& Thomas W. Cline, MBA, PhD
Hamid, F. & Cline, T. (2013). Providers’ Acceptance Factors and their Perceived Barriers to Electronic Health Record (EHR) Adoption. Online Journal of Nursing Informatics (OJNI), 17 (3). Available at http://ojni.org/issues/?p=2837
With the 2014 governmental deadline for nationwide implementation of the electronic health records (EHR) approaching, healthcare systems need to ensure successful EHR adoption among their providers. Recent reports indicate that only 55 percent of physicians nationwide have adopted the EHR (Jamoom, Beatty, Bercovitz, Woodwell, Palso, & Rechtsteiner, 2012).
This study explored acceptance factors and barriers associated with providers’ intention to adopt EHR by provider types (physicians and advanced practice providers). Physicians (n=24) and advanced practice providers (n=20) employed in acute care settings at a community healthcare system participated in the study. The participants in this study indicated that perceived management support, provider involvement, and adequate training were facilitators. Perceived lack of usefulness and provider autonomy were barriers (p<0.01). Advanced practice providers found EHR marginally easier to use, but were less inclined to accept EHR in clinical practice compared to physicians. Increasing Age was negatively correlated with EHR adoption for physicians only (r=-.476, p<.05).
Keywords: advanced practice providers, adoption, electronic health records, physicians, providers
To Err is Human (Institute of Medicine [IOM], 1999) brought national attention to approximately one million preventable hospital deaths in the United States. As a result of this alarming report, The Quality of Health Care in America Committee of the IOM proposed wide-ranging strategies that should be implemented by the government, healthcare facilities, providers, and consumers to reduce preventable medical errors. One of the prime recommendations from the report was the need to use a computerized health record system to facilitate improvement of patient safety.
The EHR can provide access to important patient information and facilitate management within healthcare systems. Edwards and Moczygema (2004) emphasized that medical errors can result from human causes such as provider recollection of necessary information or patient failure to remember information about their medical histories. Bowens and Jones (2010) also found that EHR implementation can be associated with better patient outcomes by reducing medication errors, providing faster care delivery, and accurate information exchange, thus preventing unjustifiable procedures. These authors stressed the need for constant accessibility to patient information to reduce mistakes.
The ability to store and share health records is recognized as important by both healthcare systems and governmental agencies (Davidson, 2009). The focus on improving healthcare information networks is also reinforced by the national call from former President George W. Bush to fully launch the use of EHR by 2014 (Ford, Menachemi, Peterson, & Huerta, 2009). In order to achieve this aim, healthcare systems were encouraged to expedite EHR adoption among providers (Bowens and Jones, 2010). In February of 2009 President Barack Obama also supported full implementation of the EHR by 2014 (Ford et al., 2009). President Obama signed the American Recovery and Reinvestment Act (ARRA), a $787 billion economic stimulus package that allocated $19 billion as financial incentives for providers to adopt EHR (“American Recovery”, 2009; and Ford et al., 2009).
Even with financial incentives for providers and healthcare systems through ARRA, experts believe that the national aim of full EHR adoption by 2014 is unlikely (Ford et al., 2009). According to a report published by the National Center for Health Statistics (NCHS), who measured physicians’ use of EHR systems nationwide, EHR adoption rate was 55 percent (Jamoom et al., 2012). Of additional concern, among those physician adopters 15 percent indicated that they were either somewhat dissatisfied or very dissatisfied with their EHR system. Thirty-two percent of physician non adopters did not have intention to adopt, and 20 percent of physician non adopters were undecided about purchase and use of EHR within the next 12 months (Jamoom et al., 2012). The relatively slow rate of EHR adoption by physicians nationwide does reflect the predicted failure to meet the 2014 goal. In order to facilitate the goal of full EHR adoption, Sajedi and Kushniruk (2009) and Stream (2009) support the need to identify factors that affect providers’ intention to adopt EHR. Identification of acceptance factors and perceived barriers is an important step in designing appropriate interventions to facilitate successful EHR implementation among providers.
This study focused on three specific aims related to providers’ use of EHR.
Literature from the early 2000’s indicates that the majority of EHR system implementations fail after the experimental phases (Simon et al., 2007). According to Wears and Berg (2005), one third of EHR implementations, and an alarming three quarters of large Health Information Technology (HIT) projects are unsuccessful. Studies have been conducted to determine the major barriers toward EHR adoption, and many of them indicated that physician resistance is a significant barrier (Bates, 2005; Kaplan & Harris-Salomone, 2009; and Poon et al., 2004). Other studies found that in addition to physician resistance, concerns about privacy, security, costs, and lack of funding were also significant barriers for EHR adoption (Cusack, 2008).
Since provider acceptance is a key factor in long term EHR implementation, it is essential to determine what significant acceptance factors and perceived barriers are associated with intent to adopt. Review of the literature revealed the following factors that influenced providers’ intent to adopt EHR.
Studies have indicated that providers’ perception related to the usefulness of EHR is a major factor in EHR adoption. Perceived lack of usefulness of the EHR has been identified as a significant barrier to adoption. In several earlier studies strong positive associations were noted between EHR satisfaction and providers’ perception of EHR usefulness (Chisolm, Purnell, Cohen & McAlearney, 2010; and Saleem et al., 2005). Providers in several other studies found EHR time consuming and questioned the perceived usefulness of the EHR in clinical practice (Kaushal et al., 2009; and Linder et al. 2006). Finally, in a systematic review of the literature by McGinn et al. (2011) the authors compared barriers and facilitators to EHR implementation among health care professionals (physicians, nurses, pharmacists, and medical archivists), managers, and patients. After screening 5,695 potentially relevant publications, 52 studies met inclusion criteria for the review. In this systematic review, perceived usefulness was one of the most common factors associated with intent to use EHR.
Several studies found that technology support was a factor that influenced adoption of the EHR. Saleem et al. (2005) found that prompt response from customer service was a facilitator to adoption of an electronic decision support tool for providers. Lack of technology support was also identified as a barrier to adoption. Several studies found that lack of technology support or training was a significant barrier to adoption for the providers in their studies (Chisolm et al., 2010; Kaushal et al., 2009).
Mixed perceptions exist regarding the effect of the EHR on provider-patient relationship. Linder et al. (2006), who conducted a survey of 255 physicians and advanced practice providers reported that providers felt EHR caused “loss of eye contact with patients” and perceived “using the computer in front of the patient is rude” (p. 501). However, Morton (2008) found that the physicians in his study did not identify EHR as a hindrance to their relationship with patients.
Only seven studies were found in CINAHL Plus Full Text, Cochrane Library, EBSCOhost, Medline Plus Full Text and Pub Med that explored and recognized barriers of EHR use among advanced practice providers (nurse practitioners [NP] and physician assistants [PA]). One of the few studies was by Linder et al. (2006), who explored barriers to EHR use during patient visits among physicians and a small number of advanced practice providers. They discovered that advanced practice providers were less likely than physicians to use EHR during patient visits. Another study by Saleem et al. (2005) that included nurses, physicians and advanced practice providers explored facilitators and barriers for the use of an electronic decision support tool. However, this study did not explore difference in response by physicians and advanced practice providers. Advanced practice providers along with physicians are the key coordinators of patient care and will be among the key stakeholders for EHR implementation. The limited information about advanced practice providers reinforce the need to explore acceptance factors and barriers related to EHR adoption for this population.
A review of the literature related to providers’ characteristics and intent to adopt EHR provided mixed results. Some studies found that increasing age was negatively correlated with EHR adoption (Decker, Jamoom & Sisk, 2012; Jamoom et al., 2012; Yeager, Menachemi & Brooks, 2010). Other evidence suggested no association between providers’ characteristics, i.e. age, gender, and role and their intention to adopt EHR (Chisolm et al., 2010; Hudson et al., 2012; Morton & Wiedenbeck, 2009, 2010). These mixed results regarding the correlation of providers’ characteristics and their intention to adopt EHR indicates the need for further exploration.
Finally, most of the published research investigated provider factors affecting EHR adoption after EHR implementation (Morton & Wiedenbeck, 2009). The EHR is a multifaceted, integrated, and expensive system to develop and launch (Hudson, Neff, Padilla, Zhang, & Mercer, 2012). Failures related to implementation of EHR are not uncommon and dissatisfaction can limit meaningful use of the technology.
The limited information about provider perceived acceptance factors and barriers prior to implementation is an identified gap in the current knowledge base related to EHR adoption. Identifying perceived acceptance factors and barriers prior to adoption may facilitate the development of engagement strategies for those providers who are reluctant to adopt. This information, in addition to information gathered post implementation, may contribute to the development of effective strategies that meet the needs of the providers who will use EHRs.
This study replicated a descriptive correlational study conducted as part of a doctoral dissertation completed by Morton (2008), which was later published in a two part descriptive survey study by Morton and Wiedenbeck (2009, 2010). The current study was conducted in a community healthcare system located in southwestern Pennsylvania, prior to the implementation of the EHR in the acute care setting. IRB approval was obtained from both the university and the healthcare system prior to launching the study. This study expanded the scope of the original study by Morton (2008), which only included physicians, by inviting nurse practitioners (NPs) and physician’s assistants (PAs) to participate. For the purpose of this study, the providers’ characteristics selected for correlation were gender and age.
Participants in this study were recruited from a population of 222 providers employed in the acute care settings by the healthcare system. The available population was made up of 148 physicians, 36 NPs and 38 PAs. Providers were classified in two groups: physicians and advanced practice providers (i.e. NPs and PAs). Twenty-four physicians (16.2 percent) and 20 advanced practice providers (27.0 percent) agreed to participate, producing a net response rate of 19.8 percent.
The survey used in this study contained multiple choice and Likert Scales items. It was adapted from one used by Morton (2008), who explored factors that influenced physician’s attitudes toward EHR. Morton had adapted her survey from one originally developed by Aldosari (2003), who also studied factors that influenced physicians’ attitudes towards EHR. Morton modified Aldosari’s instrument for her dissertation by adding two additional questions regarding prior computer use and experience from a survey developed by Cork, Detmer, and Friedman (1998). Both Morton and Aldosari granted permission to further adapt and use their survey for the purposes of this study.
The adapted survey consisted of 24 questions divided into ten sections. The first section collected demographic information which included gender, age, and provider type (i.e. physician, NP and PA). The following seven sections included questions about the independent variables: management support, provider involvement, adequate training, provider autonomy, provider-patient relationship, perceived ease of use, and perceived usefulness. The ninth section asked participants to respond to questions about the dependent variable, attitude about EHR usage. Finally, the tenth section included open ended questions for additional comments regarding the use of EHR from the providers.
The original survey by Aldosari (2003) had Chronbach’s alpha scores of 0.88 to 0.96 on the eight sections of the questionnaire. Alpha scores above 0.70 are considered to have high inter-item reliability. The modified survey used in this study had alpha scores of 0.77 to 0.92 indicating a high degree of reliability.
The validity of the original survey, tested with comparative fit index (CFI) and the Tucker-Lewis index (TLI), ranged from 0.94 to 1.0. Scores of CFI and TLI of above 0.90 are considered good fit, indicating excellent construct of validity for these subcategories. CFI and TLI scores were not determined for the adapted survey.
Providers were introduced to the study during provider meetings and via email communication shared by the director of clinical informatics at the healthcare system. Surveys and copies of the informed consent were provided by the principle investigator (PI). Providers completed the survey either by paper and pencil or online via Vovici Survey Software. Three more follow up emails were sent to encourage participation. Data collection was completed over a six month period.
Provider responses were evaluated with descriptive statistics (i.e. means, percentages, and p values). SPSS Statistics Version 20 was used for all statistical analysis. Multiple linear regression models were used to assess the relationship between the associated factors and providers’ intention to adopt EHR. Independent t tests were used to determine differences between the associated factors by provider group types and their intent to adopt. Analysis of variance was used to evaluate differences in intent to adopt EHR by provider group types between providers’ age. Regression models were also used to jointly identify differences in intent to adopt EHR among provider group types between providers’ gender.
Of the 44 participants the majority, 61.4 percent (n=27), were women. Of the 24 physicians 58.3 percent were men (n=14) and of the 20 advanced practice providers 85 percent were women (n=17). Table 1 provides details about distribution of providers by gender.
Physicians were predominately older than advanced practice providers in this study. Of the 61.9% (n=27) provider respondents between the age of 40-59 years, three-quarters of them were physicians. Of the 20.5% (n=9) provider respondents between 30-39 years old, two-thirds of them were advanced practice providers. Table 2 provides information about the distribution of all providers by age.
Only 43 responses were received for two categories: provider autonomy and provider-patient relationship.
Calculated mean Likert scale scores for the independent variables are displayed in Figure 1. Management support, provider involvement, and adequate training were rated significantly higher (m > 3.9) than perceived ease of use and provider-patient relationship (m > 3.5). Perceived usefulness and provider autonomy were rated significantly lower than all of the above factors. The grand mean for the seven acceptance factors was approximately 3.5. Therefore, 3.5 is viewed as the conceptual “neutral point,” instead of 3.0 in the Likert scale. Accordingly, factors including perceived ease of use and provider-patient relationship are referred as to neutral factors, because they significantly diverged from both ends of the acceptance-barrier continuum. Management support, provider involvement, and adequate training are referred as to acceptance factors. Perceived usefulness and provider autonomy were referred as to barriers.
Paired t tests conducted between management support (highest mean score), and perceived usefulness and provider autonomy (lowest mean scores) indicate that providers gave significantly lower scores for perceived usefulness vs. management support (t= 7.5, df= 43, p< 0.01).Similarly, providers rated management support significantly higher than autonomy (t= 8.3, df= 42, p< 0.01).This further demonstrates that provider autonomy and perceived usefulness are considered to be barriers. Visual presentation of the clinicians’ acceptance factors and their perceived barriers to EHR adoption is shown in Figure 1 above.
Multiple linear regression models revealed that adequate training (p=.035) and provider-patient relationship (p=.025) had the strongest positive impact on providers’ attitude about EHR usage, with standard coefficients of 0.469 and 0.354 respectively.
No significant differences emerged between the provider groups (physicians and advanced practice providers), with respect to the associated factors. However, significant differences were noted for perceived ease of use, where advanced practice providers reported higher average ratings (m=3.75) compared to physicians’ (m=3.32, t=2.072, p=0.046).
No significant differences emerged between the providers groups with respect to their attitude toward EHR use. However, advanced practice providers reported lower rating on this factor than did physicians.
An independent t-test reveals a significant gender difference with respect to perceived ease of use. Women (m=3.70) rated ease of use significantly higher than did men (m=3.22, t =2.18, p= 0.035). Both advanced practice providers (vs. physician) and women (vs. men) rated perceived ease of use higher. It is noted that 85% of advanced practice providers are women.
The data were split by provider type and simple, linear regression models were conducted with age as the predictor, and overall attitude toward EHR as the factor. A significant model emerged for physicians only, F1,22 = 6.78, p = 0.016. Specifically, for each additional year of age, physicians’ overall attitudes towards EHR decreased by nearly one half a scale point (b1 = -0.476). Further, no significant gender difference emerged between older physicians’ attitudes toward EHR and perceived usefulness. Thus, age, rather than gender, appears to be driving attitudes and perceptions, i.e., younger practitioners manifest higher perceived usefulness and better overall attitudes towards EHR.
Findings from this study indicate that management support and provider involvement are acceptance factors associated with providers’ EHR adoption. This relationship reflects provider’s expectation to management to provide adequate support for training and resolve technical issues without ado. It also reflects providers’ intention to be involved during EHR product integration, training and leadership purposes. These findings support those of Morton (2008) and Aldosari (2003) who also found a positive relationship between management support and provider involvement and physicians’ perception on overall attitude toward EHR.
In this study adequate training had the second strongest positive impact on providers’ intention to adopt EHR. Chisolm et al. (2010) also found that facilitating conditions such as adequate resource and knowledge to use EHR was the strongest predictor of physician satisfaction regarding EHR use. However, this was inconsistent with Morton’s (2008) finding, which indicated that training did not appear to have an overall impact toward physicians’ attitude.
Perceived lack of usefulness was a barrier toward EHR adoption in this study (t= 7.5, df= 43, p< 0.01), and the responses reflect providers’ concern about the potential for the EHR to complicate rather than enhance their work. Morton (2008) however found that physicians in her study had “moderately positive perception of EHR’s usefulness in clinical practice” (6.5.2, pg. 110). Providers’ negative perception regarding EHR usefulness in this study may reflect the need to clarify the role of EHR as a medium of workflow enhancement and productivity.
Aldosari (2003) and Morton (2008) found a strong negative correlation between physician autonomy and overall attitude toward EHR. This strong negative correlations was also found in the current study (t= 8.3, df= 42, p< 0.01). This may indicate a need for the healthcare systems implementation teams to communicate with providers to ensure EHR does not affect provider autonomy.
This study explored associated factors and providers’ intention to adopt EHR by two provider group types: physicians and advanced practice providers (NPs and PAs). No significant differences were found between the two provider group types regarding their perceived acceptance factors and barriers toward EHR adoption. However, the results revealed that advanced practice providers reported higher ratings for perceived ease of use than physicians but lower ratings for overall attitude toward EHR use when compared with physicians in this study. This reflects that even though advanced practice providers found EHR easier to use, they are less likely to support the acceptance of EHR in clinical practice. This is consistent with the findings by Linder et al. (2006), where the authors reported that advanced practice providers were less likely to use EHR compared to physicians.
Results of this study revealed that age, rather than gender, drove the providers’ perception of EHR use and their intention to adopt EHR. Physicians’ increasing age was negatively correlated to their overall intention toward EHR adoption, whereas attitude of advanced practice providers was not correlated with age. This could be because physicians who participated in this study were an older cohort compared to the younger advanced practice provider cohort. This finding is not consistent with Morton’s (2008) finding, who did not determine any correlation between the characteristics of age and gender and overall attitude toward EHR. The literature is mixed with conflicting evidence regarding provider characteristics to predict intention toward EHR adoption.
The results of this study revealed that the providers are more likely to adopt EHR with support from the management, with provider involvement throughout the launching process, and with adequate technology training. This study also revealed that the providers in the healthcare system have negative perceptions regarding perceived usefulness of the EHR, and also expressed their concern about the effect of EHR on their professional autonomy.
The outcomes of this study also contribute to a limited body of knowledge about the perceptions of advanced practice providers related to EHR adoption. More similarities than differences were found when compared with physician providers. This information may prove valuable when designing implementation of EHR programs and the facilitation of smoother transitions.
The study was conducted in one community healthcare system in the acute care setting only. The results may not be generalized to other clinical settings or healthcare systems. The survey was also conducted using a small convenience sample of providers. The small sample size may not be representative of the larger population.
Future studies might wish to replicate this study with a larger sample size in different clinical settings or facilities. Participants representing other professionals such as nurses, administrators and clerical services could also be included. Follow up studies should be conducted post implementation of the EHR to investigate if the factors affecting EHR adoption were addressed in programs designed to facilitate the process of adoption.
With the 2014 governmental deadline for nationwide implementation of the EHR approaching, healthcare systems need to ensure successful EHR adoption among their healthcare providers. Recent reports (Jamoom et al., 2012) indicate that only 55% of physician providers nationwide have adopted the EHR. Responses from providers in this study identified perceived acceptance factors and barriers related to EHR adoption. This provides valuable information for clinical informatics teams working to develop effective implementation strategies. Results from this study also indicated an increased reluctance among advanced practice providers to adopt EHR when compared with physicians in this study. This may also be important information for those designing implementation strategies that include advanced practice providers. Achievement of successful launch of EHR may be more possible when providers’ of all spectrums are actively involved with management system in healthcare informatics.
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Farhana Hamid recently joined Hopewell Health Centers Inc., located in Athens, OH. She completed her doctor of nursing practice-family nurse practitioner (DNP-FNP) program from Robert Morris University, located in Moon Township, PA, in 2013. She received her bachelor of science in nursing (BSN) degree from the same institution in 2009. Her capstone project, Providers’ Acceptance Factors and Their Perceived Barriers to Electronic Health Records (EHR) Adoption, was supervised by Lynn George, PhD. She also served as a co-investigator in 2012 with Dr. George in a study entitled, Use of iPad 2 Technology by Undergraduate Nursing Students in Three Distinct Learning Environments: Classroom, Clinical, and Nursing Lab. The authors are currently preparing the manuscript.
Dr. Hamid’s nursing experience includes working as a supervisor in a nursing home and as a nurse in intensive care. She also worked as a graduate assistant-technology coordinator for Robert Morris University School of Nursing and Health Sciences, serving as a resource in implementation of technology for students and faculty. Dr. Hamid was nominated for the 2013 nurse practitioner (NP) Outstanding Student Award from the NP Association of Southwest Pennsylvania. Her research interests include health information technology, technology in nursing education and technology in clinical practice.
Thomas W. Cline is professor of marketing and statistics in the Alex G. McKenna School at Saint Vincent College and adjunct professor of marketing at the University of Pittsburgh’s Katz Graduate School of Business. He is also doctoral consultant for statistical methods at Robert Morris University’s School of Science and Nursing. He teaches courses in consumer behavior, marketing research, statistical methods, advertising and promotion, and strategic marketing. He is the 2004 International Teaching Excellence Award Winner from the Association of College Business Schools and Programs (ACBSP).
Dr. Cline has published numerous articles in academic journals, including the Journal of Advertising, Journal of Consumer Psychology, and Journal of Economic Psychology, Psychology & Marketing, and Journal of Marketing Communications. Dr. Cline and his colleagues won the 2003 Young Contributors Award for best paper in the Journal of Consumer Psychology. Dr. Cline is widely cited in the popular press, including USA Today, Psychology Today, CBS News, The LA Times, MSNBC, and The Washington Times.
Dr. Cline is coauthor of Consumer Behavior, a 2011 South-Western/Cengage Learning textbook. He also coauthored Consumer Behavior: Science & Practice, International Edition, available April 2010.
Dr. Cline has twenty years experience as a marketing research consultant, specializing in experimental designs and focus groups. He is a frequent contributor to the American Psychological Association, the American Marketing Association, and the Society for Consumer Psychology. Dr. Cline serves as a reviewer for the Journal of Advertising and the American Academy of Advertising.
Dr. Cline won the PIAA State Golf Championship in 1979 and earned a four-year golf scholarship to UVA. He serves as Saint Vincent’s head coach for the men’s and women’s golf teams, hosted at Arnold Palmer’s Latrobe Country Club.
Dr. Cline and his wife, Sally, reside in Latrobe with their four children. He and his family are members of the Saint Vincent Parish.