Electronic health record usage behaviors in primary care medical practices: A survey of family physicians in Canada

Healthcare Professionals’ Perceptions, Barriers, and Facilitators towards Adopting Computerised Clinical Decision Support Systems in Antimicrobial Stewardship in Jordanian Hospitals

Understanding healthcare professionals’ perceptions towards a computerised decision support system (CDSS) may provide a platform for the determinants of the successful adoption and implementation of CDSS. This cross-sectional study examined healthcare professionals’ perceptions, barriers, and facilitators to adopting a CDSS for antibiotic prescribing in Jordanian hospitals. This study was conducted among healthcare professionals in Jordan’s two tertiary and teaching hospitals over four weeks (June–July 2021). Data were collected in a paper-based format from senior and junior prescribers and non-prescribers (n = 254) who agreed to complete a questionnaire. The majority (n = 184, 72.4%) were aware that electronic prescribing and electronic health record systems could be used specifically to facilitate antibiotic use and prescribing. The essential facilitator made CDSS available in a portable format (n = 224, 88.2%). While insufficient training to use CDSS was the most significant barrier (n = 175, 68.9%). The female providers showed significantly lower awareness (p = 0.006), and the nurses showed significantly higher awareness (p = 0.041) about using electronic prescribing and electronic health record systems. This study examined healthcare professionals’ perceptions of adopting CDSS in antimicrobial stewardship (AMS) and shed light on the perceived barriers and facilitators to adopting CDSS in AMS, reducing antibiotic resistance, and improving patient safety. Furthermore, results would provide a framework for other hospital settings concerned with implementing CDSS in AMS and inform policy decision-makers to react by implementing the CDSS system in Jordan and globally. Future studies should concentrate on establishing policies and guidelines and a framework to examine the adoption of the CDSS for AMS.

Willingness to use electronic medical record (EMR) system and its associated factors among health professionals working in Amhara region Private Hospitals 2021, Ethiopia

INTRODUCTION

Despite the high expectations of electronic medical records as a great prospect for improving performance in healthcare, the level of adoption and utilization, particularly in a developing country, is low. Knowing the willingness to use the electronic medical record system in the private hospital has an impact on the future implementation status and utilization of the electronic medical record in Ethiopia. However, there was no evidence of the status of the willingness to use electronic medical record systems in private hospitals in the Amhara region. This study aimed to assess the willingness to use electronic medical record Systems and its associated factors among health professionals working in Amhara Region Private Hospitals.

METHODS

A cross-sectional institutional study was performed among 406 health professionals selected using proportional allocation with a simple random sampling technique in Amhara region private hospitals by using self-administered structured questionnaires. The data were analyzed using SPSS version 20 software. Descriptive statistics and binary logistic regression were performed to estimate the crude and adjusted odds ratios with a 95% Confidence interval.

RESULTS

Out of the 406 participants included in the analysis, 307 (75.6%) showed a willingness to use the electronic medical record system. About three hundred twelve (76.8%) health professionals had good knowledge of electronic medical record systems, and 257 (63.3%) had good computer skills in electronic medical record systems. Health professionals who had electronic medical record knowledge (AOR = 1.85, 95% CI (1.004-3.409)), EMR training (3.29, 95% CI (1.353-8.003)), technical support personnel (1.92, 95% CI (1.122-3.305)), supportive supervision (AOR = 1.97, 95% CI (1.072-3.628)), and computer skill on electronic medical record (1.77, 95% CI (1.002-3.148)) were significantly associated with the outcome variable.

CONCLUSIONS

This finding shows a good proportion of willingness to use the electronic medical record system. The most significant factors associated with willingness to use the electronic medical record system were a lack of computer skills, computer training, and knowledge of the electronic medical record system.

Designing a reference architecture for health information systems

Background

Healthcare relies on health information systems (HISs) to support the care and receive reimbursement for the care provided. Healthcare providers experience many problems with their HISs due to improper architecture design. To support the design of a proper HIS architecture, a reference architecture (RA) can be used that meets the various stakeholder concerns of HISs. Therefore, the objective of this study is to develop and analyze an RA following well-established architecture design methods.

Methods

Domain analysis was performed to scope and model the domain of HISs. For the architecture design, we applied the views and beyond approach and designed the RA’s views based on the stakeholders and features from the domain analysis. We evaluated the RA with a case study.

Results

We derived the following four architecture views for HISs: The context diagram, decomposition view, layered view, and deployment view. Each view shows the architecture of the HIS from a different angle, suitable for various stakeholders. Based on a Japanese hospital information system study, we applied the RA and derived the application architecture.

Conclusion

We demonstrated that the methods of the software architecture design community could be used in the healthcare domain effectively and showed the applicability of the RA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01570-2.

Perception of the health surveillance users on the health electronic surveillance network (HESN), Saudi Arabia, 2016

Background

The established aim of the Saudi Health Electronic Surveillance Network (HESN) is to support the prevention and control of different health events, and to facilitate the delivery of other public health programs. This study aims to evaluate the perceptions of active HESN users regarding its general performance through five major components: practicability, design, data and communication, technical support, and general impression.

Methods

A cross-sectional study was conducted in 2016 using a sample of active HESN users. Out of 1535 active users, 700 were randomly selected. A predesigned electronic questionnaire was sent to each participant via email which was completed by 485 participants. Different composite scores were calculated and compared to the sociodemographic and other technical variables.

Results

The mean age of the participants was 36.92 ± 9.12 (24–65 years), and 57.8% of the sample were male. Riyadh and the KSA’s eastern province represented the highest two regions of participation, at (18.4%) and (14.2%) participants, respectively. About 70.8% were generally satisfied with HESN, while 86.6%% believed that it is better than the traditional paper-work system. Participants who used to work more frequently expressed more level of satisfaction compared to those with minimal use per week or month (P ≤ 0.001). Internet speed displayed a significant association with the general level of satisfaction with HESN (P < 0.001). Additionally, users who accessed HESN with the Google Chrome browser displayed higher levels of satisfaction when compared to users who relied on other browsers (P = 0.003).

Conclusion

Presently, the level of user satisfaction with HESN is reasonable. However, to achieve optimal outcomes for HESN usage, improvements should be considered.

The Adoption of Electronic Health Records in Primary Healthcare Settings

Little is known about the adoption rate of electronic health records in primary healthcare settings. This study aimed to estimate this adoption rate in Jordan, using a national survey with a descriptive cross-sectional design. The first step was to review the annual report of the Jordanian Ministry of Health as a basis for identifying the sample, which are primary healthcare settings. Then, Electronic Health Solutions, the company that vends electronic health record systems in Jordan, was used to determine which primary healthcare settings were using these electronic record systems. The final task was to determine which functionalities of the system were being used in these settings, and for this, a telephone survey of key personnel was conducted. It was found that 21.6% of the primary healthcare settings were using electronic health records, while the other 78.4% were still relying on paper records. The results also showed that the adoption rate of electronic health records was significantly associated with the type of the setting (P < .001), its size (P < .001), location (P < .001), and region (P = .04). As a conclusion, the adoption rate in Jordan is still in its infancy compared with those in developed countries. Policy and decision makers should therefore be focused on minimizing any challenges or obstacles to such adoption.

Evaluating the effects of electronic health records system adoption on the performance of Malaysian health care providers

BACKGROUND

The Ministry of Health of Malaysia has invested significant resources to implement an electronic health record (EHR) system to ensure the full automation of hospitals for coordinated care delivery. Thus, evaluating whether the system has been effectively utilized is necessary, particularly regarding how it predicts the post-implementation primary care providers' performance impact.

METHODS

Convenience sampling was employed for data collection in three government hospitals for 7 months. A standardized effectiveness survey for EHR systems was administered to primary health care providers (specialists, medical officers, and nurses) as they participated in medical education programs. Empirical data were assessed by employing partial least squares-structural equation modeling for hypothesis testing.

RESULTS

The results demonstrated that knowledge quality had the highest score for predicting performance and had a large effect size, whereas system compatibility was the most substantial system quality component. The findings indicated that EHR systems supported the clinical tasks and workflows of care providers, which increased system quality, whereas the increased quality of knowledge improved user performance.

CONCLUSION

Given these findings, knowledge quality and effective use should be incorporated into evaluating EHR system effectiveness in health institutions. Data mining features can be integrated into current systems for efficiently and systematically generating health populations and disease trend analysis, improving clinical knowledge of care providers, and increasing their productivity. The validated survey instrument can be further tested with empirical surveys in other public and private hospitals with different interoperable EHR systems.

Factors affecting the mature use of electronic medical records by primary care physicians: a systematic review

BACKGROUND

Despite a substantial increase in the adoption of electronic medical records (EMRs) in primary health care settings, the use of advanced EMR features is limited. Several studies have identified both barriers and facilitating factors that influence primary care physicians' (PCPs) use of advanced EMR features and the maturation of their EMR use. The purpose of this study is to explore and identify the factors that impact PCPs' mature use of EMRs.

METHODS

A systematic review was conducted in accordance with the Cochrane Handbook. The MEDLINE, Embase, and PsycINFO electronic databases were searched from 1946 to June 13, 2019. Two independent reviewers screened the studies for eligibility; to be included, studies had to address factors influencing PCPs' mature use of EMRs. A narrative synthesis was conducted to collate study findings and to report on patterns identified across studies. The quality of the studies was also appraised.

RESULTS

Of the 1893 studies identified, 14 were included in this study. Reported factors that influenced PCPs' mature use of EMRs fell into one of the following 5 categories: technology, people, organization, resources, and policy. Concerns about the EMR system's functionality, lack of physician awareness of EMR functionality, limited physician availability to learn more about EMRs, the habitual use of successfully completing clinical tasks using only basic EMR features, business-oriented organizational objectives, lack of vendor training, limited resource availability, and lack of physician readiness were reported as barriers to PCPs' mature use of EMRs. The motivation of physicians, user satisfaction, coaching and peer mentoring, EMR experience, gender, physician perception, transition planning for changes in roles and work processes, team-based care, adequate technical support and training, sharing resources, practices affiliated with an integrated delivery system, financial incentives, and policies to increase EMR use all had a favorable impact on PCPs' use of advanced EMR features.

CONCLUSIONS

By using a narrative synthesis to synthesize the evidence, we identified interrelated factors influencing the mature use of EMRs by PCPs. The findings underline the need to provide adequate training and policies that facilitate the mature use of EMRs by PCPs.

TRIAL REGISTRATION

PROSPERO CRD42019137526.

Perceived Value of Electronic Medical Records in Community Health Services: A National Cross-Sectional Survey of Primary Care Workers in Mainland China

Objective: To evaluate the degree to which electronic medical records (EMRs) were used in primary care and the value of EMRs as perceived by primary care workers in China. Methods: A cross-sectional survey was conducted on 2719 physicians (n = 2213) and nurses (n = 506) selected from 462 community health centres across all regions of mainland China except for Tibet. Regional differences in the responses regarding the functionality of existing EMR systems and the perceived value of EMRs were examined using Chi-square tests and ordinal regression analyses. Results: Less than 59% of the community health centres had adopted EMRs. More than 89% of the respondents believed that it was necessary to adopt EMRs in primary care. Of the existing EMR systems, 50% had access to telehealth support for laboratory, imaging or patient consultation services. Only 38.4% captured data that met all task needs and 35.4% supported referral arrangements. “Management of chronic conditions” was voted (66%) as the top preferred feature of EMRs. Higher levels of recognition of the value of EMRs were found in the relatively more developed eastern region compared with their counterparts in other regions. Conclusions: Rapid EMR adoption in primary care is evident in mainland China. The low level of functionality in data acquisition and referral arrangements runs counter to the requirements for “management of chronic conditions”, the most preferred feature of EMRs in primary care. Regional disparities in the realised value of EMRs in primary care deserve policy attention.

Intention to use electronic medical record and its predictors among health care providers at referral hospitals, north-West Ethiopia, 2019: using unified theory of acceptance and use technology 2(UTAUT2) model

BACKGROUND

Electronic Medical Records (EMRs) are systems to store patient information like medical histories, test results, and medications electronically. It helps to give quality service by improving data handling and communication in healthcare setting. EMR implementation in developing countries is increasing exponentially. But, only few of them are successfully implemented. Intention to use EMRs by health care provider is crucial for successful implementation and adoption of EMRs. However, intention of health care providers to use EMR in Ethiopia is unknown.

OBJECTIVE

The aim of this study was to assess health care provider's intention to use and its predictors towards Electronic Medical Record systems at three referral hospitals in north-west, Ethiopia, 2019.

METHODS

Institutional based cross-sectional explanatory study design was conducted from March to September among 420 health care providers working at three referral hospitals in north-west Ethiopia. Data were analyzed using structural equation model (SEM). Simple and multiple SEM were used to assess the determinants of health care providers intention to use EMRs. Critical ratio and standardized coefficients were used to measure the association of dependent and independent variables, 95% confidence intervals and P-value were calculated to evaluate statistical significance. Qualitative data was analyzed using thematic analysis.

RESULT

The mean age of the study subjects was 32.4 years ±8.3 SD. More than two-third 293(69.8%) of the participants were male. Among 420 health care providers, only 167 (39.8%) were scored above the mean of intention to use EMRs. Factors positively associated with intention to use EMRs were performance expectancy (β = 0.39, p < 0.001), effort expectancy (β = 0.24,p < 0.001),social influence (β = 0.18,p < 0.001),facilitating condition (β = 0.23,p < 0.001), and computer literacy (β = 0.08,p < 0.001). Performance expectancy was highly associated with intention to use EMRs.

CONCLUSION

Generally, about 40 % of health care providers were scored above the mean of intention to use EMRs. Performance expectancy played a major role in determining health care providers' intention to use EMRs. The intention of health care providers to use EMRs was attributed by social influence, facilitating condition in the organization, effort expectancy, performance expectancy and computer literacy. Therefore, identifying necessary prerequisites before the actual implementation of EMRs will help to improve the implementation status.

Embedding "Smart" Disease Coding Within Routine Electronic Medical Record Workflow: Prospective Single-Arm Trial

BACKGROUND

Electronic medical record (EMR) chronic disease measurement can help direct primary care prevention and treatment strategies and plan health services resource management. Incomplete data and poor consistency of coded disease values within EMR problem lists are widespread issues that limit primary and secondary uses of these data. These issues were shared by the McMaster University Sentinel and Information Collaboration (MUSIC), a primary care practice-based research network (PBRN) located in Hamilton, Ontario, Canada.

OBJECTIVE

We sought to develop and evaluate the effectiveness of new EMR interface tools aimed at improving the quantity and the consistency of disease codes recorded within the disease registry across the MUSIC PBRN.

METHODS

We used a single-arm prospective trial design with preintervention and postintervention data analysis to assess the effect of the intervention on disease recording volume and quality. The MUSIC network holds data on over 75,080 patients, 37,212 currently rostered. There were 4 MUSIC network clinician champions involved in gap analysis of the disease coding process and in the iterative design of new interface tools. We leveraged terminology standards and factored EMR workflow and usability into a new interface solution that aimed to optimize code selection volume and quality while minimizing physician time burden. The intervention was integrated as part of usual clinical workflow during routine billing activities.

RESULTS

After implementation of the new interface (June 25, 2017), we assessed the disease registry codes at 3 and 6 months (intervention period) to compare their volume and quality to preintervention levels (baseline period). A total of 17,496 International Classification of Diseases, 9th Revision (ICD9) code values were recorded in the disease registry during the 11.5-year (2006 to mid-2017) baseline period. A large gain in disease recording occurred in the intervention period (8516/17,496, 48.67% over baseline), resulting in a total of 26,774 codes. The coding rate increased by a factor of 11.2, averaging 1419 codes per month over the baseline average rate of 127 codes per month. The proportion of preferred ICD9 codes increased by 17.03% in the intervention period (11,007/17,496, 62.91% vs 7417/9278, 79.94%; χ²₁=819.4; P<.001). A total of 45.03% (4178/9278) of disease codes were entered by way of the new screen prompt tools, with significant increases between quarters (Jul-Sep: 2507/6140, 40.83% vs Oct-Dec: 1671/3148, 53.08%; χ²₁=126.2; P<.001).

CONCLUSIONS

The introduction of clinician co-designed, workflow-embedded disease coding tools is a very effective solution to the issues of poor disease coding and quality in EMRs. The substantial effectiveness in a routine care environment demonstrates usability, and the intervention detail described here should be generalizable to any setting. Significant improvements in problem list coding within primary care EMRs can be realized with minimal disruption to routine clinical workflow.

A model to measure self-assessed proficiency in electronic medical records: Validation using maturity survey data from Canadian community-based physicians

OBJECTIVE

Adoption of electronic medical records (EMRs) does not necessarily translate to proficiency -referred to here as EMR maturity. To realize the full benefit of wide scale EMR adoption, the focus must shift from adoption to advancing mature use. This calls for validated assessment models so that researchers, health system planners and digital health developers can better understand what contributes to maturity among physicians. This research aims to validate a measurement model for self-assessed EMR maturity among community-based physicians.

METHODS

As part of an Ontario government-funded EMR adoption program, the EMR Maturity Model for community-based practices was adapted from a hospital-based EMR maturity model. A survey instrument was developed on the foundation of the new model and revised by experts and stakeholders. Content validity, face validity and user acceptance were established before survey administration. Internal consistency and construct validity of the model were tested after survey data were collected. Finally, physicians' comments collected via the survey were qualitatively analyzed to provide additional insights that can be applied to refinement of the model and survey.

RESULTS

As of August 1, 2019, 1588 physicians completed the survey. Ordinal alpha tests for reliability and content validity yielded an alpha value of 0.86 across all key measures specifically associated with maturity. Among most of these, there was a pattern of weak to moderate significant (p < .0001) positive Spearman inter-correlations. One factor was extracted for items measuring dimensions of maturity and all factor loadings of the key measures were greater than 0.40. The fit of the one-factor model was moderately adequate. This indicates the model is valid and reliable, with consistency across key measures for measuring one factor: maturity.

CONCLUSIONS

This is the first known validated model published in English that measures EMR maturity among community-based physicians. While the model is shown to be valid and reliable statistically and qualitative analysis supports this, there is room for improvement. Both the statistical analysis and portions of the qualitative analysis suggest areas of exploration to strengthen the model and survey. Future efforts will include refining the survey to improve user interface and accrue further data, as the sample to date is insufficient for generalizability.

Advancing laboratory medicine in hospitals through health information exchange: a survey of specialist physicians in Canada

BACKGROUND

Laboratory testing occupies a prominent place in health care. Information technology systems have the potential to empower laboratory experts and to enhance the interpretation of test results in order to better support physicians in their quest for better and safer patient care. This study sought to develop a better understanding of which laboratory information exchange (LIE) systems and features specialist physicians are using in hospital settings to consult their patients' laboratory test results, and what benefit they derive from such use.

METHODS

As part of a broader research program on the use of health information exchange systems for laboratory medicine in Quebec, Canada, this study was designed as on online survey. Our sample is composed of 566 specialist physicians working in hospital settings, out of the 1512 physicians who responded to the survey (response rate of 17%). Respondents are representative of the targeted population of specialist physicians in terms of gender, age and hospital location.

RESULTS

We first observed that 80% of the surveyed physicians used the province-wide interoperable electronic health records (iEHR) system and 93% used a laboratory results viewer (LRV) to consult laboratory test results and most (72%) use both systems to retrieve lab results. Next, our findings reveal important differences in the capabilities available in each type of system and in the use of these capabilities. Third, there are differences in the nature of the perceived benefits obtained from the use of each of these two systems. Last, the extent of use of an LRV is strongly influenced by the IT artefact itself (i.e., the hospital's LRV available capabilities) while the use of the provincial iEHR system is influenced by its organizational context (i.e. the hospital's size and location).

CONCLUSIONS

The main contribution of this study lies in its insights into the role played by context in shaping physicians' choices about which laboratory information exchange systems to adopt and which features to use, and the different perceptions they have about benefits arising from such use. One related implication for practice is that success of LIE initiatives should not be solely assessed with basic usage statistics.

Enabling Laboratory Medicine in Primary Care Through IT Systems Use

Important problems remain regarding the efficiency and quality of laboratory testing in primary care. In view of this, a significant function of electronic medical record (EMR) systems is to enable the practice of laboratory medicine by primary care physicians. The present study aims to deepen our understanding of the nature and extent of physicians' use of EMR and other laboratory information exchange systems for patient management and care within the laboratory testing process. We conducted a survey of 684 Canadian family physicians. Results indicate that physicians use 84 percent of the laboratory functionalities available in their EMR system. The two most important impacts are the ability to gain time in the post-analytical phase and to take faster action in this same phase as they follow-up on their patients' test results. Physicians who perceive to benefit most from their EMR use are those who make the most extensive use of their system. Extended use of an EMR system allows primary care physicians to better ascertain and monitor the health status of their patients, verify their diagnosis assumptions, and, if their system includes a clinical decision support module, apply evidence-based practices in laboratory medicine.

Advancing regulatory science and assessment of FDA REMS programs: A mixed-methods evaluation examining physician survey response

Purpose:

Food and Drug Administration’s (FDA) Draft Guidance for Industry on pharmaceutical REMS (Risk Evaluation and Mitigation Strategies) assessment and survey methodology highlights physician knowledge–attitudes–behaviors (KAB) surveys as regulatory science tools. This mixed-methods evaluation advances regulatory science and the assessment of FDA REMS programs when using physician surveys. We: (1) reviewed published physician survey response rates; and (2) assessed response bias in a simulation study of secondary survey data using different accrual cut-off strategies.

Methods:

A systematic literature review was conducted of US physician surveys (2000–2014) on pharmaceutical use (n = 75). Kruskal–Wallis tests were used to examine the relationships between response rates and survey design characteristics. The simulation was conducted using secondary data from a population-based physician KAB survey on diabetes risk management with antipsychotic use in Missouri Medicaid (n = 973 accrued over 30 weeks). Survey item responses were compared using Pearson’s chi-square tests for two faster completion simulations: Fixed Sample (n = 300) and Fixed Time (8 weeks).

Results:

Survey response rates ranged from 7% to 100% (median = 48%, IQR = 34%–68%). Surveys of targeted populations and surveys using member lists were associated with higher response rates (p = 0.02). In the simulation, 9 of 20 (45%) KAB items, including diabetes screening advocacy, differed significantly using the smaller Fixed Sample strategy (achieved in 12 days) versus full accrual. Fewer response differences were found using the Fixed Time strategy (2 of 20 [10%] items).

Conclusions:

Published data on physician surveys report low response rates with most associated with the sample source selected. FDA REMS assessments should include formal evaluation of survey accrual and response bias.

Towards optimal electronic medical record use: perspectives of advanced users

BACKGROUND

While primary health care electronic medical record (EMR) adoption has increased in Canada, the use of advanced EMR features is limited. Realizing the potential benefits of primary health care EMR use is dependent not only on EMR acquisition, but also on its comprehensive use and integration into practice; yet, little is known about the advanced use of EMRs in primary health care.

OBJECTIVE

To explore the views of advanced primary health care EMR users practising in a team-based environment.

METHODS

A descriptive qualitative approach was used to explore the views of primary health care practitioners who were identified as advanced EMR users. Twelve individual semi-structured interviews were held with primary health care practitioners in Southwestern Ontario, Canada. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Researchers independently coded the transcripts and then met to discuss the results of the coding. We used a thematic approach to data analysis.

RESULTS

Three themes emerged from the data analysis: advanced EMR users as individuals with signature characteristics, advanced EMR users as visionaries and advanced EMR users as agents of change. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners.

CONCLUSIONS

To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support EMR use. This study provides a necessary building block in furthering this understanding.

Measuring Electronic Health Record Use in Primary Care: A Scoping Review

BACKGROUND

Simple measures of electronic health record (EHR) adoption may be inadequate to evaluate EHR use; and positive outcomes associated with EHRs may be better gauged when varying degrees of EHR use are taken into account. In this article, we aim to assess the current state of the literature regarding measuring EHR use.

OBJECTIVE

This article conducts a scoping review of the literature to identify and classify measures of primary care EHR use with a focus on the Canadian context.

METHODS

We conducted a scoping review. Multiple citation databases were searched, as well as gray literature from relevant Web sites. Resulting abstracts were screened for inclusion. Included full texts were reviewed by two authors. Data from the articles were extracted; we synthesized the findings. Subsequently, we reviewed these results with seven EHR stakeholders in Canada.

RESULTS

Thirty-seven articles were included. Eighteen measured EHR function use individually, while 19 incorporated an overall level of use. Eight frameworks for characterizing overall EHR use were identified.

CONCLUSION

There is a need to create standardized frameworks for assessing EHR use.

Ceiling effect in EMR system assimilation: a multiple case study in primary care family practices

BACKGROUND

There has been indisputable growth in adoption of electronic medical record (EMR) systems in the recent years. However, physicians' progress in using these systems has stagnated when measured with maturity scales. While this so-called ceiling effect has been observed and its consequences described in previous studies, there is a paucity of research on the elements that could explain such an outcome. We first suggest that in the context of EMR systems we are in presence of a "tiered ceiling effect" and then we show why such phenomenon occurs.

METHODS

We conducted in-depth case studies in three primary care medical practices in Canada where physicians had been using EMR systems for 3 years or more. A total of 37 semi-structured interviews were conducted with key informants: family physicians (about half of the interviews), nurses, secretaries, and administrative managers. Additional information was obtained through notes taken during observations of users interacting with their EMR systems and consultation of relevant documents at each site. We used abductive reasoning to infer explanations of the observed phenomenon by going back and forth between the case data and conceptual insights.

RESULTS

Our analysis shows that a ceiling effect has taken place in the three clinics. We identified a set of conditions preventing the users from overcoming the ceiling. In adopting an EMR system, all three clinics essentially sought improved operational efficiency. This had an influence on the criteria used to assess the systems available on the market and eventually led to the adoption of a system that met the specified criteria without being optimal. Later, training sessions focussed on basic functionalities that minimally disturbed physicians' habits while helping their medical practices become more efficient. Satisfied with the outcome of their system use, physicians were likely to ignore more advanced EMR system functionalities. This was because their knowledge about EMR systems came almost exclusively from a single source of information: their EMR system vendors. This knowledge took the form of interpretations of what the innovation was (know-what), with little consideration of the rationales for innovation adoption (know-why) or hands-on strategies for adopting, implementing and assimilating the innovation in the organization (know-how).

CONCLUSIONS

This paper provides a holistic view of the technological innovation process in primary care and contends that limited learning, satisficing behaviours and organizational inertia are important factors leading to the ceiling effect frequently experienced in the EMR system assimilation phase.

Effectiveness of Implementation of Electronic Malaria Information System as the National Malaria Surveillance System in Thailand

Background

In moving toward malaria elimination, one strategy is to implement an active surveillance system for effective case management. Thailand has developed and implemented the electronic Malaria Information System (eMIS) capturing individualized electronic records of suspected or confirmed malaria cases.

Objective

The main purpose of this study was to determine how well the eMIS improves the quality of Thailand’s malaria surveillance system. In particular, the focus of the study was to evaluate the effectiveness of the eMIS in terms of the system users’ perception and the system outcomes (ie, quality of data) regarding the management of malaria patients.

Methods

A mixed-methods technique was used with the framework based on system effectiveness attributes: data quality, timeliness, simplicity, acceptability, flexibility, stability, and usefulness. Three methods were utilized: data records review, survey of system users, and in-depth interviews with key stakeholders. From the two highest endemic provinces, paper forms matching electronic records of 4455 noninfected and 784 malaria-infected cases were reviewed. Web-based anonymous questionnaires were distributed to all 129 eMIS data entry staff throughout Thailand, and semistructured interviews were conducted with 12 management-level officers.

Results

The eMIS is well accepted by system users at both management and operational levels. The data quality has enabled malaria personnel to perform more effective prevention and control activities. There is evidence of practices resulting in inconsistencies and logical errors in data reporting. Critical data elements were mostly completed, except for a few related to certain dates and area classifications. Timeliness in reporting a case to the system was acceptable with a delay of 3-4 days. The evaluation of quantitative and qualitative data confirmed that the eMIS has high levels of simplicity, acceptability, stability, and flexibility.

Conclusions

Overall, the system implemented has achieved its objective. The results of the study suggested that the eMIS helps improve the quality of Thailand’s malaria surveillance system. As the national malaria surveillance system, the eMIS’s functionalities have provided the malaria staff working at the point of care with close-to-real-time case management data quality, covering case detection, case investigation, drug compliance, and follow-up visits. Such features has led to an improvement in the quality of the malaria control program; the government officials now have quicker access to both individual and aggregated data to promptly react to possible outbreak. The eMIS thus plays one of the key roles in moving toward the national goal of malaria elimination by the next decade.