred, this limited observational data to no more than
one clinic hour per participant. The researcher looked to validate the information
provided in the interview with actual practice.
Archival Data
Documents regarding the EMR transition were collected in the form of training
manuals, training agendas, and meeting minutes with the EMR vendor (Appendix G).
Training manuals were used to learn how much information and in what manner the
information was communicated to the physician. The options were; step-by-step,
screenshots, or descriptions. The training agenda was used to see what specific topics
were covered in the training sessions. Meeting minutes were used to provide a
background on how the decisions were made to roll out the new EMR system. The
archival data results were used to provide context to the learning environment of the
physicians.
The use of interviews, observations, and documents enabled data triangulation
which enhanced the reliability of the results (Fusch & Ness, 2015). Yin (2018) states that
one of the major strengths of case study data collection is the opportunity to use different
sources of evidence. Any case study finding or conclusion is likely more convincing and
accurate if based on several different sources of data (Yin, 2018).
Data Analysis
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Interview recordings were transcribed using Nuance voice recognition software,
Dragon Anywhere, and the transcripts were loaded into NVivo software. Relevant data
from organizational documents were also loaded into NVivo software, as well as
participant observation notes. Once all the data was loaded, the initial cycle data coding
methods were applied to the data. Attribute coding was applied to the data as an initial
cycle coding method which provided participant information and contexts for analysis
and interpretation (Saldaña, 2016).
Attribute coding coded all the basic descriptive information from the study such
as fieldwork setting (name, city, country), participant characteristics or demographics,
data formats including interview transcripts, field notes, documents, and date and time
(Saldaña, 2016). After attribute coding, the first cycle coding method was used to further
define the data. Descriptive coding is a first cycle coding method that assigns basic labels
to data to provide an inventory of the topics and is recommended for use by novice
researchers (Saldaña, 2016). The next step applied a second cycle coding method, and
focused cycle coding was used to develop major categories or themes from the data.
Coding is an iterative process and was repeated several times in both the first and
second cycles. After these iterations, several categories or themes were revealed. Those
themes were applied to the theoretical framework to see if additional concepts could be
added to the model based on the data collected. The researcher used the coded data to
find themes that emerged from the transcribed recordings from the participant's
interviews.
The results of this qualitative instrumental case study will not be generalizable to
a larger population but could be generalizable to an organization with similar
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characteristics to this case. This study looked at the decision-making process of accepting
and using a replacement EMR system from the family practice physicians’ perspective.
In-depth interviews provided thick descriptions of the physician’s experience, what they
were thinking, and how they were feeling. The qualitative method was the most
appropriate method to answer the research questions posed in this study.
Summary
Chapter 3 included a review of the study’s methodology, a discussion of the
research method and design appropriateness, and a review of the research questions of the
study. The research question was the basis for much of the information in chapter 3.
Discussions also included the study population and sample, the importance and
requirements of informed consent and confidentiality, the geographic location of the
study, instrumentation used, and field test to test instruments. Trustworthiness was also
discussed as it related to the proposed data collection and analysis process followed by
the specific data collection and analyses.
Chapter 4 provides the analysis and results of the data collected. Qualitative
themes are identified and details of the interviews, participant observation, and archival
documents will be presented. The specific details of the data collection process are
described.
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Chapter 4
Analysis and Results
Northeastern Indiana. The results from the data collection methods were used to identify
themes or patterns related to family practice physicians’ decision-making process to
accept and use a replacement EMR system. Drivers and challenges faced during the
transition were also identified. Additionally, the emotional experience of such a transition
was explored. This chapter will include the data collection process, the demographics of
the participants, the data analysis, and the results of the study.
Research Questions
The research questions were the focus:
RQ: How did family practice physicians form their decision to accept and use a
SQ1: How did family practice physicians overcome barriers and challenges
SQ2: How did family practice physicians feel emotionally during the transition?
Data Collection
Data collection was completed between July 28, 2020, and September 3, 2020.
The informed consent was discussed with each participant during the recruitment process.
Each prospective participant was emailed the consent for review and consideration of
participation. The collection of the signed informed consent was completed at the
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beginning of each interview. For those participants being interviewed virtually, the
informed consent was collected via email one participant interoffice mailed the consent in
a sealed envelope.
Each participant was asked at the beginning of the interview if they had any
questions regarding the informed consent. The fact that the data will be reported in
aggregate and everything said during the interview will be confidential was reiterated.
None of the participants had questions about the informed consent and informed consent
was obtained before each interview.
The semi-structured interviews were guided by the developed interview guide
(Appendix D). The questions outlined in the original interview guide were slightly
modified with feedback from the field test. One recommendation was to change the
wording of one of the questions to make it more open-ended. Another recommendation to
was include questions regarding how the next transition should be done to make it easier
and what they wished they had known before transitioning. The question about emotions
was modified to reflect past tense since the transition happened over a year ago.
The face-to-face semi-structured interviews were recorded with permission from
the participants. The semi-structured interviews were recorded using a voice memo on
the researcher’s cellphone, then downloaded as an audio file, and saved on an encrypted
flash drive. The audio files were deleted from the cell phone at the end of each interview
day.
The semi-structured interviews were transcribed using Dragon Anywhere, an app
that was downloaded to the researcher’s cellphone. The transcript was copied from the
App and pasted onto a word document. No identification of the participants was used in
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any of the files or the transcript. Each transcript was deleted from the App and the word
document was saved to the encrypted flash drive.
Virtual semi-structured interviews were conducted using the Google Meets
platform. Google Meets offers the ability to record web-meetings. With permission from
the participants, the semi-structured interviews were recorded. A feature of Google Meets
is to send a copy of the recording to all participants of the meeting; in this case, the
participant received a copy of the recording. The interviews were transcribed by using
both the closed captioning feature of the Google Meet platform and Dragon Anywhere
App. A copy of the transcript was given to the participant to review and make any
necessary modifications.
Copies of the transcripts were hand-delivered to the participants in a sealed
envelope. No modifications were requested. All participants agreed to be recorded either
audio for the face-to-face semi-structured interviews or audio and video for the virtual
semi-structured interviews. The face-to-face semi-structured interviews did not produce
as much visual data as the virtual interviews due to the participants and researcher
wearing face masks to stop the spread of the COVID-19 virus, a 2020 world pandemic.
The participants’ faces were covered so facial expressions were not visible losing some
nonverbal communication queues. Virtual interviews produced the most data.
COVID-19 has changed how the entire world socializes and interacts. The United
States government acted quickly to the 2020 COVID-19 crisis and the impact on
healthcare. The US government lifted several of the restrictions placed on Telehealth
visits enabling healthcare providers to provide and patients to receive necessary care
without potentially exposing them to the COVID-19 virus. The vulnerable patient
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population were those 65 years and old and the Medicare program allowed health care
providers to use audio-only or audio and video telehealth visits. Telehealth visits
increased due to the COVID-19 pandemic making it easier to conduct virtual interviews
as participants were familiar with using Google Meets, a CMS-approved telehealth
platform.
Participant observation was conducted on all participants of the study. The
observations were discussed during the informed consent process and the observations
were scheduled sometime after the semi-structured interview. Observation of
participant’s workflow occurred in the participant’s clinic, excluding patient exam rooms,
and lasted about 30 minutes. Dates and times were scheduled at the participant’s
convenience.
Some of the participants wanted to stop in the middle of seeing patients show how
they used the EMR, what buttons they clicked, what notes or dot phrases they brought
into their documentation but observations were limited to their natural day to day
workflow. Observations were not conducted in the exam rooms which limited the user
activity that could be observed. Staff was asked some questions regarding the documents
they provided the physicians. Participant observation was used to compare what the
participant said in their interview about EMR use to their actual practice.
COVID-19 restrictions did not prevent participant observations but did put the
researcher at risk as patients with the suspected COVID-19 virus were being seen during
some of the observations. Appropriate personal protective equipment (PPE) was not
issued to the researcher as the researcher did not hold a position within the organization
that was patient-facing, a requirement due to a limited supply of PPE. The researcher
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donned a cloth mask while observing clinic workflows.
Archival data in the form of training manuals, training agendas, and meeting
minutes with the EMR vendor were used to see how the participants were exposed and
trained on the new system. Training manuals were used to see what information was
provided to the physician to expose them to what the new system would look like. The
training agenda was used to see what specific topics and features of the system were
covered during training. Meeting minutes were used to see what the roll-out plan was for
the new system. The archival data showed a context of the learning tools provided to the
participants to prepare them for the transition.
Demographics
All participants were asked to complete a demographic questionnaire (Appendix
E). The demographics of the 8 participants (Table 1) included 4 males and 4 females. The
ages of the participants ranged from 21 – 64 years of age. Years of experience of
participants using the EMR ranged from 2 - 11+ years of age. The amount of time needed
to become comfortable with using the system ranged from weeks to years. Only 1
participant felt using the EMR was voluntary. Reasons are given for not being voluntary
included being the standard of care, governmental mandates, and organizational
expectations to use an EMR.
Table 1
Demographic Survey Results
Age Group Comfortable using EMR Years of Experience

21-64 weeks – years 2-11+ years
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All participants were family practice physicians employed by a medical group in
Northeastern Indiana who were over the age of 21, where the use of the EMR system is
required, and where the current EMR system was replaced with a new system. The
medical group is part of an integrated network that shared information between 6
hospitals and 4 medical groups. Three of the participants have had always used an EMR,
one was on an EMR during residency and moved to paper and back to an EMR, and 4
were on paper and transitioned to an EMR eight years ago. Of the 8 participants, only 2
used scribes.
Data Analysis
Data from the semi-structured interviews were transcribed and coded by hand line
by line and then coded in NVivo to find emerging themes. Bracketing in the form of
journaling was conducted during the data collection process as well as the analysis
process. The researcher's experiences from previous EMR changes were journaled as an
outlet for expression.
The coding process began with characterizing the data. Data for analysis only
included participants' responses none of the researcher's comments or questions, off-topic
comments were not included in the coding. The data to be analyzed was then cut into
meaningful segments based on responses to the open-ended interview questions. Once the
data was characterized and sorted, the coding process could begin. The coding design
followed in this research was that of Johnny Saldana which includes first cycle and
second cycle coding.
Figure 2
The Seven-Step Coding Process
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Attribute
Coding
Descriptive
Coding
First Cycle
Coding
SubCoding
Initial
Coding
First to Second
Eclectic Coding
Cycle Coding
x Emotion Coding
Method
x Versus Coding
Pattern Coding
Second Cycle
Coding
Theming the
Data
Seven steps were used to analyze the data collected from semistructured
interviews and participant observations (Figure 2). Archival data was introduced during
the Pattern coding process. The data went through an iterative process to help break down
the data into pieces using Nvivo and using the tools within the Nvivo product to help with
analysis. This iterative process is a way to break down the corpus of the data into pieces
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that focus on specific aspects of the data to assist the researcher to analyze the data from
different perspectives.
Step 1: Assigning attributes. The participant interview transcripts were coded
using Attribute Coding from the demographic survey they completed at the beginning of
the interview. Coding attributes allow for comparative data analysis based on any of the
attributes from the survey. Attributes coded included gender, age range, years of
experience using an EMR, whether the participant felt using the EMR was voluntary, and
how long it took the participant to become comfortable using an EMR system (Appendix
E). All of these data points can be compared with other participants in the study to allow
for a deeper understanding of the findings. Attribute coding allowed for first and second-
cycle data comparisons in tables by demographic variables providing for a more robust
analysis.
Step 2: Listing and preliminary grouping. The semi-structured interview
questions were arranged based on the theoretical framework and the research questions of
this study. The responses were coded based on applicability to the questions using
descriptive or topic coding. The process started with coding the first interview and
became easier with subsequent interviews. Each line of the first transcript was read and
important words or phrases were coded.
The second transcript was a little easier to code as similar words or expressions started to
develop and categories started to form. Each subsequent transcript got easier to code as
codes had developed from the previous review and fit into similar categories. Each
transcript was read line by line and coded first using descriptive coding and then initial
coding to be able to breakdown the data for further analysis. After the transcripts were
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coded the observation data was incorporated into the NVivo dataset.
The original interview transcripts entered into NVivo were edited to incorporate
data from the observations. Observation data was entered in the space above the actual
transcript. Once this data was entered into NVivo it was coded using descriptive and
initial coding allowing or computer-assisted analysis. Only one category emerged,
“Actual Workflow” with 7 subcategories for analysis.
After the transcripts and observations were coded and loaded into NVivo a more
detailed analysis could take place. Categories and subcategories using sub coding
emerged which reduced the total number of categories to 23 for a total of 4, see
Codebook (Appendix H). The final piece of data incorporated into the analysis was the
training material and notes from the vendor. These documents were reviewed against the
data from the interviews and observations. The documents outlined what was to be
covered in training, verifying access before go-live, and standard workflows.
Eclectic coding was used to assist in the transition from first cycle coding to
second. Eclectic coding uses a combination of two or more First Cycle Coding Methods.
The Eclectic coding method used for this transition incorporated Emotion Coding, and
Versus Coding.
Emotion coding was performed on the codes originally coded to the emotions
category during the description and initial coding processes. Every participant had
mentioned some sort of emotional experience during the EMR transition and emotions
had 50 references coded. Emotions were further evaluated for terms like ANGER,
ANGRY, or MAD. These terms are consequential emotions that are triggered by
emotions of EBARRASSENT, ANXIETY, or SHAME. The terms and triggers were
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evaluated during the coding process.
Versus coding was the last of the eclectic coding methods used. Versus coding
identified dichotomies expressed by the participants. This was an important element to
try to correlate some of the emotions being experienced during the transition. Identifying
struggles between the participants and their work environment is important.
Step 3: Reduction and elimination. Data were coded to see what patterns if any
existed in the data. NVivo has several queries available to assist in helping to identify
patterns.
Patterns could be found using word frequency, identifying the most frequently
used word in the dataset, or text search identifying who said a specific word, or
crosstabulations combining queries and attributed data to intersect. Word clouds and
other visualizations within the NVvio product are possible using patterns of data.
Pattern coding provided another analysis of the data to further categorize the
codes identified, merge codes, and eliminate those that are no longer needed. This
iterative process is necessary to reassess the importance of the data remaining and how it
can be arranged to give the participants a voice. Three themes and eight subthemes
emerged including recommendations for future transitions.
Findings
Theme 1: Accepting and using an EMR Means Continuity of Care
Of the physicians who participated in this study, 75% expressed that their
decision to accept and use a replacement EMR system was based on the quality of care
gained by patients from being able to share patient records within the medical group,
from the hospitals within the network, and the interface of ancillary testing. One of the
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physician’s comment,
I knew that it was necessary I knew that for to provide better health
healthcare for our patients within this particular network it was it was [sic]
imperative that we go to a new EMR that would actually communicate with
the entire network and so I wasn't having to constantly call my own
hospitals to try to get reports from the ER visits and things like that so…
Another physician shared “Well our inpatient [and] outpatient are both on the
same system, which is great”. Having a shared medical record enables physicians to have
a better understanding of the issues their patients are having, if they were in the hospital,
what happened while they were in the hospital. Referencing EMRs functional integration,
Physician E commented on a recent patient hospitalization,
I have a better understanding of like what has taken place with that patient
over the last couple of weeks with the hospitalization and visiting of any
specialist or therapist because it's all available to me. At that very moment I
can click a button and I can say here's your whole hospital H&P in your
discharge summary. And the changes they made and right here here's the CT
that you had and the MRI in the hospital. I mean I before we will often be
like well the patients here can you call the hospital can you get it faxed over
and it would come in [an] hour and a half later in the patient was already
gone you know so I think this is better. It's been very nice I mean it's nice to
login there and I can automatically see what cardiology said about them last
week and the medications they added, and I can see who's prescribing which
medications.
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When family practice physicians send their patients to a specialist, they do not
have to wonder what the specialist said or what tests were done because they are all
available in the medical record. Participant G shared “the only thing I find that has really
improved patient care with EMR's it’s nice having the notes from the other doctors.” The
two physicians who did not mention the benefit of having access to hospital records have
only ever used an EMR and their EMR was integrated with a hospital, thus making this
feature commonplace.
Another example of continuity of care facilitated by the EMR is the ability to
identify preventative services patients need or have received. An integrated EMR
provides alerts to family practice physicians for their patients needing services such as
their annual care visits, flu shots, breast cancer screenings, colorectal cancer screenings,
and other preventative services. Many times, interfaces integrate the results of such
screenings into the EMR reducing costs related to faxing and staff having to scan into the
EMR. Participant E stated,
It's [healthcare] all driven by quality of care now. I think the EMR's really
been driving more towards how do we [or] how are we able to obtain the
necessary documentation to prove our quality of care, and what patients are
having done, and are the physicians convincing these patients or getting
them to do the appropriate things to better their health? In the long run, and
you can argue is that what medicines all about? You know are we finally
trying to really target the things that need to be done for these patients
because we've identified the things that are most important to prolong your
life and hopefully decrease hospitalizations.
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Many insurance companies are asking health care organizations to capture
increasingly more quality measures at an increasingly higher rate. Family practice
physicians have a heavy burden to collect or, as the gatekeepers, make sure others have
collected needed quality measures for their patient population. The burden placed on the
family practice physicians to collect quality measures was expressed by Participant H
stating, “You know, I'm sure the subspecialists are doing some but I don't see that they're
doing half of what we're being asked to do”. Having an integrated EMR system has made
the data collection process easier as Participant B shared “HEDIS, it would be more
difficult even to look for things on paper.” However, collecting all of this data in the
EMR takes time. When Participant C was asked how transitioning to the new EMR
impacted their job performance the response was,
Well for me it impacted it [job performance] hugely because we weren’t
able to do any of the like quality stuff in it. I don't feel like it made me I
mean less productive for sure because you know it took a while to get built
back up and get things done.
Some of the features of the EMR were not available when the group went live on
the EMR. The alerts for needed preventative services were not available so identifying
those patients who needed services was a manual process, relying on reports provided by
the insurance companies. The delay in the availability of these features caused some
frustrations. For example, Participant A,
There are so many things that they say this is coming this is coming this is
coming well that is fine but none of it is here now and so none of it is
functional now. So, like all these quality things oh well they will all roll
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out in the future. Ok but I still care if my patient’s get colonoscopies now,
and I still care if they get mammograms now and there is it is not in the
system. The system is not built now to help me do that so the interim times
when the system isn’t fully functional is really hard as a provider and as
clinical staff and I feel like patient care suffers because of it.
Having quality features that once worked and then were removed was also
frustrating as expressed by Participant F:
The area that became very frustrating early on and it's the same today you
had these quality you [sic] had that quality Mpage where you could see
where things could be tracked and it was broken. So all of a sudden we're
going to get all our numbers from day one going and get all this good and
then well the quality piece doesn't work. And then we're going to take the
Mpage off altogether and then a year later, we're still not there. I think
that's where the emotional side has been very disappointing. I felt like If
we're going to roll out an EMR, I get that it takes probably three months to
get enough information in it to turn on some of the dashboards to make
any of it make sense. But most providers they like judgment they liked
reports. They like to know that what they're doing counts. And so if you
know there's a graph or there's you know a check mark that's green or
yellow or red based on how good they're doing it drives change it drives
motivation. And when that doesn't exist, they get stale they get frustrated
then they withdraw. And we're there.
The participants identified some of the benefits of transitioning to an EMR system
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where notes from other physicians, care settings, or testing are integrated. Capturing
quality data was another benefit of using an EMR. Frustrations were expressed about not
all of the available features of the EMR worked or worked and were later removed.
Barriers and challenges are inherent when transitioning EMRs and the participants shared
theirs.
Theme 2: Overcoming Barriers and Challenges Means Addressing Them
Transitioning EMR systems is an extraordinarily complex process. Decisions
need to be made on how the old data will be accessed or integrated with the new system,
when to implement the system, and how users will be trained. The organization where the
participants worked decided they would import the patient’s problem list, medications,
and pathology reports from the old system into the new. The EMR system transition was
done in a phased approach, the participants’ practice was the last group to go-live.
Subtheme 1: The challenge of importing old records. The phases started in
October 2018 and ended with the participant’s practice in April 2019. Using a phased
approach and delaying go-live dates, the historical data was loaded before the first go-live
in October 2018 causing the data to be outdated by April 2019 implementation.
Participant C expressed their frustration with the historical data load and stated,
Frustrating because we had our go-live pushback so many times that they
downloaded the med list and problem list from almost a year and a half
prior; so literally by the time we got them there wasn't I mean everybody's
medicines were obsolete like they have been changed a billion times. So it
was like basically having to do it yourself.
Bringing in data from an old system into a new system can be risky because the
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data must be mapped exactly for it to populate in the correct field in the new system. This
practice experienced mapping issues as do many system conversions as shared by
Participant F,
So you're told your patient med lists will be able to be collected from your
past EMR and brought over into the current EMR. And so they do that
basically through a linking and so ah, that sounds good except for
sometimes in the file they ended up with three or four versions of the same
medicine. You're learning that just because they say that it links [it does]
not always or you have multiple issues with past medical history where
you'll have coding that doesn't actually come over correctly or it comes
over as just a text file but isn't actually a usable piece of information in the
new system. So I think there's several different pieces where the errors
occur that creates that unknown when you end up working in the new
system for what's going to happen. My newest opinion is most of the time
I don't want the interface. I think you start from scratch. It [interfacing]
creates a lot of extra work that if you just done it up front it would be
better. One of our conversions we would have that and so if there were
multiple first name versions then that individual in the new EMR would
get that many charts.
Another Participant found that the problem list that was converted from the old
system into the new had errors, “Now some people have diabetes in their record and now
you have to say whether they're not [or] whether they are because that was information
that I don't know where it came from.” One of the ways the participants overcame chart
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errors from data migration was to access the old records.
Approximately 62% of the Participants, found that they were accessing the old
system to update charts in the new system. Participant C shared, “That was painful in
itself because we didn't have charts there [previous EMR conversion] but we also didn't
have anything in Cerner had no charts so we still had to access our old system and bring
stuff in.” Using annual wellness visits as a patient encounter to update the data in the new
system was how Participant B approached this challenge, “I thought that things were to
be transferred to Cerner but it's not so you know that's very difficult for now until next
year when I do my annual wellness visits.” Participant D also utilized the old records and
stated, “It sucks because we have to go back and find all of the old records.”
Some participants did not have access to the old system and were frustrated. The
organization was not purchasing any more user licenses for the old system but added a
link called HRV that would provide a .pdf of old chart notes. As noted by Physician C,
the HRV featured had issues and would not always launch. Having to access the old chart
is what many of the participants said they did to overcome the challenge of not having
patient’s old records in the new system; however, they also had a challenge of finding
information in the new system.
Subtheme 2: Findings records in the new system. Finding filed documents in the
new system was a challenge expressed by 75% of the participants. Participant B
conveyed how difficult it is to find documents that have been filed in the new system
either by someone scanning or the interface,
They're [documents] not filed according to [subject], for example if you're
looking for an x-ray they are all on top of each other [documents] and
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that's difficult for us really difficult to find things that you need. Say if you
want to find an abdominal ultrasound that was done like a year ago you
have to scroll down, there is [no] place like Allscripts before that
radiology you can find all the radiology in one spot [radiology folder]. [In
Cerner] everything [document types] x-ray, hospital records, if you go to
the hospital you probably depending on how many times your you were in
there you got … an endoscopy and then the next day you got a chest x-ray
the next day you have a cath so it's like filed on top of each other and then
your nurse…notes you [via messenger or I get] … a phone message
[which gets filed] on top [of all the other documents, chronologically]. If I
send a text its on top so it's harder [to find documents]. The Cerner
[system makes] is harder to find things that you need. If you have a 15-
minute time slot [for an appointment] I don't have time to scroll those
things or… I'll just say [to the patient] I will look for [it] and I will call
you if I need that test again.
All documents are filed chronologically in a file folder called documents in the
new system. There are document types and limited filters for sorting. Concurring with
Participant B, Participant C added that medical documents can be obscured as all
documents are filed in the same place, thus “every piece of paper that they sign is all in
[documents].”
The inability to find important patient information was also expressed by
Participant H, “it's hard for me to find labs at times.” Recalling important documents is
ineffective if there is not continuity of how documents are filed as noted by Participant D,
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“There needs to be a continuity … when we have different providers’ notes that are
scanned in … to be a way for us to easily coordinate all of those as opposed to just a big
dump basket.”
The lack of consistency in how documents were filed harmed their ability to find
important documents. The lack of consistency may have resulted from the training
received for this new system.
Subtheme 3: Lack of consistency in training. Every participant expressed their
disappointment with the training received. Some of the issues included having training
too far in advance of go-live, not having access to a training environment, and the lack of
knowledge from the trainers seemed to be the number one issue. Having the training a
year in advance was not effective. In reference to the timing of the training, Participant G
commented,
They had the teaching sessions prior, but they really weren’t all that
effective I mean they were not effective at all to be honest with you. They
were a year before … so the teaching sessions were not effective; but what
was effective was just being on the EMR, learning it that way.
Learning from using the system was a sentiment shared by others. Participant D
noted,
It's kind of like you got to learn on the fly and go through your step-wise
protocols as you go through your day and having somebody there to to
[sic] help guide you along in real time is really when you learn the
systems. You can only learn so much through simulation. You have to
really have the day in, and day out grind to really learn and figure out the
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system.
At-the-elbow resources became scarce after a few days and physicians found it
difficult to get needed help. Participant A expressed their frustration with the inability to
locate a needed resource:
I feel like the support they have is really intensive the first like 2 to 3 days
and then you are searching for help. And I think it is important to have
those longitudinal check-ins because on the first couple of days you are
just trying to figure out how to put in orders, how to get patients in the
office, order what they need to order, and get them out.
Some technical issues encountered included not having access to the
system in advance to train or having the wrong access. Access to features in the
system is based on job codes and where services are provided. A family practice
physician who no longer rounds in the hospital will only have access to chart in
the ambulatory space of the system. Those family practice physicians who still
round in the hospital will have access to both the ambulatory and acute space for
charting. Documents are visible irrespective of place of service, ambulatory can
see acute and acute can see ambulatory. Participant C was given access as a
hospitalist instead of a family practitioner who rounds in the hospital:
I think Cerner was horrible because we had the worst training ever I mean
the training was horrible and I wasn't nervous about going on it I was fine
because I thought well it's just another system but our training was
horrible. My training was all bad because they had me down as being
hospitalist only and so I went through all the training just for hospital stuff
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and we kept trying to like do stuff in the [clinic] like they would tell us
like you know go here and do this I had no idea what they were talking
about. It was really challenging and frustrating because I thought that
somebody dropped the ball big time there.
Some of the participants did not find the trainers or at the elbow support trainers
from the vendor very knowledgeable and just fumbled through the system. Some of the
participants were familiar with EMR systems and had some high-level questions which
the trainers could not answer. As reported by Participant F, “I had lots of high-end
questions and my trainer was like, well you click this button, and you do this button and
then that's how that works. That was about the extent of the training.” When asked if they
thought the trainer knowledgeable, Participant F replied, “not for me, no. I ended up
having a physician trainer. He came in from England and we talked, and I think he spent
two days with me and that part was super helpful.” Participant C also ended up having a
physician trainer come to the office for one-on-one training. Several participants
commented on trainers’ lack of knowledge because they were not physicians themselves.
Participant D summarized:
I think the lack of help was or the lack of helpfulness was because they
weren't Physicians that were using or providers that were using the
program…there are certain things that just aren't important and there are
other things that are way more important and you don't really know that
until you are a provider and going through the EMR all day long every day
and what, what [sic] is an appropriate workflow.
The lack of knowledgeable trainers was described as frustrating to physicians.
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Describing they’re at the elbow support team, Participant G reflected as:
There were some people in here they were not as well trained or as helpful
as we had hoped. I think they were a bunch of college kids or kids right
outta college. I think they kinda treated it like it was summer camp or
something and so I mean they just didn't have a whole lot of knowledge.
Some of the physicians were very determined to figure out this system on their
own making use of public social media sites like Participant C:
I would just go to YouTube and learn how to do I pretty much self-taught
myself because I don't think we had a really good resource and no one else
really knew a whole lot so no one had used it [before].
Archival documents were reviewed to see what the training plan was for
the transition. Physicians were offered a 4-hour training session in a classroom
setting. Those physicians who worked only in the ambulatory setting also had a 4-
hour training session. Those physicians who provide services in the acute and
ambulatory setting were provided modified training with 2 hours acute and 2-hour
ambulatory. The favorites would then be listed on a landing page so the physician
could just click on the item instead of having to search for the item in the
database. A training manual was created with “job aids” that provided instruction
with screenshots.
Favorites fair was a 2- hour one-on-one training session with a trainer who
helped the physicians build templates, and label their favorite notes, codes, and
orders. Favorites are items physicians use frequently like labs, imaging studies,
order sets, or medications to make it easier for the physician to place orders and
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bill charges. Physicians spent hours building templates. The system came with
standard templates, but physicians chose to build their own. At go-live, physicians
had at-the-elbow support to support them and their staff as they used the system
for the first time. Physicians were supported for three weeks.
Subtheme 4: Timing of go-live. Data migration, filing of documents, and
training were challenges the participants had faced, another was the timing of the
implementation. The timing of the roll-out of the new system was during spring
break for 3 out of the eight participants. These physicians already had plans to be
out the week of spring break. The plans were made when the original go-live date
was earlier in the year and would not have interfered with their spring break
plans. These participants lost a week with the vendor trainers at-the-elbow support
as stated by Participant E:
I was not a big fan of the timing that we rolled this out. It was done over
spring break which I thought maybe some may argue that it was a great
time because there were a lot of providers and people who were out the
office and it allowed the trainers to spend more with one-on-one time with
those people who were remaining but I, as one of the physicians who was
gone during the first week that we went live, I really felt like I came in
behind the eight ball with the go-live and the trainers were kinda already
felt like everyone had already had a week under their belt but there were
… eight or 10 of us docs who were like no this is our day number one and
so we did have one less week of having trainers in our office because we
were gone the first week.
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Implementing this transition during spring break gave those physicians who were out one
week less of at the elbow support as mention by Participant B:
So they were already [providing support] for a week when I came. So, I
only had I think two weeks right because the tech support were there for
three weeks. So I only had two weeks. You [had] a lot of our questions
they didn't know the answers [to]. So they would get somebody to come
and fix it. …there's a lot of ways [of] how to go into [the system and
navigate] it so; so one person might tell you a different way on how to get
to the information you want do.
Having multiple ways to accomplish a goal was a common frustration
among the participants which made it difficult for them to understand the flow
because trainers would rotate and the new trainer would teach them a different
way to accomplish their goal.
Subtheme 5: Lack of support. The ticketing system to log issues was a
barrier to the physicians. When issues with the system were encountered, a call
needed to be placed with the support line established during go-live. The support
tech answering the phone would ask for a variety of pieces of data, sometimes
including screenshots. This could be a lengthy process and at the end of the call,
the caller would be given a ticket number and the caller’s email address would be
logged with the ticket so they could get updates on the issue.
Several of these tickets would be closed without resolution. The process of
reporting the issue again was making the call and supplying the requested
information, sometimes multiple times for the same issue. The ticketing process
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was frustrating as Participant A shared:
I had like a running sticky note of how much time I had spent [logging
tickets] because you talked to one person [who could not help and sends
the call to someone else]. [I was] like oh I need to talk to someone else?
… I stopped the sticky note as an hour and a half of different
conversations [transpired]. And then after 30 days the case example
expires and so they're like, oh sorry, there’s there's [sic] nothing we can do
about it. And then they send you a lot of emails. … I mean emails are fine,
but yeah, I mean it's an excessive amount of emails … with tickets.
Especially if it's not resolved quickly like the COVID bar, I bet I got I
don't know 75 emails you know about [the status of] it. And then they're
like well give us your user experience rate your experience, you know take
the survey and I'm like, ah, you know what I mean? Yeah, and then it's
even frustrating when they close your ticket, and it's not been resolved.
The lack of support on the ground and then the ticketing process from the
vendor resulted in physicians stopping to report issues and logging tickets and
finding workarounds as expressed by a participant:
[It is] My fault because we don't really have time [for technical issues]. If I
have technical difficulties on my computer most of the time, I just ignored
I by-pass it ... But sometimes [issues] keep coming [up] like little things
and I take a picture. … I just don't want to deal with it anymore because
you know if I … have to stop what [I am] doing it might take 30 minutes
of your time while you're seeing patients [to address the issue with tech
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support] so yeah most of the time I just deal with it.
Subtheme 6: Workarounds. Disruptions in a physician’s day can set their
schedule back so they find ways to get through their day. Workflow changes happen
during the day as shared by Participant A:
If something doesn't work, there's usually something that you can do to
change or alter it to make it fit for you better. There's workarounds. So it's
just being comfortable with knowing that it's not always going to work
how using it should work, but it'll work.
Several workarounds were observed during participant observations. Staff would
print the last office note, the medication list, and any recent tests done and put in the slot
for the physician to grab as they walk into the exam room. Some of the participants used
preprinted forms that listed frequently ordered tests and referrals. The physician would
mark any tests or referrals needed for the patient on the form and hand the form to the
receptionist who would enter the orders and make the referrals into the EMR. Using
ancillary staff to enter orders and make referrals, the physician could continue to see
patients and not be delayed by entering the orders or referrals themself. A nurse was
observed taking handwritten intake assessment notes during a telehealth encounter
instead of entering the information into the EMR. The nurse then verbalized the
assessment to the physician who entered the information into the system.
One office handed their front office staff their billing sheet so the front staff could
enter the appropriate visit codes to be billed along with the above-mentioned documents.
A physician was observed having to request their clinical staff to log into the old EMR to
get a lab result. The word “cumbersome” was mentioned by three participants to describe
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entering information into the system. Participant H stated, “The iPhone … does pretty
well with anticipating what I need and what I do but our EMRs don't.”
Half of the participants found the system easy to use. The other half, 2 had scribes
so they did not speak to the ease of use and the remaining two felt like it took more clicks
to complete an encounter than in their old system. Switching EMRs gives rise to a
concern of the unknown as expressed by Participant F,
If order comes back, if a lab comes back, if there's an error message that
occurs all of these different variables of what you're exposed to over and
over and over. It makes it really tricky sometimes to know what the proper
way to do something is and it creates this unknown and we don't always
have the resource to figure out. I get slowed down by trying to double and
triple check things [so] that I know that
what I did will happen. And so you can't keep that same level of
productivity when you don't trust your system.
The participants were asked, based on their transitioning experience, what they
would recommend for future EMR transitions.
Subtheme 7: Physicians’ recommendations for future transitions. The
participants were asked what they would do differently for future EMR transitions. Some
of the recommendations included more IT resources, consistency in training and entering
data into the system, and better organization of documents. Others thought more
physician input in the choice of system and they felt that having a physician train them
was more beneficial. A couple of participants had a physician come to their office and
within that short interaction, they learned more than all the training prior. Participants had
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shared that the trainers are IT people who do not understand the needs of a physician.
Some of the other recommendations were to freeze salaries during this time so the
physicians can focus on learning the system and not have to worry about lost income. A
training environment was not provided prior to go-live which several of the participants
shared that they learned the system by using it and the classroom training was not that
helpful. Most of the participants felt the at-the-elbow support was beneficial but only for
a few days. The recommendation is to have the trainers come back a few weeks later to
see how the system is being used and offer recommendations for efficiencies. There was
also a recommendation to stick with a go-live date and have course room training over a
weekend to not interfere with the office and seeing patients.
There were conflicting recommendations when it came to interfacing the old
records from the previous system. Some of the participants had voiced frustration that the
old records were not incorporated into the new system. Other participants have had
experience changing EMR systems and recommended not interfacing the old data
because of the risk of data not being mapped correctly which causes several issues. The
recommendation is to just start from scratch and do more chart preparation work in the
new system. Not trusting the system, not being able to find documents, having to access
the old system to get old records, and creating workarounds when the system isn’t
working as expected can take an emotional toll when transitioning EMR systems.
Theme 3: Transitioning is an Emotional Experience
Words used by the participants describe their impending EMR transition included
“expected anticipation,” “a challenge,” “hopeful,” “excited,” “matter of fact,” “anxiety,”
“stress,” and “frustration.” An emotion that some of the participants felt during the
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transition was anxiety. Anxious about missing something important as expressed by
Participant D, “where my anxiety of new systems comes in is that it's just, it runs the risk
of missing things when you take care of your patients.” However, stress and frustration
leading to stress were the terms used by 75% of the participants.
Some of the participants were frustrated early in the process when features did not
work as expressed by Participant F, “when efforts to improve quality cannot be tracked or
trended, it drives change it drives motivation and when that doesn't exist, they get stale
they get frustrated then they withdraw”. When speaking about physicians’ motivations
Participant F shared their personal feeling on the matter, …”If it wasn't for me being
involved on the quality team side, I would have shut down and I would have recoiled into
my office took care of patients and went home. “Participant F had a lot of experience
transition EMR systems and was able to use prior experience to help drive change within
the organization but as was mentioned many of the other physicians disengaged.
One of the participants observed was very much disengaged from the EMR
transition and conformed the system to how they had always practiced instead of
changing to conform to the new system. As this participant shared, “I made all my own
templates. Here [they are] all the templates I made for myself. This took probably 100
hours to do [all] this [but] now it makes my life easier.”
The participants were familiar with transitioning to an EMR system. Some of
them remember what they went through in 2012 when they went from paper charts to an
EMR. That experience framed their attitude for this transition as expressed by Participant
H:
I think … emotionally wise, it's very frustrating. … I'll tell you every time
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… we switch computer … [systems] and it's only been twice for me … I
struggle with Tourette's. … I just want to cuss all the time because it's so
frustrating …. And I'm like most folks, I don't like things that change but
especially when it doesn't do what you need to do. It slows you down …
[especially] if you have to stop in the middle of the morning because
there's a problem and you have to call [IT] support. …I've got five people
[patients] stacked up. … [and IT support], they don't understand. … we
can't stop for problems. … [Computer problems] can derail a whole day
and …, that's one of the biggest stresses.
The transition experience for some participants was first hopeful about the
new system, stressful during the transition, and resignation when encountering
system glitches. System glitches as described by participant G, “if it goes down
will figure it out, if it's slow you just wait, [laughing] what else are you gonna
do,” added to their stress level. Another stress for some of the participants who
were on a productivity compensation model was the loss in income.
Subtheme 1: Decreased compensation. Several participants were on a
productivity compensation model, so their stress stemmed from a reduction in salary as
Participant E stated,
How many times are we gonna do this? Let's do this one more time and
were done. Don't keep coming to us every couple of years and throwing a
whole new system at us and having us take a month of significant pay cuts
just to learn the new system. But at the end of the day I knew it would be
nice, I knew it would be better, I know we needed it, so it's kind of
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investment. I was hopeful that going to the new system would increase my
productivity … but um I can't say that it has.
Productivity, availability, and income were also factors for Participants C and D.
The financial exposure experienced by these physicians makes them want to learn the
system quicker which exhausts them with all the extra hours they put in to learn the
system to minimize their financial loss.
Besides the feeling of stress, some of the participants were also angry. Anger due
to embarrassment, “I literally was so frustrated I would go home and cry I am like I must
be the dumbest person like everybody else can use the system I can't even use the
system.” Some providers experienced embarrassment in front of patients:
You know just looking like an idiot in front of your patients that stressful very
stressful. You know I don't know that people really understand how stressful, you
don't want to get in there [exam room] and be like it's not working I can’t get this
to work you know. And you know you want your patients to have confidence in
you as a physician you don't want to walk in there and be like oh my gosh.
Providers were angry that they could not do their job efficiently, having to focus
on a computer screen instead of on the patient. Some of the emotions expressed may have
been a result of the explicit or implicit expectations placed on the physicians. Comments
such as, “administration, they want us to do this in two days … this task in seven days so
it's an expectation” or “the expectation was that we would just go to four hours of
training and we would rock the system that was the expectation that wasn't the reality.”
Other statements such as, “when to accomplish one thing takes three or four minutes
when the expectation is that it'll take 10 seconds.”
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The physicians may have felt a little animus about the lack of volunteerism to use
the replacement EMR as was expressed, “I mean I felt like it was a blanket expectation
from our network administration that this is just what needed to happen.” Another
participant shared, “we did the new system because we were told we were going to so I
mean there was not really a voluntary thing.” Concurring with the previous statement
another participant stated, “we did it because you know the new system is being rolled
out so … if you're gonna work for [this organization] … you're gonna use Cerner so I
mean that that was the influence.
Several emotions were expressed from the participants during the EMR transition such
as; anxiety for potentially missing test results, frustration when features of the new
system did not work, stressed about potentially taking a reduction in compensation, anger
from the embarrassment of struggling to use the new system in front of patients. The
physicians expressed some animosity against the organization for feeling forced into the
new system, not feeling supported by the organization with unrealistic goals and
expectations, and for the organization implementing a new system that failed to meet all
the physicians’ needs.
Summary
Northeastern Indiana. The central research questions that guided the study were: How did
family practice physicians form their decision to accept and use a replacement EMR
system? The two sub-questions that helped to explore additional factors inherent in
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transitioning EMR systems included: how did family practice physicians overcome
barriers and challenges associated with transitioning EMR systems; and how did family
practice physicians feel emotionally during the transition?
This research was conducted using semi-structured interviews, participant
observation, and the review of archival data. Interviews were transcribed and data was
entered in NVivo qualitative data analysis software which assisted in the data analysis.
The data analysis process produced three themes: 1) Accepting and Using an EMR means
Continuity of Care; 2) Overcoming Barriers and Challenges means Addressing them,
with subthemes of (a) The Challenge of importing old records, (b) Finding records in the
new system, (c) Lack of Consistency in Training, (d) Timing of go-live, (e) Lack of
Support, and (f) workarounds (g) Physicians’ recommendations for future EMR
transitions; 3) Transitioning is an Emotional Experience with the subtheme (a) Decreased
compensation. Chapter 5 will discuss the study’s findings and include limitations and
conclusions and recommendations to leaders and practitioners as well as future research.
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Chapter 5
Conclusions and Recommendations
EMR replacement systems. The problem statement for this study called for an
understanding of the different challenges in transitioning EMR systems than from paper
and how physicians’ perceptions of the EMR system affect adoption and use.
This study took place in an ambulatory care setting in a large healthcare system in
northeast Indiana to explore factors family practice physicians believe to be drivers and
challenges of acceptance and use when transitioning EMR systems. In-depth interviews
of eight participants, participant observation, and archival documents were used to help
understand family practice physicians’ decision-making process to accept and use a
replacement EMR system. The results of the study may be useful in understanding the
complexities of family practice physician's acceptance and use of EMR systems and to
potentially expedite the adoption of future upgrades or EMR system changes. Chapter 5
will discuss the findings of the research study, the limitations of the study,
recommendations to leaders and practitioners, as well as recommendations for future
studies.
Research Questions
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The research questions were the focus:
Discussion of Findings
The findings presented in Chapter 4 addressed the research questions. The key
finding in this research study is a family practice physician’s decision to accept and use a
replacement EMR system is based on the perception that the use of the new EMR system
will improve the quality of care delivered to the patient. This chapter includes discussions
of the key findings from the eight semistructured interviews, the participant observations,
and archival data. Five major findings emerged from the study:
1. Quality of care gained for the patients was what 75% of the participants
expressed as their motivating factor to decide to use a replacement EMR
system.
2. All of the participants reported that a lack of IT support was a barrier to
EMR acceptance and use.
3. All participants identified challenges in transitioning to a replacement
EMR system.
4. All participants were observed to have developed workarounds.
5. All participants noted transitioning to a replacement EMR system was an
emotional experience.
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Each of these major findings will be compared and contrasted with the literature
from the literature review in Chapter 2 and a discussion of each will follow.
Theme 1: Accepting and Using an EMR Means Continuity of Care
Quality of care gained for the patients was what 75% of the study participants expressed
as their motivating factor to decide to accept and use a replacement EMR system which is
consistent with the literature. As one participant shared, “it was [sic] imperative that we go
to a new EMR that would actually communicate with the entire network and so I wasn't having to
constantly call my own hospitals to … try to get reports from the ER visits and things like that
…”. Likewise, a research study conducted by Michel-Verkerke et al. (2015) in the
Netherlands found that almost all of the care providers interviewed stated that integration
and availability of patient information as important elements to delivering high-quality
care. This also supports the UTAUT model that predicts that performance expectancy is
the strongest predictor of intention to use technology (Venkatesh et al., 2003).
The lack of interoperability among EHR systems was found to cause frustration
and skepticism among physicians relative to the value of EHRs (Meigs & Solomon,
2016). Frustration was also expressed by the participants of this study when they could
not locate patient information in the chart that came from outside their network. In
addition, Meigs and Soloman (2016) concluded that there was a need for more evidence
to support the assertion that EMR use leads to improved quality of care to “counter the
physicians’ ambiguity or uncertainty regarding the perceived usefulness of this
technology”(p.8). One of the participants of this study shared that they received a thank
you card from a patient because they encouraged the patient to get a mammogram and the
patient thanked the physician for saving her life because they were able the catch the
tumor early. The EMR system alerted the physician that this patient was due for a
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mammogram and the physician placed the order and informed the patient.
Based on several studies, extended use of EMR systems leads to improvement in
performance benefits (Raymond et al., 2015). Krousel-Wood et al. (2017) conducted a
baseline study with a follow-up study 12-24 months after implementation and found that
positive perceptions of the benefits of an EMR system had significantly increased for the
entire study population. Similarly, the current research study found that the participants
were satisfied with the improved performance in the benefits of the replacement EMR
system. The participants of the current study have been using the new system for about
18 months and have had time to experience the benefits of the replacement EMR system,
confirming previous research findings.
Theme 2: Overcoming Barriers and Challenges Means Addressing Them
Ayanso et al. (2015) found that physicians are willing to change and adapt to new
ways of caring for patients if it improves outcomes for the patient. There are several
barriers to switching EMR systems. Some of the barriers identified in the literature
included interoperability with no standard protocol for data exchange, training and
maintenance and upgrades, staff shortages, privacy, lack of infrastructure, missing data,
cost, too time consuming, perceived lack of usefulness, the transition of data, facility
location, implementation issues, user/patient resistance, lack of technical assistance, and
medical errors (Kruse et al., 2016). One significant barrier related to switching EMRs
identified in the literature is the cost (Andresen et al., 2017). The cost was not a factor for
the participants of this study; however, they shared many of the other barriers identified.
Consistent with prior research, interoperability with no standard protocol for data
exchange was identified as a challenge by the current research participants as they were
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not always able to locate medical information about their patients from facilities outside
of their current network. Training and maintenance was another barrier these participants
shared with findings in the literature. The training was a significant barrier for the
research participants of this study. Other similar barriers experienced by the current
research participants included: lack of infrastructure, missing data, too time consuming,
the transition of data, lack of technical assistance, and the potential for medical errors.
Subtheme 1: The Challenge of importing old records. One of the risks associated
with transitioning EMR systems is the inability to retrieve old data (Andresen et al.,
2017). One solution to bringing data over from a previous EMR system is interfacing.
Interfacing is very complex and not a viable option for some data elements. Bentley et al.,
(2016) stated that interfacing is especially problematic for applications requiring
frequently updated data such as medications, allergies, and problems. The participants of
this study shared their frustration about the data that was interfaced, data was outdated,
created duplicate entries, and attaching problems to the wrong patient. In accordance with
Saleem et al.’s study, participants were frustrated with unanticipated challenges with data
conversion from switching EMR systems and had to access legacy data (Saleem et al.,
2018). In addition, in the current study, the participants were not only frustrated with not
having their legacy data interfaced, but they were also frustrated about not being able to
find information in the new system.
Subtheme 2: Finding records in the new system. Indexing of files and folders in
the EMR has caused issues for the participants and their ability to locate documents. One
study found the same problem after they switched EMR systems and created a multi-
disciplinary committee to simplify and facilitate the readability of the EMR architecture
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(Ologeanu-Taddei et al., 2016). Bardach et al., (2017) also found a provider’s difficulties
locating documents exacerbated by a lack of standardization in EMR use. Information
retrieval is critical for rapid and effective access to patient information such as diagnosis
results, treatment plans, and patient summaries (Yang et al., 2015). The lack of
standardization could have been the result of a lack of consistency in training.
Subtheme 3: Lack of consistency in training. The lack of consistency of the
training was directed toward the trainers that were there to help the participants during
their go-live. Similar to the participant’s experience, Halas et al. (2015) shared that their
study also found that the trainers were not training the same way and would get off track.
In addition, Halas et al. (2015) revealed that training was too long and not helpful
because it did not focus on specific patient scenarios so trainees could not follow along.
Some organizations used the same methodology and approach from training across all
disciplines and customized the content and duration for each discipline (Bentley et al.,
2016). According to the findings of several studies, a variety of training methods, types,
and levels of training is more effective than having a single method (Younge et al., 2015).
The need for training methods was evident by the responses from the participants where
some found value in the training sessions where others did not; they preferred a different
method. One approach to training was to train staff within the organization to be super
users who would go out and train the rest of the team.
Subtheme 4: Timing of go-live. The timing of the go-live for the study
participants was changed several times. The participants had their classroom training
approximately a year before their go-live. The recommendation for large-scale go-lives is
for training to occur 2 to 8 weeks before implementation; training more than 8 weeks
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from go-live will likely not be remembered (Pantaleoni et al., 2015). The fact that
training occurred a year before go-live for the current research participants may have
contributed to some of them not finding value in the classroom training that was offered
as confirming the findings of Pantaleoni et al. (2015).
Subtheme 5: Lack of support. All of the participants in the current research study
reported that a lack of IT support was a barrier to EMR acceptance and use. Similarly, the
Halas et al. (2015) study found that on-site support was lacking. The study site for Halas
et al. (2015) did offer a practice environment for new users to get exposure to the system;
however, it was not accessible remotely requiring users to be on-site. The participants of
the current study were not offered a practice environment to become familiar with the
program before go-live, which was a frustration.
A study conducted by Lambooij et al. (2017) found that IT support yields a
successful EMR implementation. Likewise, Cucciniello et al. (2015) shared that EMR
systems are complex systems serving different stakeholders, and implementations should
be viewed as much as a change management exercise as an IT program. The current
study and similarly the Halas et al. (2015) study both demonstrate that just having IT
support is not enough for a successful EMR implementation. The type and quality of
support are other factors that need consideration when implementing an EMR system,
regardless if it is a new or a replacement system.
Subtheme 6: Workarounds. Similar to the study conducted by Megis et al. (2016)
the participants of this study were observed using workarounds to the EMR workflow.
The most utilized workaround was to document on paper and to later transcribed it into
the EMR. The nurses would print the last patient visit, any recent labs or X-rays, and a
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medication list and place it in the slot on the exam room door. Some participants used a
prepopulated form with a listing of commonly ordered tests and diagnosis codes and
would complete the form and hand it to a staff member to enter into the system.
According to Megis et al. (2016) that though this tactic assisted in avoiding disruptions
for the provider while seeing the patient, this strategy added to the provider’s workload;
using paper.
Bhattacherjee et al. (2018) found that those who hate IT or view it as an intrusion
to their workflow may develop workarounds. It is important to find out why there is a
need for workarounds to improve workflows and enhance education for EHR use (Evans,
2016). Workarounds may be a byproduct of the UTAUT direct determinant of intention
to use technology, effort expectancy, and why despite the extra efforts needed to
complete a patient encounter, physicians are still intending to use the system (Venkatesh
et al., 2003). The participants' encountered several barriers and challenges switching their
EMR system but have also offered recommendations for future transitions.
Subtheme 7: Physicians’ recommendations for future transitions. The
participants of this study have each offered recommendations for future transitions such
as having physician input, more IT resources, consistency in training and data entry,
physician trainers, and organization of documents. Recommendations from the literature
include EMR designers finding features in the EMR that are most and least satisfying to
users and whose usage improves and disrupts performance (Raymond et al., 2015).
Penrod (2017) recommended using the results from their study to evaluate the current
state and the future state of EMR transitions to provide a foundation for future success.
The full benefits of the EMR are not realized until the system is fully utilized and an
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optimization phase will help to refine workflows, enhance the system, and add
functionality and should be part of the go-live implementation (Bentley et al., 2016).
There is much to learn about EMR transitions and the emotional toll this change takes on
the providers.
Theme 3: Transitioning is an Emotional Experience. People respond to their
emotions with either an adaption strategy or a vacillating strategy and these coping
behaviors are reflected in IT use patterns (Stein et al. (2015). Furthermore, if physicians
perceive aspects of their job as burdensome, anxiety-provoking, or dissatisfactory, such
as using the EMR, they risk reduced job satisfaction (Carlton et al., 2016). Saleem et al.
(2018) stated that health care organizations should expect to see physician satisfaction
decrease with a new EMR for up to two years after implementation. Jacobs et al. (2015)
shared that managers wanting to increase implementation effectiveness should focus on
creating an environment supportive of the change and provide an incentive program
highlighting expectations, support, and rewards for EMR use.
Every participant in this current research study had an emotional response to the
EMR change. Some participants felt anger because they did not want the embarrassment
of looking incompetent in front of their patients as they struggled to use the new EMR.
Others experienced anxiety thinking that they would somehow miss a critical finding
because of a glitch in the system. The emotional experience expressed by the participants
confirms the findings that transitions are psychological events and supports the three-
phase Transitional Model of Bridges et al. (2016). A supportive environment from the
organization would be difficult to promote if the physicians are negatively impacted,
financially, by the EMR change.
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Subtheme 1: Decreased compensation. Some of the participants in this study
were on a productivity type of compensation where they get paid for the work they
perform. The EMR transition caused a schedule reduction of about 50% for a few weeks
and 6 days of training out of the office which reduced the physician's compensation
which increased their anxiety. McAlearney et al. (2015) shared that some of the barriers
physicians have to an EMR implementation are lack of participation in the selection
process, the lack of consideration to the impact on physician compensation, reduced
productivity during training, a lack of physician champion for the innovation, and lack of
supportive leadership. The impact of an EMR transition is a reduction in total outpatient
visits and the number of work Relative Value Units (wRVUs) generated by the provider;
however, a steep rise in the level of care and the wRVU per visit increased at the end of
the study’s sample period (Meyerhoefer et al., 2016). Other organizations have allotted
administrative time so physicians were not financially impacted for training (Bentley et
al., 2016). The financial impact should be a consideration when organizations decide to
transition EMR systems.
Limitations
The present study was limited in several ways. First, the generalizability of the
research findings was limited by the fact that only one type of EMR was referenced in
one type of organizational context. Second, the purposeful sample might not be
representative of the entire population of family practice physicians limiting the
generalizability to one health care organization. Thirdly, the study only included EMR
users in the ambulatory care setting and did not include EMR users in the hospital.
Fourth, the case was selected based on the maximization of information gained and
123
accessibility. Fifth, this study only focused on perceptions of family practice physicians
working in the United States, though adoption is a global problem. A final limitation was
that this design does not allow for inference of cause. However, conducting an
instrumental case study at the research site allowed for an in-depth investigation.
Recommendations to Leaders and Practitioners
EMR system. The decision-making process focused on the acceptance and use of a
physicians during an EMR system transition; to accelerate acceptance and use of future
EMR replacement systems.
The general problem was, despite previous EMR use, transitioning to a different
EMR system or upgrading the current system has unique and significant challenges that
differ from transitioning from paper records (Edsall & Adler, 2015). Edsall and Adler
(2015) found that the number one challenge in switching EMR systems was the time
investment followed by productivity loss, difficulty learning the new system, cost to
switch systems, data loss in the conversion, difficulty using the new system, and lastly
the loss of functions of the old system. Understanding those differences are important
because as technology, industry, and policies change, systems need to be upgraded or
replaced (Edsall & Adler, 2015).
Understanding the key decision-making factors of family practice physicians
related to EMR acceptance and use could be used to better develop and plan future EMR
transitions to help expedite acceptance and use. The benefits gained from an EMR system
124
are only accomplished by getting the greatest number of physicians using an EMR
system (Lakbala & Dindarloo, 2014) and increases exponentially with prolonged use of
the system (King et al., 2014). Recommendations based on the three themes and the eight
subthemes that emerged from this research study are in Table 2:
Table 2
Recommendations to Leaders
THEME RECOMMENDATION
Highlight the features of the new system

Theme 1: Accepting and Using an EMR that increase the quality of care delivered
means Continuity of Care. such as sharing notes across a health care
network or a decision support system to
identify gaps in preventative care.
Develop a multidisciplinary quality training

Theme 2: Overcoming Barriers and program that addresses workflows and
Challenges means Addressing them. standards for data input and filing of
outside records.
The recommendation by the participants as

well as the literature is to not interface old
data because of the risks involved. Make
Subtheme 1: The challenge of importing the system available before go-live so the
old records. minimum of allergies, problems, and
medications can be entered into the new
system. Maintain access to the old system
for as long as possible, ideally 3 years.
Work with physicians so that a standard

Subtheme 2: Finding records in the new
filing system can be developed so
system.
documents are easy to locate.
Recommendations from the participants

and the literature are to offer a variety of
types of training but make sure the trainers
Subtheme 3: Lack of consistency in are well trained themselves and consistent
Training. in the information and processes they train.
125
Another recommendation is to try to stick
to the go-live date to ensure training occurs
Subtheme 4: Timing of go-live.
between 2 to 8 weeks before go-live for
optimal retention.
It is highly recommended to have a

training environment before go-live so the
Subtheme 5: Lack of support physicians can get acclimated to the new
system and to have highly trained support
staff, super users.
The literature recommends identifying any

workarounds and improve workflows or
Subtheme 6: Workarounds.
enhance EMR education on use to
eliminate workarounds.
Based on the findings of this research and

supported by the literature,
Subtheme 7: Physicians’ recommendations include enhanced
recommendations for future transitions. physician participation in planning,
training, and execution of new EMR
systems.
Be prepared to address some of the

emotional aspects transitioning EMRs
Theme 3: Transitioning is an Emotional
have on physicians and have conversations
Experience.
with the physicians to address them as they
arise.
A supportive environment with realistic

goals and expectations of performance
should be created and maintained by
Subtheme 1: Decreased compensation. leadership. Develop a plan to address the
financial impact an EMR transition has on
physicians who are on a productivity
compensation model.
Recommendations for Future Research
The old EMR system that this group transitioned from did not have an ambulatory
medical record system that interfaced with the hospital. The ability to share medical
126
records and ancillary testing seemed to be a driver to acceptance and use based on what
the participants expressed. The story from waiting an hour and a half for hospital reports
to being able to access them with a click of a button must also give the patients a sense of
comfort knowing that their family practice has all their medical history and is informed.
Improvements in interoperability are increasing as well as innovations in EMR systems.
More research is needed to determine a best- practice in the EMR transition to help
expedite adoption and use.
Recommendations for future research would be to conduct a survey based on the
findings of this study to explore a larger population of providers. Likewise, conduct a
comparative study with other types of health care providers or with allied health
professionals for a multidisciplinary perspective. Similarly, conduct a comparative study
with other health systems that have transitioned EMR systems. Further investigation is
needed into the strong emotional impact these EMR transitions have on physicians to try
to mitigate them in future transitions.
Chapter Summary
Northeastern Indiana. The problem statement for this study called for an understanding of
the different challenges in transitioning EMR systems than from paper and how
physicians’ perceptions of the EMR system affect adoption and use. The research
questions were the focus:
127
Five major findings emerged from the study; 1) quality of care gained for the
patients was what 75% of the participants expressed as their motivating factor to decide
to use a replacement EMR system, 2) all of the participants reported that lack of IT
support was a barrier to EMR acceptance and use, 3) all participants identified challenges
to transitioning to a replacement EMR system 4) all participants were observed to have
developed workarounds, and 5) all participants noted transitioning to a replacement EMR
system was an emotional experience. The themes from Chapter 4 were compared and
contrasted with the literature from Chapter 2 and included in Chapter 5. The study
findings have contributed to a better understanding of the experiences and emotions of
physicians transitioning EMR systems. Consideration needs to be given to the emotional
impact EMR transitions have on physicians.
128
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Appendix A
144
145
Appendix B
Recruitment Protocol
PARTICIPANT RECRUITMENT
Researcher: Hello, this is Diana Berich Brieva. I am calling because I am conducting a
research study in partial fulfillment of my doctorate degree in Health Administration
from the University of Phoenix. The title of my research study is FAMILY PRACTICE
PHYSICIANS’ ACCEPTANCE AND USE OF A REPLACEMENT ELECTRONIC
MEDICAL RECORD SYSTEM: AN INSTRUMENTAL CASE STUDY. The purpose of
this qualitative instrumental case study will be to explore the decision- making process of
family practice physicians transitioning to a replacement EMR system at a multi-
specialty ambulatory clinic located in a metropolitan area of Northeastern Indiana. The
decision-making process will focus on the acceptance and use of the replacement EMR
system and the drivers and challenges faced by family practice physicians during the
transition with a goal of accelerating acceptance and use of future EMR replacement
systems.
You were selected because you are a family practice physician who is at least 21
years of age and practicing at a multi-specialty medical group in Northeastern Indiana
who transitioned to a replacement EMR system in 2019. Your participation will involve
either a face-to-face or virtual Google Meet (due to COVID-19 restrictions) interview
that should not last longer than an hour. With your permission, I would like to audio or
audio/video (Google Meet) record the interview so that I capture your words accurately.
If you are uncomfortable with an audio or audio/video recording, I will take hand notes.
For your convenience and confidentiality, face-to-face interviews will be conducted in
146
your private office at the clinic and after work hours.
Participation will also include (pending COVID-19 restrictions) being observed in your
clinic, excluding patient exam rooms, for about an hour to see how you are currently
using your electronic medical record. Observations will be documented in field notes and
stored electronically. Date and time of observation will be at your convenience.
If you have any questions about the research study, please call me at 260-417-4985
or email me at dberich@email.phoenix.edu.
147
Appendix C
INFORMED CONSENT: PARTICIPANTS 21 YEARS OF AGE AND OLDER
Dear Participant (__________________________),
My name is Diana Berich Brieva and I am a student at the University of Phoenix working
on a Doctorate in Health Administration degree. I am doing a research study entitled
FAMILY PRACTICE PHYSICIANS’ ACCEPTANCE AND USE OF A
REPLACEMENT ELECTRONIC MEDICAL RECORD SYSTEM: AN
INSTRUMENTAL CASE STUDY.
Participation in this study will provide useful information to lawmakers, electronic

medical record (EMR) system developers, and health care administrators on the
challenges, drivers, and emotional factors involved in EMR transitions for physicians.
The purpose of this qualitative instrumental case study will be to explore the decision-
making process of family practice physicians transitioning to a replacement EMR system
at a multi-specialty ambulatory clinic located in a metropolitan area of Northeastern
Indiana. The decision-making process will focus on the acceptance and use of the
EMR replacement systems.
Your participation will involve either a face-to-face or virtual Google Meet (due to
COVID-19 restrictions) interview that should not last longer than an hour. With your
permission, I would like to audio or audio/video (Google Meet) record the interview so
that I capture your words accurately. If you are uncomfortable with an audio or
audio/video recording, I will take hand notes. For your convenience, face-to-face
interviews will be conducted in your private office at the clinic. Participation will also
include (pending COVID-19 restrictions) being observed in your clinic, excluding patient
exam rooms, for about an hour to see how you are currently using your electronic
medical record. Observations will be documented in field notes and stored electronically.
You can decide to be a part of this study or not. Once you start, you can withdraw from
the study at any time without any penalty. Should you withdraw from the study, all the
data collected from you will be destroyed within 24 hours. The results of the research
study may be published but your identity will remain confidential and your name will not
be made known to any outside party.
148
In this research, there are no foreseeable risks to you.
Although there may be no direct benefit to you, a possible benefit from your being part of
this study is to help fill gaps in the literature of the decision-making process of family
practice physicians in ambulatory care settings and help health care leaders and
policymakers better understand some of the potential drivers, challenges, and emotional
factors of EMR acceptance and use when transitioning or upgrading EMR systems.
If you have any questions about the research study, please call me at 260-417-4985 or
email me at dberich@email.phoenix.edu. For questions about your rights as a study
participant, or any concerns or complaints, please contact the University of Phoenix
Institutional Review Board via email at IRB@phoenix.edu.
As a participant in this study, you should understand the following:
1. You may decide not to be part of this study or you may want to withdraw from
the study at any time. If you want to withdraw, you can do so without any
problems by emailing me at dberich@email.phoenix.edu.
2. Your identity will be kept confidential.
3. Diana Berich Brieva, the researcher, has fully explained the nature of the
research study and has answered all of your questions and concerns.
4. Interviews may be recorded. If they are recorded, you must give permission for
the researcher, Diana Berich Brieva, to record the interviews. You understand
that the information from the recorded interviews will transcribed using Nuance
Dragon speech recognition software. The transcript of the interview will be
shared with you to review for accuracy. The data will be coded to assure that
your identity is protected.
5. Data will be kept secure. Data files will be kept on an encrypted flash drive that
is password protected. Data files, informed consents, paper documents and notes
will be kept in a fireproof safe locked in a room at the researcher’s residence.
Informed consents will be stored separately from raw data in a fireproof safe in a
locked room at the researcher’s residence. The data will be kept for three years,
and then destroyed by burning.
6. The results of this study may be published.
“By signing this form, you agree that you understand the nature of the study, the possible
risks to you as a participant, and how your identity will be kept confidential. When you
sign this form, this means that you are 21 years old or older and that you give your
permission to volunteer as a participant in the study that is described here.”
( ) I accept the above terms. ( ) I do not accept the above terms. (CHECK
ONE)
149
Signature of the research participant ______________________________ Date
____________
Signature of the researcher _____________________________________ Date

____________
150
Appendix D
Interview Guide
1. Ask participant to review and sign informed consent.
BEGINNING THE INTERVIEW – REVIEW INFORMED CONSENT
Researcher: Hello. I want to thank you for taking the time to meet with me today and
allow me to interview you as part of my research project. Your participation will
involve either a face-to-face or virtual Google Meet (due to COVID-19 restrictions)
interview that should not last longer than an hour. With your permission, I would like
to audio or audio/video (Google Meet) record the interview so that I capture your
words accurately. If you are uncomfortable with an audio or audio/video recording, I
will take hand notes. Participation will also include (pending COVID-19 restrictions)
being observed in your clinic, excluding patient exam rooms, for about an hour to see
how you are currently using your electronic medical record. Observations will be
documented in field notes and stored electronically.
You can decide to be a part of this study or not. Once you start, you can withdraw
from the study at any time without any penalty. Should you withdraw from the study,
all the data collected from you will be destroyed within 24 hours. The results of the
research study may be published but your identity will remain confidential and your
name will not be made known to any outside party.
RISKS OF PARTICIPATION
In this research, there are no foreseeable risks to you.
151
BENEFITS OF PARTICIPATION
Although there may be no direct benefit to you, a possible benefit from your being
part of this study is to help fill gaps in the literature of the decision-making process of
family practice physicians in ambulatory care settings and help health care leaders
and policy makers better understand some of the potential drivers, challenges, and
emotional factors of EMR acceptance and use when transitioning or upgrading EMR
systems.
QUESTIONS
If you have any questions about the research study, please call me at 260-417-4985 or
email me at dberich@email.phoenix.edu. For questions about your rights as a study
participant, or any concerns or complaints, please contact the University of Phoenix
Institutional Review Board via email at IRB@phoenix.edu.
PARTICIPANT’S RIGHTS
As a participant in this study, you should understand the following:
1. You may decide not to be part of this study or you may want to withdraw from
the study at any time. If you want to withdraw, you can do so without any
problems by emailing me at dberich@email.phoenix.edu.
2. Your identity will be kept confidential.
3. Diana Berich Brieva, the researcher, has fully explained the nature of the research
study and has answered all of your questions and concerns.
152
4. Interviews may be recorded. If they are recorded, you must give permission for
the researcher, Diana Berich Brieva, to record the interviews. You understand that
the information from the recorded interviews will be transcribed using Nuance
Dragon speech recognition software. The transcript of the interview will be shared
with you to review for accuracy. The data will be coded to assure that your
identity is protected.
5. Data will be kept secure. Data files will be kept on an encrypted flash drive that is
password protected. Data files, informed consents, paper documents, and notes
will be kept in a fireproof safe locked in a room at the researcher’s residence. The
data will be kept for three years and then destroyed by burning.
6. The results of this study may be published.
DURING THE INTERVIEW
Researcher: I want to be engaged with you and listen carefully to what is being said.
The tape recorder will allow me to listen intently without braking eye contact. I may
periodically need to take notes and they will be quick jots as to not distract the you
while speaking.
Researcher: After the interview I will check the recording to make sure everything
was captured. I will spend time filling in notes about my observations before I leave
to make sure everything is fresh in my mind. I may ask you to review my notes to
ensure I have accurately captured what was said.
2. Ask participant to complete demographic survey
153
3. 1st Question: Would you please share with me your experience with accepting and
using an electronic medical record system in your clinic and how you prepared for the
transition to the new system? How were you able to overcome barriers and challenges
inherent in EMR system acceptance and use?
Performance Expectancy:
Effort Expectancy:
Social Influence:
Facilitating Conditions:
Does the response from question 1 answer the below questions; if not, please ask these
supplemental questions:
A. Performance Expectancy: Please share with me your experience of any increased
job performance because to the EMR system?
B. Effort Expectancy: Please share with me your experience on the ease of using the
system?
C. Social Influence: Please share with me your perception of others expectation of

you on use of the system; was anyone specific influential?
D. Facilitating Conditions: Please share with me your thoughts on the organizational

and technical infrastructure to support the EMR system?
4. 2nd Question: Would you please share with me how you have been feeling
emotionally about this impending EMR system change?
CONCLUDING THE INTERVIEW
Researcher: I want to thank you again for your time today. Should you have any
questions or concerns about the study after I leave here today please feel free to reach me
at reach me at 260-417-4985 or email me at dberich@email.phoenix.edu.
Participant #_______________
For researcher use only
154
Appendix E
Demographic Survey
The theoretical framework for this study is the Unified Theory of Acceptance and Use of
Technology (UTAUT) which identifies certain demographic characteristics as mitigating
factors in the model. Those demographic characteristics are included below:
Please CIRCLE the most applicable response.
1. Gender: MALE FEMALE
2. Age (in years): 21-34 35-44 45-54 55-64 65+
3. Years of experience using an electronic medical record (EMR) (in years):
<2 years 2-5 years 6-10 years 11+ years
4. Do you feel use of the EMR system is voluntary: Yes No
5. How long do feel it took for you to become comfortable with using an EMR system?
(Please fill in with the appropriate number in the respective time frame)
__________ Days _________ Weeks __________ Months __________ Years
155
Appendix F
Observation Guide
Name of Observer: ________________________ Role of Observer: Participant
Observer
Location: _____________________________________ Date:
_______/________/_______
Start Time: _____:____ am or pm End Time: _____:____ am or pm Duration:
______mins
Pseudonym of participant: ____________________________________
What to Observe - Research Questions: (specific focus of observation based on research

questions highlighted and underlined and participant’s responses to interview questions
within the context of Performance Expectancy, Effort Expectancy, Social Influence, and
Facilitating Conditions; UTAUT Model)
x How did family practice physicians form their decision to accept and use a
replacement EMR system?, (Acceptance and use of the system will be observed
by how the participant uses the EMR system and if any “workarounds” have been
created. Workarounds such as documenting on paper and scanning the paper
document instead of entering the data in the system or the physician having the
staff print documents out of the EMR instead of using the system as designed
will be the focus. Also looking for increased job performance and ease of using
the system, performance expectancy and effort expectancy)
x How did family practice physicians overcome barriers and challenges
156
associated with transitioning EMR systems?, (Barriers and challenges, if any,
identified by the participant during the interview will be the focus during the
observation. Also looking for how the organizational and technical infrastructure
supports the EMR system, ie hardware, software, network connections, end-user
support, and interfaces to name a few, facilitating conditions.)
x How did family practice physicians feel emotionally during the transition?
(Focusing on any emotions exhibited while using the EMR system, frustrations,
excitement, etc. and any collaborations with other physicians or staff on
navigating the system, social influence.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________
Reflections – initial impressions and interpretations of activities and events under
157
observation.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________
158
Appendix G
159
160
Appendix H
Coding Interviews
Codes
Name Description Files References
Acceptance and Use of an Effort Expectancy, Performance 0 0

EMR System means Expectancy, and Social Influence
Continuity of Care
Effort Expectancy Participant's perception of how easy the 8 38

new system is to use
cumbersome A term used by several participants 3 4

regarding the new system
Experience Accepting Participants shared their experience 8 45

and Using EMR accepting and using EMR systems
Performance How has the new system impacted job 8 43

Expectancy performance
Social Influence The expectation of others to use the 7 26

system was anyone specifically helpful
during the transition
Expectation of Participant's perception of expected use of 6 10

Use the system
Next Transition Advice for the next transition 8 51
Old Records Advice on what to do with old records for 5 17

next transition
Would have done What if anything would they have done 3 7

differently differently looking back
Overcoming Barriers and How were barriers and challenges 8 39

Challenges means overcome
Addressing Them
161
Actual Workflow 0 0
Charting How was charting done 5 6
Documentation When and where is the physician 7 10

by Physician documenting into the patient's chart
Gives nurses Giving verbal orders instead of entering 1 1

verbal them
instruction
Pace What was the pace of the clinic like 3 5
Paper What type of paper documents are being 7 9

supplements used
Scribe What tasks are the scribes performing and 2 8

where
Telehealth Visit What is the workflow for a telehealth visit 1 1
Benefits of the new What were some of the benefits the 6 12

system participants found in the new system
Facilitating Participant's thoughts on how the 8 48

Conditions organizational and technical infrastructure
supported the new EMR system
Communication How information about the system is 5 18

shared
Latency Slowness and/or wifi connection issues 6 10

Connectivity experienced by participants
Issues
Old Records Access/availability/interface of old records 3 10
Training Participant's experience with training to 8 69

prepare for the new system
Consistency Records are getting filed into the new 6 13

in Filing system
162
Elbow Participant's experience with the elbow 7 19

Support support for the first three weeks of go-live
Favorite Participant's experience with the vendor's 4 6

Fair favorites fair
Spring Go-live occurred during spring break for 3 3

Break some participants
Workarounds What workarounds, if any, are being used 2 3
Transitioning is an Participant's sharing how they felt 4 9

Emotional Experience emotionally transitioning EMR systems
Anger 2 4
Embarrassment Looking inept in front of patients 2 2
Offended 1 1
Anxiety 6 10
Disappointment 2 3
Excitement 2 3
Exhausted 1 1
Hopeful 1 1
Resentment 2 2
Resolve 1 1
Stress 5 9
Frustration 7 21
Loss in Loss of pay/production was the result of 4 7

Pay_Productivity transitioning systems for some participants
Versus Coding 1 1
163
Administration 1 1
vs Physician
Expectation vs 1 1
Reality
Our Needs vs 1 1
System
Capabilities
164

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FAMILY PRACTICE PHYSICIANS’ ACCEPTANCE AND USE OF A REPLACEMENT

ELECTRONIC MEDICAL RECORD SYSTEM: INSTRUMENTAL CASE STUDY

Diana Cointa Berich Brieva

A Dissertation Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Health Administration

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practice physicians transitioning to a replacement EMR system at a multi-specialty

physicians feel emotionally during the transition. Semi-structured interviews of 8 family

leaders, policymakers, and health information technology designers and implementors in

always give you the attention you wanted.

I do not have the words to express my gratitude to my dissertation chair, Dr.

presentation at an international research conference. I was so impressed with that

time and valuable feedback.

Contents: .......................................................................................................... Pages

List of Tables .......................................................................................................... X

List of Figures ....................................................................................................... XI

Chapter 1: Introduction ...........................................................................................1

Chapter 2: Review of the Literature.......................................................................24

Table 1: Demographic Survey Results...................................................................85

Table 2: Recommendations to Leaders........................................................... 125

Figure 1 Unified Theory of Acceptance and Use of Technology (UTAUT).........16

Figure 2 The Seven-Step Coding Process..............................................................86

Transitioning from an older legacy electronic health record (EHR) system to a

(MarketsandMarkets, 2018). As ambulatory care settings rushed to adopt an EMR system

This study was an opportunity to gain a better understanding of the decision-

EMR can be accelerated by vendors and health care organizations understanding

implementers, and policymakers transitioning to or upgrading an EMR system. Health

of the research method, design appropriateness, research question, and theoretical

concluded with a chapter summary.

Background of the Problem

an incentive program created to encourage widespread EHR adoption by easing the

years for Medicaid providers (CDC, 2012).

reached 69.6% (IQVIA, 2018).

significantly decreased over time in areas of overall satisfaction, productivity, better

government incentives (Andresen et al., 2017). A survey of eligible providers (EP)

focus from patient care to reporting requirements by imposing greater compliance

leaders, policymakers, and EMR system implementers a better understanding of the

literature by addressing gaps in the literature in understanding physicians’ decision to

because as technology, industry, and policies change, systems need to be upgraded or

based (Martin, 2017).

Understanding the key decision-making factors of family practice physicians related to

when physicians transition to a new EMR system.

process of family practice physicians in ambulatory care settings transitioning an EMR

challenges of EMR acceptance and use when transitioning or

upgrading EMR systems.

Purpose of the Study

decision- making process of family practice physicians transitioning to a replacement

EMR system at a multi-specialty ambulatory clinic located in a metropolitan area of

accelerating acceptance and use of future EMR replacement systems.

Busaidi, 2008). The goal of qualitative research is to understand issues or situations by

methods (Strauss & Corbin, 1998).

that investigates a contemporary phenomenon in-depth and with a real-world context. An

issues (Grandy, 2010). Gaining a better understanding of the decision-making processes

environment is a perfect example of the Scholar, Leadership, Practice model of the

University of Phoenix, and what drives this study.

Population and Sample

The population for this study included all physicians transitioning to a

physicians transitioning to a replacement EMR system at a multispecialty group located

they are especially informative, 2) would like to recruit a difficult-to-reach, specialized

Participants included a sample of 8 family practice physicians employed in an

owned multi-specialty practice in a metropolitan area of Northeastern Indiana. All

studies is to provide a rich, contextualized understanding of human experience by

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