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Behaviour & Information TechnologyVol. 28, No. 1, January–February 2009, 5–20Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staffPascale Carayona,b*, Paul Smithc,d, Ann Schoofs Hundta, Vipat Kuruchitthame and Qian LifaCenter for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA; bDepartment ofIndustrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA; cDepartment of Family Medicine,University of Wisconsin Medical School, WI, USA; dUniversity of Wisconsin Medical Foundation, WI, USA; eCollege of PublicHealth, Chulalongkorn University, Bangkok, Thailand; fCenter for Quality and Productivity Improvement, University of WisconsinMadison, WI, USA(Received November 2005; final version received August 2007)In this study, we examined the implementation of an electronic health records (EHR) system in a small familypractice clinic. We used three data collection instruments to evaluate user experience, work pattern changes, andorganisational changes related to the implementation and use of the EHR system: (1) an EHR user survey, (2)interviews with key personnel involved in the EHR implementation project, and (3) a work analysis of clinic staff. Alongitudinal design with two data-collection rounds was employed: data were collected prior to EHRimplementation and after EHR implementation. Both quantitative and qualitative data were collected andanalysed. Employees of the small clinic perceived few changes in their work after the implementation of the EHRsystem, except for increased dependency on computers and a small increase in perceived workload. The workanalysis showed a dramatic increase in the amount of time spent on computers by the various job categories. TheEHR implementation did not change the amount of time spent by physicians with patients. On the other hand, thework of clinical and office staff changed significantly, and included decreases in time spent distributing charts,transcription and other clerical tasks. The interviews provided important contextual information regarding EHRimplementation, and showed some positive elements (e.g., planning of training), but also some negative elements(e.g., unclear structure of the project) that would have deserved additional attention.Keywords: technology implementation; healthcare; electronic health records system (EHR)1.IntroductionThe importance of implementing and using healthinformation technology (HIT) to improve the deliveryof health care has been increasingly recognised(Institute of Medicine 2000, 2001, Thompson andBrailer 2004, Ash and Bates 2005, Berner et al. 2005,Middleton et al. 2005). The Institute of Medicine(2001) highlighted the central role of HIT in theredesign of the health care system: ‘‘Automation ofclinical, financial, and administrative transactions(through information technology) is essential toimproving quality, preventing errors, enhancing consumer confidence in the health system, and improvingefficiency’’ (p. 16). In the United States, federal andregional efforts are under way to accelerate theadoption and use of electronic health records as ameans of facilitating clinical data sharing, protecthealth information privacy and security, and quicklyidentify emerging public health threats (Thompson andBrailer 2004, Overhage et al. 2005).Driven by the needs to facilitate clinical andadministrative processes, to reduce medical errors,*Corresponding author. Email: carayon@engr.wisc.eduISSN 0144-929X print/ISSN 1362-3001 onlineÓ 2009 Taylor & FrancisDOI: omand to reduce healthcare costs, many healthcareinstitutions are deciding to implement electronic healthrecords (EHR) systems to allow clinical informationgathering and access at the point of patient care. AnEHR system can access progress notes or proceduresdata, and may support other functions such as CPOE(computerised provider order entry) and CDSS (clinical decision support systems). Tools to supportadministrative procedures, such as billing and scheduling, are also becoming common EHR features. The useof EHR can facilitate clinical decision-making andminimise the potential for mistakes due to theinaccuracy and incompleteness of paper records(Institute of Medicine 2001, Thompson and Brailer2004, Kawamoto et al. 2005, Ohsfeldt et al. 2005).However, the effects of EHR use on quality of care arenot necessarily automatic (Linder et al. 2007); theyvery much depend on the specific characteristics of theEHR system and its impact on the work of healthcareproviders and other staff.Recently, the need to adopt and adapt methods andtechniques to understanding human factors and

6P. Carayon et al.organisational issues of the technology implementationprocess has been increasingly recognised (Smith andCarayon 1995, Carayon and Karsh 2000, Carayon andHaims 2001, Karsh 2004). Regarding EHR implementation, these include poor usability of EHR userinterfaces, clinicians’ resistance to EHR acceptance,and patients’ reaction to EHR (Ash and Bates, 2005).The key to a successful EHR implementation project ishow well the technology is implemented and how thetechnology can be used to improve clinician performance and produce positive individual and organisational outcomes (Smith and Carayon 1995, Berneret al. 2005). Increased efficiency in healthcare deliveryand improvements in patient information collection,administrative processing, working conditions, anduser acceptance should lead to improvements in safety,efficiency, and quality. Without a comprehensiveunderstanding of end user experience and the organisational changes produced by the EHR technology, weare missing opportunities to develop better approachesto designing and implementing EHR technology.According to the Center for Disease Control andPrevention, general and family practices representabout 24% of all physician office visits (Centers forDisease Control and Prevention 2000). It is thereforeimportant to understand the barriers to effective andsuccessful implementation of EHR technology infamily practice clinics as a substantial portion ofambulatory health care occurs in these settings. EHRhas been estimated to be used by about 24% ofphysicians in ambulatory settings in the United Statesin 2005 (Jha et al. 2006). Challenges in dealing withhuman and organisational factors can partially explainwhy the majority of small family practice clinics arestill unwilling or unable to consider the use of EHR intheir patient care. In addition, as compared to largehospitals, small clinics face further challenges due tolimited financial and human resources (Middletonet al. 2005). Healthcare professionals and administrative staff of small clinics frequently have to share jobresponsibilities and cover for their coworkers becauseof high workload, patient emergencies, and staffingissues such as employee vacation and illness.In this study, we evaluated the implementation ofPractice Partner Patient Records, by Physician’sMicrosystems, Inc., in a small family practice clinic;before the EHR implementation, health records werecompletely in paper records. This EHR system is avendor software intended to replace paper-basedpatient health records. We evaluated the organisational aspects of the EHR implementation process andthe human factors issues resulting from the EHRimplementation. A systematic evaluation approach wasemployed: both quantitative and qualitative data werecollected. This allowed us to evaluate how employeesin the clinic perceived their work as it related to theEHR technology and the changes in work patterns dueto the EHR implementation. The direct impact ofEHR technology on clinical performance and patientcare (e.g., quality and safety of patient care) was notexamined in this study.2.Conceptual frameworkThe most common reason for failure of technologyimplementation is that the implementation process istreated as a technological problem, and the humanfactors and organisational issues are not fully addressed (Eason 1988). In reaction to this problem,Carayon and Karsh (2000) have proposed a conceptualmodel that specifies the human and organisationalissues related to technology implementation (seeFigure 1).The introduction of a new technology is likely tochange jobs and work processes. It can create bothpositive and negative impacts on job characteristics(Carayon-Sainfort 1992); therefore, it is important tounderstand the impact of the technology on multipledimensions of the jobs and work processes. Technology characteristics can also impact job characteristicsand quality of working life in both positive andnegative manners (Carayon-Sainfort 1992). For instance, a technology with usability deficiencies canincrease the workload of the users, and affect theirfrustration at work and other attitudes toward theirorganisation. This conceptual framework is used as thebasis for selecting measures to assess EHR implementation in a small family practice clinic.3. Study designIn this study, three data collection instruments wereused to assess user experience and organisationalchanges related to the implementation and use ofEHR: a user survey, interviews with key personnelinvolved in the EHR project, and a work analysis. Alongitudinal design with two data collection roundsbefore and after the EHR implementation wasemployed.The study site is a University of Wisconsin familymedicine residency clinic in a small community with apopulation of about 1800, located 18 miles southwestof Madison, Wisconsin. At the time of study, it had 6family medicine faculty, 7 resident physicians, and 12medical support and office staff. It had approximately11 000 patient visits annually. Participation in thestudy by the clinic personnel was voluntary.Each data collection is described separately. Theresults of each data collection are reported after thedescription of the data collection method.

Behaviour & Information Technology Figure 1.4.Tcrhnology characlcristics: type oftcrhnology. funclionality, and usabilily issucsJob characterislics: job conlrol. workload. uncertainly/clarily. challenge. and role ambiguilyQuality of working lifc: job salisfaction. Slress, sclf-report -d health, and perceived performanceTcrhnological changc process: employee participalion. feedback, projccl management. information andcommunication, and lraining and leamingImpact of EHR technology on quality of working life and performance (adapted from Carayon and Karsh 2000).Survey of EHR users4.1.7Pre- and post-implementation surveyBased on the conceptual framework (see Figure 1) ofCarayon and Karsh (2000), the pre-implementationsurvey examined the following human and organisational factors:(a) Job information: job position (e.g., office staff,nurse, doctor), job experience, and computerexperience(b) Job characteristics: role ambiguity (Caplanet al. 1975), quantitative workload (Caplanet al. 1975), uncertainty (Seashore et al. 1983),challenge (Seashore et al. 1983), task control(McLaney and Hurrell 1988, Greenberger et al.1989), decision control (McLaney and Hurrell1988, Greenberger et al. 1989), resource control(McLaney and Hurrell 1988, Greenberger et al.1989), and general job control (McLaney andHurrell 1988, Greenberger et al. 1989)(c) Quality of working life: organisational identification (Cook and Wall 1980), organisationalinvolvement (Cook and Wall 1980), daily lifestress (Reeder et al. 1973), job satisfaction(Quinn et al. 1971), musculoskeletal discomfort(Sainfort and Carayon 1994), and anxiety(Sainfort and Carayon 1994)(d) Technology characteristics: dependency oncomputers (Carayon 1994), informationreceived about EHR system (Bailey andPearson 1983), input regarding design andimplementation of the EHR system (Bailey andPearson 1983), attitude toward EHR system(Bailey and Pearson 1983), EHR effect onperformance (Davis 1989), overall user acceptance, learning, and EHR system capabilities(Chin et al. 1988)(e) Self-rated performance (Carayon 1994)(f) Demographics: gender, age, educational level,and marital status.The first five sections (a, b, c, d, and e) of the preimplementation survey were also included in the postimplementation survey. Twelve questions on technology characteristics were added to the post-implementation survey. These questions were derived from theQuestionnaire for User Interface Satisfaction (QUIS)(Chin et al. 1988). As a usability evaluation tool, QUIS(Chin et al. 1988) consists of five categories ofquestions on user experience with software user interface: overall reactions to the software, learning, systemcapabilities, terminology and system information, andscreen. We used the first three sections (reactions to thesoftware, learning, and system capabilities) in the postimplementation survey. The demographics section(Section f) was excluded from the post-implementationsurvey based on a recommendation by the UniversityInstitutional Review Board.4.2. ParticipantsTwenty-one out of 25 clinic employees completedthe pre-implementation survey, while 20 out of

8P. Carayon et al.25 employees completed the post-implementationsurvey. Response rates were 84% and 80%,respectively.4.3. ProceduresThe pre-implementation survey, along with the consentform, was distributed to all 25 clinic employees in thespring of 2000, six months before the EHR implementation. Clinic employees who agreed to participatein the study signed the consent form and thencompleted the survey. They left the signed consentforms and completed surveys in a secured mailboxthat was accessed only by the researchers. In February2002, 15 months after the implementation, thepost-implementation survey was administered usingthe same procedure as in the pre-implementationsurvey.4.4. Data analysisData from the survey were manually entered into anSPSS database and double-checked by anotherresearcher for quality control. The first step of thedata analysis produced normalised scores, from 0(low) to 100 (high), for each measure included in thefollowing four sections of the survey: job characteristics, quality of working life, technology issues, andself-rated performance. Descriptive statistics werecalculated. Survey data were collected at twodifferent points in time: before and after the EHRimplementation; however, because of the smallsample size and the threat to anonymity, individualresponses were not tracked over time. Therefore,Mann-Whitney tests were performed to compare thegroup responses of the pre- and the post-implementation surveys.The section on quality of working life consisted oftwenty-two four-point health questions with answersranging from 1 (‘‘never’’) to 4 (‘‘constantly’’) andconcerning three dimensions: (1) back, neck, shoulderdiscomfort, (2) other musculoskeletal discomfort, and(3) anxiety (Sainfort and Carayon 1994). Responsesto each of the 22 questions were grouped into‘‘never,’’ ‘‘occasionally,’’ and ‘‘frequently and constantly’’ in order to examine participants with no,some, and a lot of perceived discomfort and anxiety.Kruskal Wallis tests were performed to compare theresults of the pre- and the post-implementationsurveys.4.5. ResultsDescriptive statistics of job characteristics, qualityof working life, technology issues, and self-ratedperformance, along with the results of Mann-Whitneytests, are reported in Table 1. Two measures, resourcecontrol and dependence on computer, were significantlydifferent between the pre- and the post-implementation surveys (p 5 0.05). Participants reported lessresource control and more dependence on computersafter EHR implementation. Perceived quantitativeworkload increased slightly after EHR implementation, compared to before EHR implementation(p 5 0.10).Descriptive statistics of the 22 health questions aswell as the results of Kruskal Wallis tests can befound in Table 2. The measure of tight feeling instomach was found to be significantly differentbetween the pre- and the post-implementationsurveys (p 5 0.05). Fewer participants reported tightstomach feeling after EHR implementation. Therewas a slight increase in the percentage of participantswho reported back pain and pain or stiffness in armsor legs (p 5 0.10), and a slight decrease in terms ofswollen or painful muscles and joints (p 5 0.10), afterEHR implementation.5. Interviews of key personnel involved in EHRimplementation project5.1. Pre- and post-implementation interview guideStructured interviews were conducted using an interview guide based on the IT project managementinterview guide (Korunka et al. 1997, Korunkaand Carayon 1999). The timeframe of the questionswas modified to reflect the pre- and post-implementation times. For example, a question on trainingactivities planned for the clinic staff was asked inthe pre-implementation interview, while a question onthe actual training activities that had taken place wasasked in the post-implementation interview. Theinterview guide was structured as on backgroundProject identityProject teamProject managerSteering committeeImplementation process, including goals,processes, schedule, budget, information diffusion, evaluation, problems/difficulties, projectcrises, feedback/complaints (only in thepost-implementation interviews), and userparticipationTrainingEHR supportChanges in the working environmentInterviewee profile.

9Behaviour & Information TechnologyTable 1.Survey of EHR users: descriptive statistics and results of Mann-Whitney tests.Post{ (normalisedscores: 0 – 100)Pre{ (normalisedscores: 0 – 100)Job characteristicsRole ambiguityQuantitative workloadUncertaintyChallengeTask controlDecision controlResource controlGeneral job controlQuality of working lifeOrganisational identificationOrganisational involvementDaily life stressJob satisfactionMusculoskeletal discomfortBack, neck, shoulderOther musculoskeletalAnxietySelf-reported performanceTechnology characteristicsDependence on computersInformation received about systemDesign inputImplementation inputEffect on performanceAttitude toward systemOverall reactionsLearningSystem capabilitiesMeanS.D.MeanS.D.Mann-Whitneytests (p -implementation survey.Post-implementation survey.*p 5 0.10; **p 5 0.05.{5.2.Interviewees5.4.Data analysisFour key personnel who were directly involved in theimplementation process of the EHR system wereinterviewed: the project director, the project manager,the clinic manager, and the information system manager.Data collected during the interviews were entered intoan Access database. Descriptive information about theEHR implementation process is provided in the nextsection.5.3.5.5.ProceduresThe face-to-face pre-implementation interviews wereconducted with the four interviewees in April 2000.They were provided with a copy of the interview guidebefore the interviews. An interviewer asked questionsone by one following the structure of the interviewguide. In addition to answering the questions, interviewees were encouraged to give feedback about thequestions and to provide additional information thatmay be helpful to understand the EHR implementation process. The individual interviews lasted 60 –120 min. The post-implementation interviews wereagain conducted with the same four people bytelephone between March and April 2001.5.5.1.ResultsImplementation backgroundThe primary factors driving EHR implementation werethe need for improving medical care and the trend in theindustry. Secondary factors included the desire for workreduction, adjustment to market demands, and thereduction of employee workload. These resulted in theintroduction of an EHR system to replace an existingpaper-based medical record system. It took four monthsto complete the actual implementation. The workstationselection was based on vendor recommendations.Selection criteria for the software included capability,serviceability, user friendliness, popularity, and recommendations of the product. Decisions on project scope

10Table 2.P. Carayon et al.Survey of EHR Users – Descriptive Statistics of Health Questions and Results of Kruskal-Wallis TestsPost{Pre{Back, neck, shoulder discomfort1. Back pain2. Pain or stiffness in your neck and shoulders3. Feeling of pressure in the neck4. Shoulder soreness5. Neck pain that radiates into shoulders, arms or handsOther musculoskeletal discomfort6. Swollen or painful muscles and joints7. Pain or stiffness in your arms or legs8. Persistent numbness or tingling in any part of your body9. Pain down your arms10. Leg cramps11. Difficulty with feet and legs when standing for prolonged periods12. Loss of feeling in the fingers or wrists13. Cramps in hands/fingers relieved only when not working14. Loss of strength in arms or hands15. Stiff or sore wristsAnxiety16. Occasions of easy irritability17. Difficulty sleeping18. Periods of depression19. Times of severe fatigue or exhaustion20. Tight feeling in stomach21. Periods of extreme anxiety22. High levels of tensionNxO{F/C{{NxO{F/C{{Kruskal-Wallistest (p re-implementation survey.Post-implementation survey.xNever.{Occasionally.{{Frequently and constantly.*p 5 0.10; **p 5 0.05.{and hardware/software selection were made jointly bythe steering committee, the project team, expert endusers, and the information systems department.5.5.2. Project identityDuring the pre-implementation interviews, all fourinterviewees said that the project was given a specialidentity using the project name. Three intervieweesreported that the project had no special identity wheninterviewed after the implementation.5.5.3. Project teamAll four interviewees agreed that the project team hadan informally defined scope, authority, and responsibility. However, their understanding of the projectteam composition diverged. For example, their answers to the question on how many expert end userswere on the project team varied from 1 to 5. The fourinterviewees agreed that the project team memberswere chosen based on professional expertise and EHRknowledge by top management. Besides their regularjob duties, team members were granted time to workon project-related activities, including 30 weeklyproject meetings throughout the EHR implementationprocess. The four interviewees agreed that the overallattitude of the project team was good.5.5.4. Project managerThe project manager was hired externally and temporarily for the EHR implementation project andreported to the project director. Top managementmade the hiring decision based on criteria such asexperience as project manager, professional expertise,and personality. The project manager did not receiveextra training on project management. It was unclearwhether the project manager had authority to makedecisions in cases of diverging opinions: two interviewees said that the project manager did not have thisauthority, while the other two considered that theproject manager had informal authority.5.5.5. Steering committeeThere was not an officially designated steering committee specifically for this project. The project team

Behaviour & Information Technology11and the project director reported to the department’sstanding executive committee.regular job duties were covered by other employees.No extra work hours were explicitly needed.5.5.6. Implementation processThe goals of EHR implementation were to enhancehealthcare quality and patient safety, to improve workquality and reliability, to improve information sharingand communication, and to reduce work steps anderrors. These goals were formulated by the project teamand local top management through preliminary workdone before implementation, including goal setting,cost-benefit analyses, and risk assessment activities.Two interviewees indicated that technical difficultiesduring EHR implementation were significant, the othertwo reported noticeable but slight difficulties. Criticalissues included how the EHR system could interfacewith billing functions. Problems with the vendor werereported, such as corrupted configuration with lab data(took six weeks to get it corrected), and system upgradecrash before going live (lost days of data). Oneinterviewee rated the problems as significant, one asnoticeable, and the other two as slight. Underestimationof the amount of work required for EHR implementation was another major difficulty reported by threeinterviewees, in addition to the concern regarding theauthority of the project manager, the lack of interestand resistance from end users, the disagreement withinthe project team, the resistance from middle management, and the lack of priority for the project. Accordingto the interviewees, end users complained of an increaseof work due to the implementation, technical interruption, and time pressure during EHR implementation.The project manager complained about software bugs,while local top management was concerned withdecreased productivity during the implementation andthe cost. Patients were reported to have concernregarding privacy of their medical data. User acceptanceof the EHR was evaluated through informal discussion.5.5.8. EHR supportThere were support staff present from the EHR vendoron the day the EHR system went live. In the followingtwo weeks, at least one expert end user was present atthe clinic. The software maintenance was doneinternally. In addition, there were plans for improvingthe EHR system by correcting software bugs, addingnew applications, upgrading new releases, as well asupgrading hardware components.5.5.7. TrainingThe four interviewees considered that local topmanagement had been very positive towards training.The amount of training that users received was decidedjointly by the project team and the EHR vendor. Thetraining scheduling was established by the projectteam. All clinic employees were informed that theywould need to be trained. Training schedules andtraining materials were provided. Groups of users withsimilar needs were trained together through hands-onpractice. Expert users were trained for 8 h, while otherswere trained for 4 h. The training consisted of twosessions on basic Windows and the EHR system. Whena user was attending a training session, his (or her)5.5.9.Changes in working environmentAll 4 interviewees agreed that clinic employeesexperienced changes in skills and work flow, andincreased workload due to the implementation and useof EHR. The use of EHR did not result in reduction ofpersonnel. There was an increase in time spent usingthe computer, although it varied depending on the jobcategory (e.g., nursing staff and physicians experiencedmore changes than others). Two interviewees observeda slight change in social climate as a result of theimplementation, while the other two observed nochange or did not know. In general, all intervieweesagreed that the climate of the entire clinic was positiveafter EHR implementation.6. Work analysis of clinic staff6.1. Work analysis formPre- and post-implementation work analyses wereconducted using the multidimensional work samplingtechnique (Sittig 1993, Murray et al. 1999). Themultidimensional work sampling technique was usedto determine time spent on a variety of predefinedactivities (‘‘activity’’), the purpose of the activity(‘‘function’’), and with whom the person was in contactwhile performing the activity (‘‘contact’’). The workanalysis form and the definitions for the activities,functions, and contacts were first created usinginformation from the position descriptions providedby the clinic manager. After creating the form and thedefinitions, the researchers met with the medicaldirector of the clinic and the clinic manager to discussand revise the data collection form. The frequency,duration, and timing of the work analysis were alsodiscussed. The same form was used in both the preand post-implementation studies. It included 13activities, 22 functions, and 14 contacts. For eachentry on the form, study participants could also recordcomments when they were unsure what activity,function, or contact to record (see Appendix).

126.2.P. Carayon et al.ParticipantsAll clinic employees were invited to participate in thework analysis in the pre- and post-implementationphases. Twenty-seven clinic employees participated inthe pre-implementation study, while 26 employeesparticipated in the post-implementation study. Unlikethe employee survey, where primarily full time employees were recruited to participate, the work analysisrecruitment included everyone who worked at theclinic, be they part-time, full-time, permanent, ortemporary. For that reason there were more participants in the work analysis than there were in the surveyquestionnaire.6.3.ProceduresThe pre-implementation work analysis was conductedin April 2000 for a period of 10 working days. It beganon a Tuesday due to the hectic nature of Mondaysfollowing a weekend. It was believed that staff wouldhave more time to adjust and be familiar with the workanalysis tool by beginning on Tuesday. The workanalysis forms were distributed to all employees,including the medical staff, at the clinic. Participantsindicated their position and the beginning and endingtimes of their workday. During each day, participantswere asked to record activities, functions, and contactsevery 30 min. They were encouraged to write downcomments when they were uncertain about what torecord. An announcement via overhead speaker wasmade appro

EHR technology and the changes in work patterns due to the EHR implementation. The direct impact of EHR technology on clinical performance and patient care (e.g., quality and safety of patient care) was not examined in this study. 2. Conceptual framework The most common reason for failure of technology implementation is that the implementation .

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