FAMILY PRACTICE PHYSICIANS’ ACCEPTANCE AND USE OF A REPLACEMENT

ELECTRONIC MEDICAL RECORD SYSTEM: INSTRUMENTAL CASE STUDY

by

Diana Cointa Berich Brieva

Copyright 2020

A Dissertation Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Health Administration

University of Phoenix
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 ABSTRACT

Transitioning or upgrading electronic medical record (EMR) systems have unique and

significant challenges than moving from paper charts to electronic charts. Physicians’

perceptions of EMR systems affect the rate of adoption and use. The purpose of this

qualitative instrumental case study was to explore the decision- making process of family

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

ambulatory clinic located in a metropolitan area of Northeastern Indiana. This study sought

to understand how family practice physicians form their decision to accept and use a

replacement EMR system, how the family practice physicians overcame the barriers and

challenges associated with transitioning EMR systems, and how did family practice

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

practice physicians explored the decision-making process to accept and use a new EMR

system. NVivo for Windows computer software was used to assist with the analysis of semi-

structured interviews, questionnaires, and artifacts to identify themes. Three themes and 8

subthemes emerged from the data analysis. Key recommendations from the study include

highlighting how the new system will improve the quality of care of patients, develop a

multidisciplinary quality training program, and be prepared to address with the physicians the

emotional impact inherent in transitions. The study findings may be important to health care

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

understanding how family practice physicians decide to accept and use future technology.

iii
 DEDICATION

This dissertation is dedicated first and foremost to my Lord and Savior, Jesus Christ,

through him all things are possible. To my family and friends who have supported me

throughout my journey; their love and support were the fuel that kept me going. To my fur

baby, Zoe, thank you for your unconditional love, kisses, and snuggles even when I did not

always give you the attention you wanted.

iv
 ACKNOWLEDGEMENTS

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

Joann Kovacich, who stuck with me during this long journey. Dr. Kovacich provided me

invaluable feedback and encouragement that carried me to the finish line. Dr. Kovacich

also introduced me to the research world where I had the opportunity to have a poster

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

experience that I attended another qualitative research conference where I had the

opportunity to attend workshops with Johnny Saldana, something I would have never

done on my own. Thank you Dr. Kovacich for sharing the opportunity of the conferences

and exposing me to the research world, a genuinely nice and supportive network. I also

want to thank my dissertation committee members, Drs. Kroposki and Nandy, for their

time and valuable feedback.

v
 TABLE OF CONTENTS

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

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

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

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

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

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

Title Searches, Articles, Research Documents, and Journals .......................25
Historical Content .........................................................................................26
Brief History of Early EMR Systers ...................................................26
Current Content.............................................................................................28
Acceptance (Adoption) .......................................................................28
Use ......................................................................................................39
Challenges ...........................................................................................40
Drivers/Facilitators .............................................................................42
vi
 Barrier .................................................................................................43
Physician Perceptions .........................................................................44
Leadership ...........................................................................................45
Theoretical Framework Literature ................................................................45
Technology Acceptance Model (TAM) ..............................................45
Unified Theory of Acceptance and Use Of Technology (UTAUT) ..47
William Bridges' Transition Model ...................................................51
Methodology Literature ................................................................................52
Qualitative Research .........................................................................52
Quantitative Research .......................................................................53
Mixed Methods Research .................................................................54
Research Design............................................................................................54
Phenomenology.................................................................................55
Grounded Theory ..............................................................................55
Ethnographic Research .....................................................................56
Case Study ........................................................................................57
Conclusion ....................................................................................................58
Chapter Summary .........................................................................................59
Chapter 3 : Method ................................................................................................61
Research Method and Design Appropriateness...........................................62
Research Questions .....................................................................................63
Population and Sample ................................................................................64
Population.........................................................................................64
Sample ..............................................................................................64
Recruitment ......................................................................................65
Informed Consent/Confidentiality ...............................................................66
Informed Consent .............................................................................66
Confidentiality ..................................................................................68
Geographic Location ...................................................................................69
Instrumentation ............................................................................................69
Field Test ....................................................................................................70
Trustworthiness ...........................................................................................70
Transferability ..................................................................................70
vii
 Credibility.........................................................................................71
Confirmability/Dependability .........................................................72
Researcher's Acknowledgement of Biases ..................................................73
Data Collection ............................................................................................74
Interviews .......................................................................................75
Participant Observation ..................................................................77
Archival Data .................................................................................78
Data Analysis ..............................................................................................78
Summary .....................................................................................................80
Chapter 4: Analysis and Results ............................................................................81
Research Question .......................................................................................81
Data Collection ............................................................................................81
Demographics ..............................................................................................85
Data Analysis ..............................................................................................86
Step 1. Assigning attributes. ....................................................88
Step 2. Listing and preliminary grouping ................................88
Step 3. Reduction and elimination ..........................................90
Findings .......................................................................................................90
Theme 1: Accepting and using an EMR means continuity of care .90
Theme 2: Overcoming Barriers and Challenges means addressing 95
Subtheme 1: The challenge of importing old records ............95
Subtheme 2: Findings records in the new system ...................97
Subtheme 3: Lack of consistency in training ..........................99
Subtheme 4: Timing of go-live..............................................103
Subtheme 5: Lack of support ................................................104
Subtheme 6: Workarounds ...................................................106
Subtheme 7: Physicians' Recommendations for future ........107
Theme 3: Transitioning is an Emotional Experience ...................108
Subtheme 1: Decreased compensation .................................110
Summary ...................................................................................................112
Chapter 5: Conclusions and Recommendations ..................................................114
Research Question ...................................................................................114
Disscussion of Findings ...........................................................................115
viii
 Theme 1: Accepting and Using An EMR Means Continuity of Care116
Theme 2: Overcoming Barrier And Challenges Means of Address ..117
Subtheme 1: The challenge of importing old records ...............118
Subtheme 2: Finding records in the new system .......................118
Subtheme 3: Lack of consistency in training ............................119
Subtheme 4: Timing of go-live ..................................................119
Subtheme 5: Lack of support.....................................................120
Subtheme 6: Workarounds ........................................................120
Subtheme 7: Physicians' recommendations for future .............121
Theme 3: Transitioning is an Emotional Experience......................122
Subtheme 1: Decreased compensation ....................................123
Limitations ...............................................................................................123
Recommendations for Leadership and Practitioners ...............................124
Recommendations for Future Research ...................................................126
Chapter Summary ....................................................................................127
References ............................................................................................................129
Appendix A: Premises, Recruitment, and Name (PRN) Use Permission ...........144
Appendix B: Recruitment Protocol ......................................................................146
Appendix C: Informed Consent ...........................................................................148
Appendix D: Interview Guide..............................................................................151
Appendix E: Demographic Survey ......................................................................155
Appendix F: Observation Guide ..........................................................................156
Appendix G: Data Access and Use Permission ...................................................159
Appendix H: Coding Interviews ..........................................................................161

ix
 LIST OF TABLES

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

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

x
 LIST OF FIGURES

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

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

xi
 Chapter 1

Introduction

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

more comprehensive EHR system will become more common as the first generation of

EHRs are becoming dated (Saleem et al., 2018). Black Book Rankings has named 2013

“The Year of the Great EHR Switch,” (Schaeffer, 2013). The global ambulatory EHR

market is projected to grow from $3.92 billion in 2016 to $5.20 billion by 2021

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

to take advantage of financial incentives and avoid financial penalties from the Centers

for Medicare and Medicaid Services (CMS), many of the EMR systems fell short of

expectations.

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

making process of family practice physicians regarding the acceptance and use of a new

EMR system after having used an EMR system for more than five years. Researchers

have found that the rate of physician acceptance and ultimately adoption and use of an

EMR can be accelerated by vendors and health care organizations understanding

physician perceptions and tailoring education to those perceptions (Lakbala & Dindarloo,

2014). Information from this study may be helpful to health care leaders, EMR system

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

care providers are the primary users of EHRs and their perceptions of the benefits of

these systems are important and may influence successful integrations of EHR systems

(Krousel-Wood et al., 2017). Lessons from a system transition may also be useful to

health systems that are considering a system upgrade or a switch to a new system

1
(Saleem et al., 2018).

Chapter 1 included the background of the problem, the statement of the problem,

the purpose of conducting the study, the significance of the problem, and the significance

of the study to leadership. The chapter also included the nature of the study, an overview

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

framework for this study. The end of the chapter defined terms, described assumptions

made, described the scope and limitations of the study, showed delimitations, and

concluded with a chapter summary.

Background of the Problem

The American Reinvestment & Recovery Act (ARRA) of 2009 created the Health

Information Technology for Economic and Clinical Health (HITECH) Act of 2009 to

support the concept of electronic health records (EHRs) and meaningful use. Meaningful

use is defined as the use of certified EHR technology in a meaningful way; making sure

that the EHR certified technology provides an electronic exchange of health information

to improve the quality of care through interconnections (CDC, 2012). Meaningful use is

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

financial burden associated with system implementation (CDC, 2012). Meaningful use is

a staged approach divided into three stages beginning 2011 (data capture and sharing),

2013 (advanced clinical processes), and 2015 (improved outcomes). The incentive

payments range from $44,000 over 5 years for Medicare providers to $63,700 over 6

years for Medicaid providers (CDC, 2012).

Since the passing of the HITECH Act of 2009, the rate of adoption has been

steadily increasing. In 2012 71.8% of office-based physicians reported using any type of

2
EHR system, an increase of 34.8% from 2007 (Hsiao et al., 2014). In 2012 23.5% of

office-based physicians had an EHR that was categorized as fully functioning compared

to 3.8% in 2007 (Hsiao et al., 2014). Healthit.gov (2015) reported that in 2015 54% of all

office-based physicians have a fully functioning EHR system and are successfully

meeting the meaningful use measures. In April 2018 overall physician office adoption

reached 69.6% (IQVIA, 2018).

The percentage of providers who had a positive perception of EHR systems has

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

patient care, clinical decision making, access to patient information, monitoring patients,

more time with patients, coordination of care, computer access, adequate resources, and

satisfaction with ease of use (Krousel-Wood et al., 2017). Researchers reported that 70%

of physicians stated that implementing an EHR was not worth the transition even with the

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

participating in the MU incentive program perceived that the MU program diverted the

focus from patient care to reporting requirements by imposing greater compliance

requirements (Weeks et al., 2014). Some eligible providers dropped out of the MU

program after the first year, when the majority of the money was available, as they did

not find the requirements worth the incentive money available (Weeks et al., 2014).

The factors related to primary care physicians’ acceptance and use of EMRs are

complex. As more studies are conducted on the topic, the results should help health care

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

complexities and why they exist. The longer it takes to understand these complexities and

how to manage them the longer it will take to manage the health care costs in the United

3
States. The scope and effort transitioning between EMR systems are similar to the

transition from paper to an EMR system (Penrod, 2017). This research added to the

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

accept and use a new EMR when transitioning between EMR systems.

Problem Statement

The general problem is, despite previous EMR use, transitioning to a different

EMR system or upgrading the current system has unique and significant challenges that

differ from transitioning from paper records (Edsall & Adler, 2015). Edsall and Adler

(2015) found that the number one challenge in switching EMR systems was the time

investment followed by productivity loss, difficulty learning the new system, cost to

switch systems, data loss in the conversion, difficulty using the new system, and lastly

the loss of functions of the old system. Understanding those differences are important

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

replaced (Edsall & Adler, 2015). The ability of an EMR system to capture, analyze, and

report data is critical as the current payment models move from fee-for-service to value-

based (Martin, 2017).

The specific problem is that physicians’ perceptions of EMR systems affect the

rate of adoption and use (Lakbala & Dindarloo, 2014). This impacts reimbursement under

the Quality Payment Program (QPP) where adjustments of up to plus or minus 9% for

Medicare recipients are applied to eligible clinicians (Quality Payment Program, n.d.).

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

EMR acceptance and use could be used to better develop and plan future EMR transitions

to help expedite acceptance and use. The benefits gained from an EMR system are only

4
accomplished by getting the greatest number of physicians using an EMR system

(Lakbala & Dindarloo, 2014). This increases exponentially with prolonged use of the

system (King et al., 2014). Adoption of the EMR by family practice physicians has

steadily increased over the years to 75% in 2015 (ONC, 2016); however, health care

organizations and the health care system cannot afford for this adoption rate to decrease

when physicians transition to a new EMR system.

Edsall and Adler (2015) reported that an EMR system switch will slow operations

and productivity down for the first three to four months, they recommend preparing as if

you are implementing an EMR system for the first time, the process is that disruptive.

Lakbala and Dindarloo (2014) found that knowing how physicians perceive an EMR

gives leadership and vendors the necessary tools to be able to train and accelerate the rate

of adoption. This study addressed the gaps in the literature on the decision-making

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

system and the emotional impact of such a transition. The study results may help health

care leaders and policymakers better understand some of the potential drivers and

challenges of EMR acceptance and use when transitioning or

upgrading EMR systems.

Purpose of the Study

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The decision-making process focused on the acceptance and use of

a replacement EMR system. The decision-making process also focused on the drivers and

5
challenges faced by family practice physicians during the system transition with a goal of

accelerating acceptance and use of future EMR replacement systems.

Interest has grown for more qualitative research in health informatics (Rahimi et

al., 2008). Qualitative methods in health care research have provided much insight into

health professionals’ perceptions and barriers to changes in health care operations (Al-

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

“investigating the perspectives and behavior of people” within those situations and the

context of the action (Kaplan & Maxwell, 2005, p.30). Qualitative research methods can

be used to obtain specific details about phenomena such as emotions, feelings, or thought

processes that would be difficult to see using more conventional quantitative research

methods (Strauss & Corbin, 1998).

Yin (2014) identified the elements of a case study as being an empirical inquiry

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

instrumental approach to case study research focuses on providing insight into an issue or

issues where the case is acting as a conduit to assist in understanding something else, the

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

of physicians and using that information to help them navigate in today’s healthcare

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

University of Phoenix, and what drives this study.

Population and Sample

The population for this study included all physicians transitioning to a

replacement EMR system. The target population, the group of people the researchers

wanted to generalize the findings to, including all family practice physicians transitioning

6
to a replacement EMR system. The accessible population included all 40 family practice

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

in Northeastern Indiana. The sampling strategy used to select participants was purposeful

purposive sampling.

The purpose of purposeful sampling was to select information-rich cases that illuminate

the questions under study (Patton, 1990). Patton (1990) stated that a sampling strategy must be

selected to fit the purpose of the study, available resources, the questions being asked, and the

constraints faced. Mohd Ishak and Abu Bakar (2014) stated purposive sampling is useful for case

study research in three instances when the researcher: 1) wants to select unique cases because

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

population, and 3) wants to identify the specific types of cases for in-depth research. This

research study fit all three criteria; the case selected was unique because of the recent transition to

a replacement EMR system, physicians under study were a specialized population, and the

specific type of case was family practice physicians because the amount of information they are

tasked with entering into the EMR that are not asked of other physicians because of their

specialty.

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

ambulatory care setting. Participants were limited to family practice physicians residing

in the state of Indiana and only included family practice physicians at a specific hospital-

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

participants had at least two years’ experience on an EMR to ensure basic computer

skills.

The sample size is not a definitive number in qualitative studies. The sample size

depends on the research question, the purpose of the research study, what is useful, what

7
will be credible, semi-structured interviews, observations, and documents reviewed were

limited to the point of saturation. Data saturation occurs when no new insights occur from

collecting one more piece of data (Hanson et al., 2011). The purpose of qualitative

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

studying a particular case not to generalize findings to a larger population like

quantitative studies so the sample size is less important (Robinson, 2014).

The information gained from this study may be used to form strategies to expedite

the adoption of future replacement EMRs. The family practice physicians are in a multi-

specialty practice which is part of a larger network system. The decision to replace the

EMR system was not made with the input of the physicians. The adoption of the system

is not optional. The network is part of an Accountable Care Organization (ACO) and the

EMR is a tool used to validate quality measures.

Significance of the Study

The study findings may be important to health care leaders, policymakers, and

health information technology designers and implementors in understanding how family

practice physicians decide to accept and use future technology. No known knowledge

exists on how to best design, implement, and use HIT (Rippen et al., 2013). Slabodkin

(2015) stated a 2014 report from KLAS reported that 27% of ambulatory practices were

considering changing EMR systems. Factors driving the need to switch EHR systems

include mergers and acquisitions, a practice’s growth, dissatisfaction with the systems,

inefficient workflows, and lack of reporting capabilities (Kosiorek, 2014; Andresen et al.,

2017). The current EMR systems are not robust enough to meet future advances in health

care which are driving the need to switch from legacy EMR systems to more

8
comprehensive EMR systems (Saleem et al., 2018).

Significance of the Study to Leadership

Innovative technologies in health care are already being designed and physicians

will need to adapt quickly to this changing environment as the expectations of care are

also changing. The accelerating rate of commercial EMR implementations, aided by

Federal government investments, has widened the scope of researchers trying to decide

the most efficient way to use HIT (Atkins & Cullen, 2013). The transition from one EHR

system to another will become more common as the first-generation systems are

becoming outdated (Saleem et al., 2018).

Ellis (2014) reported that it took his practice four months for patient volumes to

return to the same levels as before the change. Patient safety issues will likely emerge and

organizations need to be prepared (Saleem et al., 2018). Health care organizations should

expect to see a decrease in physician satisfaction after an EMR system transition which

could last up to two years (Saleem et al., 2018). As business leaders gain a better

understanding of how family practice physicians decide to accept and use a replacement

EMR system and a better understanding of some of the drivers and challenges faced with

such a transition, the gap may close between the clinical care world of the physician and

the business world of leadership.

Nature of the Study

The purpose of this instrumental case study was to explore the decision- making

process of family practice physicians to accept and use a replacement EMR system and to

better understand some of the drivers and challenges faced with such a transition. The

study results may help health care leaders and policymakers better understand some of

9
the potential drivers and challenges of EMR acceptance and use when transitioning

between EMR systems. Understanding of EMR acceptance and usage drivers and

challenges could be incorporated in developing training programs that may expedite

acceptance and use of future system implementations.

Overview of the Research Method

A qualitative method was appropriate for this study since the aim of this

qualitative instrumental case study was to understand how family practice physicians

decide to accept and use a replacement EMR system to better prepare for future EMR

changes. Yin (2011) stated that qualitative studies have five features: to study the

meaning of people’s lives under real-world conditions, to represent the views and

perspectives of participants, to evaluate the contextual conditions within which people

live, to contribute insights into new or existing concepts that may help explain human

behavior, and to enable the use of multiple sources of evidence rather than relying on just

one.

Qualitative researchers are interested in understanding the meaning people have

constructed from their perspectives, how individuals make sense of their world and

experiences (Merriam, 1998a). In qualitative research, the researcher is the primary

instrument for data collection and analysis typically involving fieldwork and inductive

research strategies (Merriam, 1998a). Since qualitative studies usually focus on process,

meaning, and understanding the final product is richly descriptive in words and pictures

as opposed to numbers typically found in quantitative studies (Merriam, 1998a).

Since the aim of this qualitative instrumental case study was to understand how

family practice physicians decide to accept and use a replacement EMR system, a

10
qualitative study would be a more appropriate method for this research. Qualitative

research questions seek patterns of anticipated as well as unanticipated relationships

whereas quantitative research questions seek relationships between a small number of

variables (Stake, 1995). Bogdan and Taylor (1975) stated that qualitative research

methods enable researchers to explore concepts that would have otherwise been missed

using different approaches. Concepts such as beauty, pain, faith, suffering, frustration,

hope, and love can be studied in their real-world context as they are experienced and

defined by people. A quantitative study would be able to quantify by stating how many

users and non-users or how many accepted or not but the study would not be able to

explain the physicians’ motivations behind the action or inaction to understand their

decision-making process.

Overview of the Design Appropriateness

Case studies allow researchers to focus on a unit of analysis while retaining a

holistic and real-world view (Yin, 2014). A case can be an individual or a group or can be

simple or complex (Suryani, 2008). Some examples of an individual case might be a

child, an adult, a student, a teacher, a person’s experience, or a phase in life (Suryani,

2008). A case study is ideal when researching contemporary events where the

participants’ behaviors cannot be manipulated (Yin, 2014).

The goal of case study research may be exploratory to define questions or

hypotheses, descriptive to depict a phenomenon within its context, or explanatory to

identify a cause-and-effect relationship (Curry et al., 2009). Case study research can also

be intrinsic, the case is of primary interest, instrumental, the case provides an

understanding of something else, and collective, studying many cases at the time (Stake,

11
1995). An instrumental case study was an appropriate design for this study since the

purpose of this qualitative instrumental case study will be to explore the decision- making

process of family practice physicians transitioning to a replacement EMR system at a

multi-specialty ambulatory clinic located in a metropolitan area of Northeastern Indiana.

The decision-making process focused on the acceptance and use of the

replacement EMR system and the drivers and challenges faced by family practice

physicians during the transition with a goal of accelerating acceptance and the use of

future EMR replacement systems. Concepts such as acceptance, use, drivers, and barriers

were explored as they are experienced and defined by the study participants through

semi-structured interviews. The case (physicians) was used to help better understand

something other than the case, potential drivers, and challenges of replacement EMR

systems.

Other qualitative designs were considered for this study. Phenomenology seeks to

describe what an experience means to the people who had the experience and can provide

a detailed account of that experience (Schram, 2006). Ethnography is the study of

peoples’ culture and rituals where the researcher is a participant-observer who lives

among the study participants to try to see the world from their perspective (Shank, 2006).

Grounded theory uses procedures to generate theory describing a phenomenon and is

grounded in the views from study participants (Curry et al., 2009). The purpose of this

study was to explore the decision-making process of family practice physicians to accept

and use a replacement EMR system and understand some of the drivers and challenges

faced with such a transition; therefore, none of the other qualitative designs considered

were appropriate for this study.

12
 Case study research was the preferred method over other qualitative studies when

the main research questions are how or why, the researcher has little control over the

participants’ behavior, and the study is looking at a contemporary phenomenon (Yin,

2014). Stake (1995) explains that a case is studied when the case is of very special

interest. Merriam (1998) describes a case study as an intensive, holistic description and

analysis of a bounded phenomenon. The phenomena could be a program, an institution, a

person, a process, or even a social unit making a case study the most appropriate method

for this study.

Commonly used data collection methods for qualitative case study research

includes documents, archival records, interviews, direct observation, participant-

observation, and physical artifacts (Yin, 2014). Yin (2014) shared that individual sources

of evidence are not recommended for case study research; researchers need to use

multiple sources of evidence, triangulation, which is a strength of case study research and

improves the overall quality of the study. Knowing how much data to collect is described

as being similar to the law of diminishing returns; there is no way to be sure you have

found all pertinent information but the patterns of repetition make it unlikely that more

investigation will produce any new information, saturation (Shank, 2006). Rigor in

qualitative research comes from the researcher’s presence, the interaction between

research and participants, the triangulation of data, the interpretation of participants’

perceptions, and thick description (Merriam, 1998a).

Data was gathered using, semi-structured interviews, participant observations, and

organizational documents such as meeting minutes, training plans, and training agendas

regarding the EMR transition from the organization. Semi-structured open-ended

13
interviews were used to obtain an in-depth understanding of the participants’ decision-

making process to accept and use the replacement EMR system. Stake (1995) shared that

the two principal uses of case study research are to obtain the description and

interpretations of others as each person has their reality and interviewing is an avenue to

multiple realities. The interview questions were field-tested by a group of 5 multi-

specialty physicians not participating in the study who just experienced the transition to a

new EMR system so they will have great insight.

Participant observation was used to collect environmental and organizational data

at each participant’s clinic and to help corroborate self-reported acceptance and use

claims by the participants. Archival data such as meeting minutes, training plans, and

training agendas were used to describe organizational support during the system

transition. Questionnaires were used to collect demographic information on the

participants.

Research Question

The central question was:

Q1: How did family practice physicians form their decision to accept and use a

replacement EMR system?

Two sub-questions used to explore additional factors inherent in transitioning between

EMR systems:

S1: How did family practice physicians overcome barriers and challenges

associated with transitioning EMR systems?

S2: How did family practice physicians feel emotionally during the transition.?

Understanding the providers’ decision-making process to accept and use a

14
replacement EMR system, how they overcame barriers and challenges with such a

change, and how they felt emotionally during the process may be important to health care

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

understanding how family practice physicians decide to accept and use future technology

and at which stage of the transition.

Theoretical Framework

The theoretical framework to guide this study was the Unified Theory of

Acceptance and Use of Technology (UTAUT) and William Bridges’ Transition Model.

Technology acceptance models or theories are usually used in studies to identify the how

and why of individual behaviors in acceptance and use of new technology (Trimmer et

al., 2009; Dulle & Minishi-Majanja, 2011). Venkatesh et al. (2003) incorporated eight

prominent theoretical models of adoption and acceptance of technology (Fig. 1). The

result of the study was the development of a new model, UTAUT; which can identify as

much as 70 percent of the variation of intention to use technology (Venkatesh et al.,

2003).

Unified Theory of Acceptance and Use of Technology (UTAUT)

Yin (2014) stated that the use of theory in case study research is an important aid

in defining the appropriate research design and data to be collected for the study. The

UTAUT framework identified direct determinants of acceptance and usage behavior to

include performance expectancy, effort expectancy, social influence, and facilitating

conditions (Venkatesh et al., 2003; Wright & Marvel, 2012). UTAUT incorporates

perceived usefulness and perceived ease of use into the effort expectancy, and subjective

norm into the social influence (Holden & Karsh, 2010).

15
 UTAUT is believed to be a more robust model than other technology acceptance

models (TAM) in evaluating and predicting acceptance (Taiwo & Downe, 2013).

UTAUT proposes variables that directly influence the outcome variables of Behavioral

Intent and Usage of Technology (Trimmer et al., 2009). These variables are mediated by

one or more of a set of demographic variables (gender, age, experience, and voluntariness

of use) (Trimmer et al., 2009).

Figure 1

Unified Theory of Acceptance and Use of Technology (UTAUT) Model

Note: Adapted from “Going Beyond Intention: Integrating Behavioral Expectation into

the Unified Theory of Acceptance and Use of Technology,” by L. Maruping, H. Bala, V.

Venkatesh, and S. Brown, 2017, Journal of the Association for Information Science and

Technology, 68(3), p. 627.

16
 According to the UTAUT model, performance expectancy, effort expectancy, and

social influence constructs are the strongest predictors of adoption/acceptance whereas

behavioral intention and facilitating factors are the strongest predictors of use (Venkatesh

et al., 2003). Behavioral expectation was introduced into the original UTAUT model to

address the uncertainty that could not be adequately addressed in the behavioral intention

construct (Venkatesh et al., 2008). The central question was how do family practice

physicians form their decision to accept and use a replacement EMR system? A

subquestion was how did they overcome barriers and challenges associated with

transitioning EMR systems? Using semi-structured interviews provided insights into the

perceptions of family physicians and to see how they align with the UTAUT constructs.

William Bridges’ Transition Model

The William Bridges’ Transition Model was used to help understand the level of

transition each participant was in. The Transition Model has three phases in which one

passes during times of transition: the ending, the neutral zone, and the beginning. The

model starts by letting go of the old ways, travels through a neutral zone, and ends with a

new way of doing things. Transitions are psychological events whereas changes are

situational events (Bridges & Bridges, 2016).

Phase 1 is called the Ending. Bridges and Bridges (2016) stated that it is not the

change that people resist, it is the losses and endings they experienced and the transition

that is being resisted. Some of the emotions associated with the endings phase include

anger, sadness, frightened, depression, and confusion. Bridges and Bridges (2016) have

found that many times organizations confuse bad morale with the signs of grieving which

include: denial, anger, bargaining, anxiety, sadness, disorientation, and depression.

17
 Phase 2 is called the Neutral Zone. The neutral zone is a period of flux where

people’s anxiety rises and motivation decreases, a feeling of disconnectedness and self-

doubting, resentful and self-protecting, and people’s energies are drained from working

on coping mechanisms (Bridges & Bridges, 2016). During this phase, people miss more

work than normal, at best productivity falls but at worst medical claims and disability

increase, older weaknesses from the past emerge, people are overloaded, mixed signals

are sent because systems are in flux and unreliable, priorities get confused, information

gets miscommunicated, important tasks go undone, discord arises, teamwork and loyalty

to the organization are undermined, vulnerability to outside threat increases because tired

people respond slowly to such threats, but it is a great time for innovation (Bridges &

Bridges, 2016).

Phase 3 is called New Beginnings. New Beginnings occur after people come out

of the neutral zone and are ready to make an emotional commitment to do things in a new

way and they see themselves as new people (Bridges & Bridges, 2016). The timing of

New Beginnings is driven by the transition process; however, they can be encouraged,

supported, and reinforced. Getting people through the transition process is important if

the change is to work as planned (Bridges & Bridges, 2016).

Understanding what phase of the transition process a participant is in, may shed

some light on their decision to accept and use a replacement EMR system. The

psychological impact transitions have on people was worth exploring in this study.

Bridges and Bridges (2016) puts the responsibility on leadership to help guide staff

through these phases of transitions. This information may be helpful to leadership and

could be applied to any transition an organization is facing.

18
 Definition of Terms

This section is to clarify the meaning of some key terms used throughout this

study.

Behavioral Intention – “An individual’s conscientiously formulated plan to

perform a behavior” (Maruping et al., 2017, p. 625).

Effort Expectancy – the degree of ease in using an information technology

system (Venkatesh et al., 2003).

Electronic Medical Records (EMR) – an electronic record of health-related

information on an individual that can be created, gathered, managed, and consulted by

authorized clinicians and staff within one health care organization (Healthcare

Informatics, 2008).

Facilitating Conditions – the degree to which an individual believes that the

organization has the infrastructure in place to support the use of the new system

(Venkatesh et al., 2003, p. 447).

Health Information Technology (HIT) - is a broad term for technologies that

store, share, and analyze health information. HIT includes electronic health records

(EHR), personal health records (PHRs), and e-prescribing (HealthIT.gov, 2013).

Health Information Technology for Economic and Clinical Health

(HITECH) Act of 2009 -- The American Recovery and Reinvestment Act of 2009

provides opportunities for the Department of Health and Human Services (DHHS) and

the States to improve the nation’s health care through HIT and promoting MU of EHRs

via incentives. Funds will be distributed through Medicare and Medicaid incentive

programs to those who use the system in a meaningful way, as outlined in the program

19
(CMS.gov, 2009).

Institute of Medicine (IOM) – The Institute of Medicine (IOM) was established

in 1970 as the health arm of the National Academy of Sciences (NAS). President

Abraham Lincoln signed a congressional charter in 1863 which was the catalyst for the

NAS. The NAS was created to operate outside the government to advise the nation when

needed. The NAS added the National Academy of Engineering (NAE) in 1964 to

complete their needs. On July 1, 2015, the NAS voted to change the name from the

Institute of Medicine to the National Academy of Medicine which joins the NAE and

NAS in advising the United States on matters of science, technology, and medicine (The

National Academies of Science-Engineering-Medicine, 2015).

Perceptions – a process where individuals organize and interpret their sensory

impressions to give meaning to their environment. People’s behavior is on what reality is,

not on reality itself (Robbins & Judge, 2013).

Performance Expectancy – the degree to which an individual believes that using

a particular technology will assist in improved job performance (Venkatesh et al., 2003).

Social Influence – the degree to which the individual perceives important people

believe that the individual should use the system (Venkatesh et al., 2003).

User Acceptance – “the demonstrable willingness within a user group to employ

information technology for the tasks it is designed to support” (Dillon, 2001).

Assumptions, Limitations, and Delimitations

Assumptions

The first assumption was that the participants will answer truthfully. Participation

in this research was voluntary so there was no reason to assume that the participants were

20
not truthful. The second assumption was that the participants were willing to share their

perceptions of the EMR system. The third assumption was that findings from this

research may be important to health care leaders and policymakers in understanding how

the use of future technological advances will be perceived to project their rate of

adoption. The final assumption was that semi-structured interviews are the most effective

way to collect data on perceptions.

Limitations

Some limitations of qualitative research included a lack of generalizability. The

research findings are so in-depth they refer to the specific participant population.

Subjectivity was another limitation of qualitative research where the researcher has some

influence on the findings of the study. Bias can be reduced but never eliminated because

of the nature of qualitative research. Bias is made explicit in qualitative research designs

(Watkins & Gioia, 2015).

The present study was limited in several ways. First, the generalizability of the

research findings was limited by the fact that only one type of EMR was referenced in

one type of organizational context. Second, this research included only family practice

physicians despite the importance of knowing there are other health care professionals’

who hold beliefs about EMRs. Thirdly, the study included EMR users in the ambulatory

care setting and did not include EMR users in the hospital. Fourth, the case was selected

based on the maximization of information gained and accessibility; case studies are not

sampling research (Stake, 1995). Fifth, this study only focused on perceptions of family

practice physicians working in the United States, though adoption is a global problem. A

final limitation was that this design does not allow for inference of cause.

21
Delimitations

The focus of this study was to explore perceptions of family practice physicians in

a multi-specialty ambulatory clinic located in a metropolitan area of Northeastern

Indiana. Participants were limited to family practice physicians practicing in Indiana who

have had at least two years of experience on an EMR system. Participants were limited to

one specific location in Northeastern Indiana. The participants were all from the same

multi-specialty group. The population included only those working in an ambulatory care

setting.

The study had a small sample size and was conducted over a month. Semi-

structured interviews were conducted at the physician’s office or virtually using Google

Meets. The results of the study may be different using a larger sample, or conducted at a

different period of time, and if conducted at a different location. The results will not be

transferable to other physicians working in different settings, in different parts of the

country. Additionally, using a different research method and design may result in

different findings. The epistemological orientation of this instrumental case study was

that of a constructivist and results may be different with a different orientation.

Chapter Summary

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The decision-making process focused on the acceptance and use of

the replacement EMR system and the drivers and challenges faced by family practice

physicians during the transition with a goal of accelerating acceptance and the use of

22
future EMR replacement systems. The general problem was, despite previous EMR use,

transitioning to a different EMR system or upgrading the current system has unique and

significant challenges that differ from transitioning from paper records (Abramson et al.,

2012).

The specific problem was that physicians’ perceptions of EMR systems affect the

rate of adoption (Ajami & Bagheri-Tadi, 2013). The theoretical framework used to guide

this study was the Unified Theory of Acceptance and Use of Technology (UTAUT) and

Bridges Transition Model which supported the research questions and method. The

constructs of UTAUT and the Bridges Transition Model were used to help guide the

interview questions to help understand how family practice physicians decide to accept

and use a replacement EMR system to better prepare for future EMR changes.

Chapter 1 provided a background discussion of the problem and purpose

statements, the significance of the study, the nature of the study, the research question,

and the theoretical framework that frames the research study. Sections that were also

included were definitions of terms, assumptions of the researcher, scope and limitations

of the study, and researcher-imposed delimitations of the study to put the study in

context. Chapter 2 is the literature review where several pieces of literature about

physicians’ perceptions of EMRs were compared and contrasted to bring validation for

the need for this study. The review included seminal research as well as current articles to

better understand the gaps that currently exist in understanding the phenomenon of this

study.

23
 Chapter 2

Literature Review

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The decision-making process focused on the acceptance and use of

the replacement EMR system and the drivers and challenges faced by family practice

physicians during the transition with a goal of accelerating acceptance and use of future

EMR replacement systems. Reviewing prior research studies on evaluating family

practice physicians’ perceptions of EMRs including barriers and facilitating factors, were

necessary for understanding the key factors that influence their decisions. Evaluating

what research methods have been used to investigate family practice physician

perceptions of EMRs in an ambulatory setting helped identify key variables or measures

as well as the advantages and disadvantages of each method. Reviewing what central

theories have been used to explain family practice physicians’ perceptions of the EMR in

an ambulatory setting was necessary for understanding what theories already exist, any

relationships between them, and by what means existing theory has been investigated to

identify gaps that exist.

The focus of this chapter was to provide insight into the barriers and challenges

influencing EMR adoption and use and to examine how underlying theoretical models are

used to assess EMR use by family practice physicians. Gaining a better understanding of

providers’ perceptions of the EMR may give information technology implementers and

leadership insights to achieve expeditious adoption, reduce healthcare costs, and to have

24
improved the sharing of medical information. Chapter 1 provided some background

information on the importance of an expeditious adoption rate and some of the challenges

leadership, policymakers, and physicians have had implementing EMRs. It has been

estimated that more than $81 billion in health care costs will be saved annually with the

widespread adoption of health information technology (HIT) (Gee & Newman, 2013).

Yet, there is a lack of consideration on how to best design, implement, and use HIT

(Rippen et al., 2013).

Title Searches, Articles, Research Documents, and Journals

The resources for the literature review were from online databases at the

University of Phoenix and Google Scholar. The databases used were EBSCOhost and

ProQuest with the filtering set to peer-reviewed journals. Approximately 1,014 scholarly

sources were reviewed for this study. The search terms included: family practice

physicians EMR, family practice physicians’ perceptions of EMR, physicians’ perception

of EMR, electronic medical records (EMR), EMR adoption, EMR implementation, EMR

use, health information technology (HIT), qualitative research, case study research,

diffusion of innovation, TAM, UTAUT, and William Bridges’ Transition Model.

The majority of the articles included in the literature review were published

within the last three years; however, not every article reviewed applied to the research

study. Resources were stored and managed in the Mendeley software system. Resources

were also imported into NVivo 12 where nodes were created to help manage and sort

through the data. Nodes that were coded included: purpose, gap, theory, sample, method,

findings, future research, and limitations. Word frequencies were run as well as word

clouds to help identify recurrent themes.

25
Historical Content

Brief History of Early EMR Systems

The study of health information technology, including EMRs, is a fairly new

phenomenon. The earliest reference to an EMR appeared in publications in the 1950s and

the earliest peer-reviewed journals in medical informatics published in the United States

started in 1967 (Collen, 1986). The first definition of medical informatics appeared in the

preliminary announcements for the 1977 Third World Conference on Medical

Informatics in Tokyo where the chairman defined the term as the application of computer

technology to all fields of medicine (Collen, 1986).

The early development and evolution of medical informatics in the United States

were mostly supported by government grants and contracts (Collen, 1986). The first

EMR designed for ambulatory care as an out-of-the-box application was the COSTAR

(Computer Stored Ambulatory Record) system version 5 (Barnett et al., 1982). The

COSTAR system was originally developed in the late 1960s by the Laboratory of

Computer Science at Massachusetts General Hospital (MGH) in collaboration with the

Harvard Community Health Plan (HCHP), a prepaid group practice established in 1969

and located in Boston. The HCHP version of COSTAR, COSTAR 4, is a system that had

been used successfully but customized for the operations of HCHP and therefore not

suitable for other organizations without modifications (Barnett et al., 1982). Barnett et al.

(1982) wrote that the need for computer technology in ambulatory settings is “becoming

acute” (p.8). They also wrote that many practices have started using computer technology

in their practices but it was being used for billing purposes and not for patient care

(Barnett et al., 1982). COSTAR 5 was developed to satisfy the clinical needs Barnett et

26
al. (1982) saw missing in ambulatory care practices.

Implementation of COSTAR 5 included a phased implementation approach

(Barnett, et al., 1982). Some of the implementation issues cited were the lack of

knowledge between the system engineers and the needs of the end-users (Barnett et al.,

1982). The minimal amount of training available to the end-users was another problem

identified in the implementation of COSTAR 5 (Barnett et al., 1982). Barnett et al. (1982)

identified that physicians are specifically attuned to on-the-job training and would benefit

by having a resource person available to answer any questions or solve any issues, and

identified that the cost of the system could be a barrier. Good local leadership is essential

to implementation according to Barrett et al. (1982). The University of Utah Department

of Biophysics and Bioengineering, which was established in 1963, designed and

implemented a hospital-based computer system that utilized medical decision logic, the

HELP system. The HELP system was implemented at the LDS Hospital in Salt Lake

City, Utah which started in 1975 and used a phased-in approach which ended in August

1981 (Pryor et al., 1982). The researchers requested an independent evaluation of the

HELP system and found that overall end users were happy with the system. The most

favorable responses revealed from the evaluation were regarding what the physicians

expected and received from the system, from those who used the system. Some future

recommendations were for upgrades to the HELP system included addition to the medical

decision-making module, increase the speed of the system, and putting the HELP system

in the doctor’s office (Pryor et al., 1982).

The COSTAR 5 and the HELP systems were early EMRs that showed promise

but, yet widespread adoption was aborted even after a phased implementation. These two

27
implementations did provide leadership, policymakers, and system implementers

feedback on what worked well in their implementations and what were some of the

challenges and barriers to adoption. Some of the challenges included lack of at-the-elbow

support, system design, and slow computer speeds. Yet more than thirty years later we

are still discussing some of the same barriers to EMR adoption.

Current Content

Acceptance (Adoption)

Researchers sought to gain a better understanding of the factors affecting

physician acceptance of EHR systems (Steininger & Stiglbauer, 2015). A nationwide

survey of Austrian doctors in private practice was conducted in 2010 with 204 useful

questionnaires returned.

The results of the study revealed that attitude was a significant predictor of use, perceived

usefulness had a significant positive effect on the intention to use as well as attitude

towards the system, and the external factors; social influence, health information

technology experience, and privacy concerns, had a significant positive effect on the

intention to use (Steininger & Stiglbauer, 2015).

The researchers were able to confirm from these results that resident doctors with

experience in similar computer systems found the system useful and beneficial, were

more comfortable about collecting and sharing health data, and were more likely to use

the system as soon as it was implemented. A significant concern of the physicians the

safety and security of the data from third parties with malicious intent (Steininger &

Stiglbauer, 2015). This information will be very important to this study as the participants

have had experience using EHRs in the past and it will be interesting to see if the results

28
are the same. The Austrian residents were on a national EHR system it will be interesting

to see if the results of this study differ or if EHR adoption is contagious among healthcare

providers.

Gan (2015) suggests that EHR adoption is contagious among health care

providers; however, the contagion effect is dependent on the fit between the

characteristics of the system and the health care provider. Gan (2015) uses both task

technology fit (TTF) theory and social contagion theory as a framework for the study. A

survey of 51 Health Organization Management students with practical experience in

health care using EHR systems was conducted. A research model was developed with the

constructs of TTF, social contagion, organizational valence to EHR, and intention to

adopt, and data were analyzed using partial least squares (PLS).

The researcher found a positive association between an organization’s perception

of fit between the EHR system and clinical activities and the organization’s valence

(feeling) towards the EHR system. The organizational valence will be higher when strong

(positive) social contagion (behavior) presents, and the organization's valence toward the

EHR system is positively associated with intention to use the system (Gan, 2015). The

terminology was a little misleading, in health care, a provider is typically a physician,

nurse practitioner, physician assistant, midwife, or certified registered nurse anesthetist,

but in this study, the researcher used students who had experience in health care and with

EHRs; the sample selection would have been more meaningful if actual providers or

organizational leaders participated. Gan (2015) was able to validate the data, but the

results may not be as meaningful as they could have been had physicians been used.

Gagnon et al. (2014) conducted a study to identify the main determinants of

29
physician acceptance of an EHR in Canada. The basis for the theoretical framework was

the Theory of Acceptance Model (TAM). Understanding the limitations of the model and

using recommendations from previous research, the researchers extended TAM to

include computer self-efficacy and demonstrability of the results and integrated that

model into a psychosocial model with constructs from the Theory of Interpersonal

Behavior (TIB) and additional constructs of resistance to change and information about

the change, ending with 4 theoretical models to test behavioral intention to use. The

sample consisted of 150 physicians who were members of the Quebec Medical

Association (QMA) and had valid email addresses on file (Gagnon et al., 2014).

The researchers first conducted descriptive analyses, computed Pearson

correlations between constructs, performed path analysis to test for direct and indirect

effects of both TAM models, and performed a multivariate linear regression (Gagnon et

al., 2014). The findings surmise that TAM explained 44% of the variance in physician’s

intention to use the system, Perceived Usefulness (PU), and Perceived Ease of Use

(PEoU) explained a significant portion of the behavioral Intention to Use (BIU). PEoU,

modified by computer self-efficacy, is a strong and significant determinant of physicians’

intention to use EHR and influenced their PU. Computer self-efficacy was found to have

a significant overall effect on BIU; training physicians on computers would improve their

overall PEoU (Gagnon et al., 2014).

Normative factors were found to be the most important factors in determining

physician use. Professional Norm (PN) was the second determinant of physician’s BIU;

the more physicians associate EHR use as behavior for a physician the more likely they

are to use the system. The third most important determinant was Social Norm (SN) which

30
predicts that EHR acceptance by physicians can be strongly influenced by their peers;

recommending physician champions and super users to increase acceptance (Gagnon et

al., 2014).

Looking at sociodemographic and professional characteristics, researchers found

that PU and SN has a higher effect on BIU for general practitioner under 50 years of age.

Physicians 50 years old and older with no EHR experience, PEoU had more impact on

BIU. PN on BIU is stronger for women and RD has more influence on BIU among

general practitioners. Strategies need to be built for new users based on individual

characteristics such as age and gender (Gagnon et al., 2014). This was a very complex

study that had several constructs and identified many associations to influence BIU. The

factors identified from this study will be useful when trying to adopt a new EHR system

into practice.

The study evidenced the main determinants of physician acceptance of an EHR

system in Canada. Illustrations of determinants of acceptance that need to be considered

when physicians are introduced to an EHR system suggest individual user characteristics

need to be considered. This paper advances the idea that a standard implementation

strategy may not be effective. The approach of this study failed to address longitudinal

acceptance behavior as it was simply a snapshot in time.

Johnson et al. (2014) also used TAM but added two new constructs,

institutionalized use, and developmental pattern to test actual longitudinal acceptance

behavior. Institutionalized use is described as the technology being used as part of the

end user's everyday work; only then can the benefits of technology be realized. The

second construct of the developmental pattern was defined as a way to model the process

31
from the introduction of the innovation to actual institutionalized use. The sample was 44

internal medicine residents working at a hospital ambulatory primary care clinic for 11

months in 2002 where the use of the system was strongly encouraged but not mandatory,

user’s acceptance behavior stabilized after 10 months. Data was collected by several

questionnaire surveys to access the perceptional constructs, Cork’s instrument was used

to assess computer literacy and the general optimism toward the use of information

technology, and IBM Satisfaction Questionnaire was used to assess the satisfaction with

the innovation being tested (Johnson et al., 2014).

The results revealed that when examining developmental trends, light users stayed

at a 33% utilization rate during the 10 months, the medium user started strong at 70 %

and after 10 months were at 33%, and heavy users started at about 50% and finished at

100% by the end of the 10 months. Stepwise regression was applied to the data to test the

hypotheses and found that Perceived usefulness (PU) did not have a significant influence

on usage measures nor did PU nor perceived ease of use (PEoU) correlate with initial use

which is contrary to the TAM findings; however, PEoU had a significant positive impact

on self-reported usage and user satisfaction. The findings extrapolated that computer

knowledge harmed user satisfaction, institutionalized use is positively related to general

enthusiasm about the system where neither PU nor PEoU had an impact on this measure

nor did PU or PEoU impact usage group membership. Johnson et al. (2014) concluded

that the probability of one following a specific developmental trajectory was based on

computer knowledge and computer optimism (Johnson et al., 2014).

Reviewing the antecedents of PU and PEoU, PEoU had a significant positive

influence over PU, computer knowledge (CK) negatively impacts PU, and general

32
optimism is a significant determinant of PU. PEoU has one significant antecedent which

is computer experience and computer experience was found to positively influence PEoU

(Johnson et al., 2014). The findings evidenced that computer knowledge may shed some

light on the shortcomings of computer systems influencing the negative impact of

satisfaction. Contrary to the findings of Gagnon et al. (2014) where PU and PEoU were

factors of BIU; PU and PEoU were not found to be factors influencing actual use.

This longitudinal study clarified user behavior after a period of use. The

information will be helpful in better understanding long term use and the importance of

general optimism in keeping users engaged for a long time. The results of this study are

very important to EHR developers in understanding the users of their products and the

expectations of savvy computer users. One factor not yet explored was the organizational

environment and its impact on EHR adoption.

Sherer et al. (2016) wanted to explain how institutional forces affect EHR

adoption in ambulatory physician practices. Sherer et al. (2016) used the institutional

theory as the theoretical framework for their study. The institutional theory posits that an

institution’s environment is stronger at influencing the development of structures than

market pressure. An institution’s environment consists of the cultural belief system,

normative frameworks, and regulatory frameworks that provide meaning and stability

within their industry. Institutional forces such as mimetic (imitate), normative

(community), and coercive forces (competition and regulation) can influence an

organization's environment (Sherer et al., 2016).

Data was collected from two different surveys, the 2008 Health Tracking Survey

and the 2012 National Electronic Health Records Survey which were sent to practicing

33
physicians asking questions about demographics, practice characteristics, and use of

information technology. Approximately 9,200 total respondents from both surveys were

included in the sample. The decision to adopt was modeled, from knowledge to use, at

the organizational level, in ambulatory practice, and as a function of coercive, normative,

and mimetic forces. Using descriptive statistics, the percentage of adoption doubled

between 2008 and 2012, the ordered logit model results were mixed supporting the 2008

data but did not support the 2012 data for the hypothesis that stated physicians subjected

to higher mimetic forces are more likely to adopt but it did support the hypothesis that

physicians subjected to higher normative forces are likely to adopt EHRs, but the

coercive forces were mixed; supporting Medicare but not supporting Medicaid (Sherer et

al., 2016).

Demographic data was found to influence the decision to adopt, older physicians

and smaller independent practices were less likely to adopt and organizations are more

likely to adopt compared to independent physician groups. The results of this study

confirmed some of the information already known such as the increased adoption rate

and the influence of demographic information on use but capturing the impact of the

HITEC Act of 2009 under coercive forces was a new approach. The varying results

between the two programs are described as having more participants in one program over

the other, plausible, and easily determined. The Medicaid program is directed more

toward the pediatric population and did not implement such a significant penalty for not

meeting the program goals; participation could have been less since participation is

limited to one or the other program but not both (Sherer et al., 2016). Other

organizational forces impacting adoption were the EMR’s impact on patient flow.

34
 Bushelle-Edghill et al. (2017) conducted a pre-implementation (one year prior)

time and motion study and a post-implementation study (immediately after and one year

later) to see what changes may have occurred in their pediatric clinic. A total of 2,448

patient visits were collected from all three timeframes, 4 workflow steps were reviewed:

1) check-in to the front desk, 2) check-in to triage, 3) triage to the room and 4) room to

check-out. Time from check-in to front desk decreased after implementation and was

sustained, time from check-in to triage quickly decreased after implementation but

stabilized after a year, the time from triage to room increased significantly from 4.5 mins

to 12.5 mins a year after implementation, room to check out also increased significantly

from 35 mins to 41 min; which is time spent with the provider including shots and check-

out process. The total patient time increased from 56 mins to 81 mins down to 64 mins a

year later. The researchers found that training before implementation and technology

support after implementation will help to realize the benefits of the system (Bushelle-

Edghill et al., 2017).

A common theme found in the EMR acceptance and adoption literature was an

attitude (Gan, 2015; Johnson et al., 2014; Steininger & Stiglbauer, 2015). Bushelle-

Edghill et al. (2017) findings regarding increased time for both patients and providers

may be a contributing factor to the decision to accept and adopt a new EMR system.

Likely, attitude will also be a factor discussed by the physicians in the study. The

discussions may provide more insights for developers, system implementors, and

organizations for future implementations or system optimizations.

Expanding on the findings of Bushelle-Edghill et al. (2017), Nambisan (2014)

examined the impact of peer support and online forums for EMR adoptions. Social

35
contagion and social cohesion theory were used as the theoretical framework. Social

contagion states that when people encounter others who have adopted a particular

innovation there will be a tendency to adopt. Social cohesion theory describes the social

interaction between an adopter and a laggard and if empathic conversations transpire the

laggard will likely adopt the innovation.

Nambisan (2014) collected data from survey questionnaires of 153 respondents.

Questionnaires were sent to members of local physician associations, national-level

healthcare professional associations, local networks, and online physician forums;

Medical Group Management Association (MGMA) supplied most of the responses. The

demographics of the respondents are 108 practices adopted EMR and 45 practices had

not, 63 respondents were from small practices, 77 from medium practices, and 11 from

large groups. The majority of the respondents, 81.9 %, were from primary care providers

(Nambisan, 2014).

Using regression analysis to test the study’s hypothesis, all 5 hypotheses were

supported. The first hypothesis stated that opportunities to interact with other physicians

or office-based practice owners regarding EMR selection had a positive impact on

adoption. The second hypothesis stated that participating in online forums that supported

peer-level interaction about the EMR was positively related to adoption. The third

hypothesis stated that peer support from physicians within your specialty regarding the

selection of EMR or a vendor can positively influence EMR adoption. The fourth

hypothesis stated that peer support was more influential in EMR adoption than financial

incentives. Finally, the fifth hypothesis stated that economic penalties will have more of

an impact on the adoption that incentives (Nambisan, 2014).

36
 Nambisan’s (2014) findings are like those of Sherer et al. (2016) who found that

financial penalties have a positive impact on EMR adoption. In addition, Bushelle-

Edghill et al. (2017) found that support after implementation will help with efficiencies.

The HITECH Act of 2009 has spent millions of dollars in incentives to increase the

adoption rate and the data from these two studies revealed that penalties were the most

important driver. However, this approach may be problematic in areas of the country

where broadband is limited.

Whitacre and Williams (2015) investigated the link between broadband

availability and EMR adoption in Oklahoma. Data were used from a survey conducted by

SK&A Office-based Providers Database in 2011. There were 2,743 physician office

respondents. The survey asked questions about the type of practice, the number of

physicians, patient volume, type of providers, whether Medicare and Medicaid were

accepted, whether they are affiliated with a health system, whether they were owned by a

hospital, whether they had an EMR and if so what features were they using, and the

location was based on the street level address (Whitacre & Williams, 2015).

The research findings reviled that rural practices were typically primary care, solo

practices, low patient volumes, and were staffed by non-physician providers. When

comparing urban to rural practice EMR adoption rates, Whitacre and Williams (2015)

found that rural practices had a significantly higher adoption rate especially in obstetrics

and gynecology, solo physicians, psychiatry, and low patient volume, and where

Medicare was not accepted. However, ophthalmology practices and practices owned by a

hospital had a higher urban adoption rate (Whitacre & Williams, 2015). After the

researchers analyzed the characteristics of the practices, they started analyzing the

37
availability of broadband access.

Whitacre and Williams (2015) used the National Broadband Map (NBM) from

2010 and compared that to the addresses of all the practices to see the number of

broadband providers as well as upload and download speeds (Whitacre & Williams,

2015). The findings exposed that urban areas did have greater download speeds, only two

rural practices were shown to not have broadband available, adoption rates seemed higher

for areas with many broadband providers available; however, the greatest adoption rates

were found in areas that had the slowest upload and download speeds. Whitacre and

Williams (2015) then used regression analysis to identify the characteristics that most

influenced adoption in urban areas. They found that obstetrics/gynecology, psychiatry,

and solo practices are less likely to adopt EMRs in urban areas. They also found that

large practices with a larger number of physicians increased the odds of adoption, as well

as higher patient volume, the acceptance of Medicare, an affiliation with a health

network, hospital ownership, employing a DO, and employing non-physician providers;

however, these relationships did not show significant differences between urban and rural

practices (Whitacre & Williams, 2015).

Broadband availability did not show to be a determinant of EMR adoption. The

researchers could not find a relationship between practice level EMR adoption and

broadband availability (Whitacre & Williams, 2015). Whitacre and Williams (2015)

suggested that future efforts to increase EMR adoption should focus on targeting specific

categories of physicians as they found obstetrics and gynecology to be low EMR adopters

in urban areas ). Identification of characteristics of EMR adaptors and new research on

the impact of broadband availability expanded the literature on EMR adoption. Though

38
this study was to be conducted in an urban setting, wireless connectivity was found to be

an issue with some of the physicians.

Use

Raymond et al. (2015) conducted a study to understand the factors that lead to

greater performance outcomes from EMR systems in primary care. A research model was

developed and tested based on the concept of extended EMR use. Extended use of an

EMR system by family practice physicians was found to improve performance benefits.

Performance benefits include quality of care, efficiencies, operational performance,

economic performance, and social performance (Raymond et al., 2015). Raymond et al

(2015) also found increased physicians’ satisfaction with the EMR system lead to

increased performance benefits for the physicians and the practice. The study also found,

when physicians find the EMR system easy to use they are usually satisfied with the

system, and physicians will use the EMR system when more useful features are offered.

A finding that was not as strong as the previous findings were that physicians use the

EMR system more extensively when they perceive use to be free of effort. What could

not be confirmed was the association between EMR use and user satisfaction (Raymond

et al., 2015).

Stein et al. (2015) examined the role of emotions had a role in how Information

technology (IT) use patterns emerged. The study also found that affective responses from

IT stimulus can be categorized into four classes; 1) loss emotions (anger, frustration), 2)

achievement emotions (satisfaction, pleasure), 3) deterrence emotions (worry, fear), and

4) challenge emotions (excitement). In addition, Stein et al. (2015) defined five different

types of affective characteristics (cues): 1) IT instrumentation, 2) interactions with others,

39
3) involvement in change, 4)) identity work, and 5) IT symbolism. Five patterns of use

were also identified: 1) exercising discretion, 2) being a good citizen, 3) gaming the

system, 4) personalizing, and 5) opting out.

Stein et al. (2015) concluded that users respond emotionally to cues present in an

IT stimulus event. The type of response depends on the nature and content of the cues

and their interactions. People respond to their emotions with either clear adaptation

strategies or vacillating strategies (Stein et al., 2015). These coping behaviors and

strategies are reflected in IT use patterns. Tracing use patterns back to responses and cues

to prompt emotions allows researchers to better understand how and why users make

their IT choice (Stein et al., 2015). Adding to the literature, the current study included

William Bridges’ transition Model to gain more in-depth insights into the emotional

response of the participants and how they are managed during the EMR transition

process. A better understanding of emotional responses will provide organizations more

information to better prepare users for the change.

Challenges

Paré et al. (2014) conducted a Delphi study to see why so many primary medical

care practices in Canada had not adopted an EMR system. The study surveyed 431

physicians without an EMR system and asked them to mark why their practice had not

yet implemented an EMR system. Paré et al. (2014) learned that barriers were both

intrinsic (behavioral and knowledge-based) and extrinsic (economic and technological-

based). Paré et al. (2014) called for more research given their study’s findings that many

medical practices faced no barriers to adoption while others differed greatly as to types of

barriers. A limitation of the study was the potential of survey bias from relying on

40
perceptions of a single-family practice physician to characterize the medical practice

(Paré et al., 2014). The findings of Pare et al. (2014) are similar to Whitacre and Williams

(2015) where technology was found to be a challenge to EMR adoption and use.

An Andalusian case study using statistical descriptive analysis of results from an

online survey of 705 physicians who worked in clinics, found three common barriers to

adoption: lack of financing, physician’s lack of computer skills, and security issues for

telemedicine. A limitation of this study and internet-based surveys is the possibility of

underrepresentation of those who are not using an EMR system (Villalba-Mora et al.,

2015). The Andalusian health system is a public integrated system managed and

governed by the Andalusian Public Health System (SSPA). Andalusia is located in

Southern Spain and accounts for 17.8% of the Spanish population or about 8 million

citizens. The SSPA has made the integration of HIT a priority and part of the Andalusian

health policy since its foundation in 2000 (Villalba-Mora et al., 2015).

The SSPA managed the implementation of Diraya in primary and specialty care

practices which included EHR, electronic prescribing, and appointments made to a call

center or online. This program started in 2004 and covered more than 94% of the

population by January 2010. The stability of the Andalusian governmental leadership of

some 30 years provided a strong commitment to a policy allowing for the reorganization

of services and new governance mechanisms to continue funding these programs’

infrastructure (Villalba-Mora et al., 2015). This study is a perfect example of the

complexities involved in the adoption of HIT. The health system had the support of their

governmental constituents for policies and funding and still encountered barriers to

adoption.

41
Drivers/Facilitators

Jacobs et al. (2015) examined the innovation implementation framework among

physicians using structural equation modeling. The framework postulates that the

consistency and quality of innovation use is a result of organizational implementation

policies and practices (IPP) and individual climate perceptions. Jacobs et al. (2015) found

that ensuring physicians feel supported and perceive they are getting what they need to

effectively implement innovation is more important than having a certain number of staff

available. The findings of Jacobs et al. (2015) are similar to Gagnon et al. (2014) where

the need for the physicians to feel supported was identified and the use of physician

champions was a recommendation to support the need.

Ayanso et al. (2015) examined physicians’ intentions to continue using the EMR

in the post-adoption phase within the framework of expectation-confirmation theory

(ECT) incorporating perceived risk to the model. A field survey of 135 Canadian

physicians who use EMR systems was used to test their hypothesis. Ayanso et al. (2015)

found that physicians are willing to change and adapt to new ways of practicing as long

as the change creates better outcomes for the patients; however, perceived risks reduce

the physician's willingness to continue using or adopting extended features of the system.

McAlearney et al. (2015) saught to improve understanding of the facilitators of

EHR system implementation, focusing on the opportunities to maximize physician

adoption and effective implementation. The frameworks used for this study were Kubler-

Ross’s five stages of grief model and Kotter’s eight-step change management. Data was

collected using interviews and focus groups consisting of 47 physicians and 35

administrative key informants from six U.S. health care organizations. Ten EHR

42
deployment strategies were identified based on the participants’ recommendations: 1)

manage expectations, 2) focus on quality, 3) recruit champions, 4) communicate, 5)

acknowledge the painful transition, 6) provide good training, 7) improve functionality, 8)

acknowledge competing priorities, 9) allow time to adapt to the new system, and 10)

promote a better future (Ann Scheck McAlearney et al., 2015). McAlearney et al. (2015)

used a model to address the emotional experience of EMR implementations as did Stein

et al. (2015) indicating that the emotional implications of the change may have more

impact than what was originally thought.

Research on EMR adoption has provided a better understanding of the

drivers/facilitators for EMR adoption from the physicians faced with the change.

Understanding ways to reduce the stress and anxiety felt by some providers may help

future implementation strategists appeal to the needs of the physicians. The findings from

these studies shed more light on the needs of physicians and how to facilitate the

maximization of physician adoption. The methods used were both qualitative and

quantitative providing a deeper understanding of the physicians' needs.

Barrier

Arndt et al. (2017) conducted a study to assess the amount of time primary care

physicians spent documenting in the EHR both during hours and after hours using system

event logs. The study was a retrospective cohort study of 142 family practice physicians

using the same EMR system for three years. Arndt et al. (2017) found that clinicians

spend 5.9 hours of an 11.4-hour workday in the EHR per 1.0 full-time equivalent, 4.5

hours during clinic hours, and 1.4 hours after clinic hours. Bushelle-Edghill et al. (2017)

had similar results to Arndt et al. (2017) where the amount of time to complete a patient

43
encounter and document the visit post-EMR increased for the providers instead of

decreasing which may contribute to physician burnout.

Shanafelt et al. (2016) evaluated the association between the electronic

environment, clerical burnout, and burnout in US physicians. Physicians across all

specialties throughout the US were surveyed between August and October 2014.

Physicians who used the EHR and computerized physician order entry (CPOE) had low

EHR satisfaction, were less satisfied with the amount of time spent on clerical tasks, and

were at a higher risk of burnout (Bushelle-Edghill et al., 2017; Arndt et al. 2017 ). More

research is needed to learn if the associations observed were causal (Shanafelt et al.,

2016)

Physician Perceptions

Jamoom et al. (2014) compared perspectives of physicians who have and have not

adopted EHRs focusing on three areas: the experienced or expected impact of EHRs on

clinical care, practice efficiency, and operations; barriers to adoption; and the influence of

major policy initiatives that seek to increase EHR adoption. Data was collected from the

2011 National Ambulatory Medical Care Survey (NAMCS) and the NAMCS Physician

Workflow Survey (PWS). The researchers used a quantitative, multivariate logistic

regression model to analyze the data.

The results of the study revealed that a large portion of physicians, regardless of

their adoption status, felt that EHRs had positive impacts on clinical care, practice

efficiency, and finances; cost and loss in productivity were major barriers; and physicians

cite financial penalties and sharing information via health information exchanges (HIE)

as top factors that would influence adoption (Jamoom et al., 2014). The results of the

44
Jamoom et al. (2014) study disagree with the productivity findings of Bushelle-Edghill et

al. (2017) and Arndt et al. (2017) and the coercive forces of penalties found in the Sherer

et al. (2016) study.

Leadership

Transformational leadership uses intellectual stimulation and inspirational

motivation to increase the use of new system features and reduce legacy system habits

(Venkatesh et al., 2016). Two other characteristics of transformational leadership include

charisma, and individualized consideration (Yurov & Potter, 2006). Transformational

leadership was added to the UTAUT model to try to mitigate old habits from the legacy

EMR system which may hinder the learning and use of the new EMR system (Venkatesh

et al., 2016). Venkatesh et al. (2016) posit that transformational leadership positively

affects the learning curve slope.

Yurov and Potter (2006) included leadership in technology acceptance models

specifically in post-adoption technology use. They found that employees are more

motivated to contribute information about a new computer system features if the manager

offers challenging tasks about learning new technology features. Transformational

leadership is a leadership model that works best in post computer implementation and

within the UTAUT framework. This is important to this study as the UTAUT framework

will be used for this study.

Theoretical Framework Literature

Technology Acceptance Model (TAM)

The Technology and Acceptance Model was first introduced in1986 as a doctoral

dissertation by Fred Davis, a student at Massachusetts Institute of Technology (MIT).

45
The theoretical framework for the model was based on the Theory of Reasoned Action

(TRA), an intention model that has been successful in predicting and explaining behavior

over a variety of different settings (Davis et al., 1989). TAM uses TRA to find linkages

between two constructs: perceived usefulness and perceived ease of use and users’

attitudes, intentions, and actual computer adoption behavior. According to TRA, the

performance of a particular behavior is determined by behavioral intention which is

influenced by a person’s attitude and subjective norms about the particular behavior

(Davis et al., 1989). TAM is an adaptation of TRA used to model user acceptance of

information systems (Davis et al., 1989).

TAM posits that perceived usefulness and perceived ease of use are primary

determinants for acceptance and use behaviors for computer systems. Perceived

usefulness is one’s subjective probability that using the computer system will increase

their job performance. Perceived ease of use is the degree to which the prospective user

expects the computer system to be free of effort (Davis et al., 1989). The main purpose

of TAM is to have a mechanism to trace the impacts of external factors on internal

beliefs. Computer use can be predicted based on one’s intentions, perceived usefulness is

a major determinant of use intention, and perceived ease of use is a secondary

determinant of use intention (Davis et al., 1989).

This information is useful in predicting, explaining, and increasing user

acceptance of computer technology (Davis et al., 1989). One of the limitations of TAM is

that user data are self-reported (Davis et al., 1989). Another limitation is the model’s

inability to factor in external variables and barriers to adoption (Yarbrough & Smith,

2007). Understand physician perceptions of usefulness and ease of use are important

46
factors but so are the barriers and external factors that have made adoption and use such a

complex phenomenon. These limitations are the reasons this model was not a good fit for

this study on its own as barriers were a focus for this study.

Unified Theory of Acceptance and Use of Technology (UTAUT)

The Unified Theory of Acceptance and Use of Technology (UTAUT) model is a

useful tool for management to assess the likelihood of a successful introduction of new

technology by providing insights into the drivers of acceptance and use. The UTAUT

model was developed in 2003 by conducting a meta-analysis of eight prior technology

acceptance models which include: the theory of reasoned action (TRA), technology

acceptance model (TAM), the motivational model (MM), the theory of planned behavior

(TPB), a model combining the technology acceptance model (TAM) and theory of

planned behavior (TPB), the model of PC utilization, the diffusion of innovation theory

(DOI), and the social cognition theory (SCT) (Venkatesh et al., 2003). The constructs

derived from the consolidation of the various models include Performance Expectancy

(PE), Effort Expectancy (EE), Social Influence (SI), Facilitating Conditions (FC),

Behavioral Intention (BI), and Use Behavior (UB). The model included these moderating

factors: gender, age, experience, and voluntariness of use. The UTAUT model can

explain 70 percent of the variance in intention to use new technology (Venkatesh et al.,

2003).

Venkatesh et al. (2003) confirmed that there are three direct determinants of

intention to use (Behavioral Intention) performance expectancy, effort expectancy, and

social influence. Performance Expectancy was found to be the strongest predictor of

intention and is significant in both voluntary and mandatory settings. Effort Expectancy

47
was also found to be a significant predictor of intention in both voluntary and mandatory

settings but becoming less significant with increased and sustained use. Social Influence

was not found to be significant in voluntary settings but was significant in mandatory

settings due to compliance expectations, significance attenuates with sustained use

(Venkatesh et al., 2003).

Two direct determinants of usage behavior (Use Behavior); intention to use

(Behavioral Intention) and facilitating conditions were found. Facilitating Conditions are

predictive of intention only in the absence of Effort Expectancy. The moderating

influences of age, gender, experience, and voluntariness were significant and essential

features of the UTAUT model (Venkatesh et al., 2003).

The results from testing the UTAUT model highlighted the significance of

moderating factors. The findings supported the researchers’ hypothesis that gender and

age moderate performance expectancy on behavioral intention, stronger for men and even

more so for younger men. Another hypothesis supported was that age, gender, and

experience moderate the influence of effort expectancy on behavioral intention; stronger

for women, more so younger women, and happening in the early stages of the experience.

The final moderating hypothesis was that gender, age, voluntariness, and experience were

found to moderate social influence on behavioral intention; stronger for women,

specifically older women in mandatory settings in the early stages of the experience

(Venkatesh et al., 2003). Moderating factors have been shown to have a significant role

in the UTAUT model.

Facilitating conditions are individual users’ beliefs that organizational and

technical infrastructures are in place to support use. The researchers’ hypothesis that

48
facilitating conditions do not have a significate influence on behavioral intention was

supported. The researchers did find that when predicting usage behavior, both behavioral

intention and facilitating conditions were significant, where facilitating conditions were

more important to older users especially with increased use. No significant influence on

behavioral intention was found regarding self-efficacy, computer anxiety, or attitude

toward using technology; however, the behavioral intention was found to have a

significant positive influence on computer usage (Venkatesh et al., 2003). Additional

research helped identify constructs that can add to the prediction of use behavior

(Venkatesh et al., 2003).

Venkatesh et al., (2008) expanded the original UTAUT model (Venkatesh et al.,

2003) to include an additional construct, behavior expectation, and to expand user-

behavior to include three conceptualizations: duration, frequency, and intensity. The

expansion was necessary as there were three known limitations of the behavioral

intention construct: behavioral intention addresses internal personal factors and not

external factors, behavioral intention is unable to predict and explain unforeseen events

that happen between the time the intention is decided and when it is acted upon, and

lastly, behavioral intention is unable to predict behaviors that are not within the

individual's control (Venkatesh et al., 2008). Facilitating conditions have also been found

to have limitations.

Facilitating conditions is a construct used to identify how an individual perceives

their control over a behavior; more generally, their perception of the availability of

resources to mitigate barriers to use. Facilitating conditions can only predict behaviors

when information is complete and certain, facilitating conditions are not a good predictor

49
of behavior when presented with ambiguous or incomplete information (Venkatesh et al.,

2008). Behavioral expectation is a new construct used to combat these limitations.

Behavioral expectation is the subjective probability of behaving based on one’s

cognitive appraisal of behavioral determinants such as behavioral intention and

facilitating factors (Maruping et al., 2017). Behavioral intention is driven by internal

factors and motivation whereas behavioral expectation is driven by external factors,

making it a better predictor of use under conditions of uncertainty. Behavioral intention

was found to be a better predictor of the duration of system use and behavioral

expectation is a better predictor of system frequency and intensity (Maruping et al.,

2017). Venkatesh et al. (2008) found these differences between behavioral intention and

behavioral expectation: behavioral intention was positively influenced by behavioral

expectation, behavioral intention is a better predictor of duration after some time, they

also found that behavioral expectation is better at predicting frequency and intensity of

system use, behavioral intention to use a system increases the more the system is used but

the opposite will happen with behavioral expectation, behavioral expectation had a

significant direct effect on use while facilitating conditions had a significant direct effect

on behavioral expectation, and finally they found that facilitating conditions on

behavioral expectation is moderated by age, gender and experience and would be

stronger on older women who have system experience (Venkatesh et al., 2008). These

additions to the original UTAUT model have made it better at predicting use under

conditions of uncertainty and the ideal tool for this research.

Additional constructs added to the UTAUT model include perceived security, in

the context of home health robots, which were found to have a direct association with

50
behavioral intention, and cultural differences (Alaiad et al., 2014; Lin, 2014, 2017;

Venkatesh & Zhang, 2010). These were found to have a significant influence on

behavioral intention, education level, and academic discipline. Which were moderating

factors that affected behavioral intention and use behavior (Awwad & Al-Majali, 2015).

A longitudinal study was conducted and showed how time and experience influenced the

user's perceptions and behavioral intentions and use (Abualbasal et al., 2016). A

limitation to all of these studies is that the UTAUT model was not replicated in its

entirety, not using constructs and moderating factors from the original model an issue

with many current and past studies (Venkatesh & Zhang, 2010). Overall the UTAUT

model was found to be simple, accurate, and robust at predicting acceptance and use of

technology (Khechine et al., 2016).

William Bridges’ Transition Model

Bridges and Bridges (2016) defined change as situational and transition as

psychological. Transition is a three-phase process people go through when they come to

terms with the details of the new situation that the change brings. Getting people through

change is essential if a change is to work as planned. Transitioning involves three phases:

letting go, the neutral zone, and the new beginning. Bridges and Bridges (2016) states

that because the transition is a process it could be said that transition begins with an

ending and ends with a beginning. Failure to get ready for endings is the largest difficulty

for people in transition.

Transitioning is letting go of something; the next step is understanding what

happens after letting go, the transitioning limbo. The gap between the old and new is

where innovation is most possible and the organization can be most revitalized (Bridges

51
& Bridges, 2016). One of the important roles for leadership during this time is to

articulate what needs to be left behind. The task is twofold; first, get your people through

the transition phase in one piece and then encourage them to be innovative (Bridges &

Bridges, 2016).

Methodology Literature

The purpose of the research is to answer questions and gain new knowledge

(Marczyk et al., 2005). Research can be used to describe, explain, and predict which

make important and valuable contributions to knowledge and how we live our lives

(Marczyk et al., 2005). A researcher’s decision on which method to select should be

based on decisions about why, where, the concerns, and from what perspective (Schram,

2006). The form of the research question determines the appropriate research method to

use (Yin, 2014). There are three research methodologies: qualitative, quantitative, and

mixed methods.

Qualitative Research

The goal of qualitative research is to create concepts that assist in the

understanding of a social phenomenon in a natural setting while focusing on the meaning,

experiences, and views of the participants of the study (Al-Busaidi, 2008). Shank (2006)

defined qualitative research as a form of systematic empirical inquiry into meaning.

Systematic describes the research as planned, ordered, and public. An empirical inquiry is

an inquiry-based on the world of experience. Inquiry into meaning is the development of

a complex picture into the phenomenon or situation using rich, deep, thick, textured,

insightful, and illuminative descriptions of meaning (Shank, 2006).

Qualitative research can be used to obtain specific details about a phenomenon

52
such as feelings, thought processes, and emotions which are hard to obtain through

quantitative research (Strauss & Corbin, 1998). Qualitative research data refers to

people’s lives, lived experiences, behaviors, emotions, feelings, organizational

functioning, social movements, cultural phenomenon, or international interactions. Some

of the data can be quantified such as census data or background information but most of

the analysis is interpretive. The most common qualitative research tools for data

collection include interviews, observations, and analysis of documents (Al-Busaidi,

2008).

Qualitative research does not require variables or causal models, observations and

measurements are not based on random assignment to experimental groups, and

qualitative research does not generate hard evidence like quantitative research (Denzin &

Lincoln, 2008). Qualitative research is a type of research that produces findings without

using statistical procedures or other quantification (Strauss & Corbin, 1998). There are

many reasons to conduct qualitative research such as preference or experience, but the

most valid reason is the nature of the research problem (Strauss & Corbin, 1998).

Quantitative Research

Qualitative research seeks to answer questions on how social experience is

created and given meaning, whereas quantitative research emphasizes the measurement

and analysis of causal relationships between variables. Quantitative researchers are

unable to capture their subject’s perceptions because they rely on more inferential

empirical data methods such as surveys (Schram, 2006). Quantitative researchers report

findings in terms of complex statistical measures or methods such as path, regression, and

log-linear analysis (Denzin & Lincoln, 2008).

53
 Quantitative researchers are not interested in rich descriptions because that would

hinder the ability to make generalizations (Denzin & Lincoln, 2008). Quantitative

researchers abstract from the world on an etic science based on probabilities from many

randomly selected cases. Qualitative research is inductive and depends on a purposeful

sampling of participants. Qualitative research is action research that uses observation and

interview methods (Al-Busaidi, 2008). The blending of qualitative and quantitative

methods gives rise to a third method, mixed methods.

Mixed Methods Research

Mixed methods research is defined as a class of research where the researcher

mixes or combines quantitative and qualitative research techniques, methods, approaches,

concepts, or language in a single study to minimize the limitations inherent in each

method (Johnson & Onwuegbuzie, 2004). An important principle of mixed methods

research is that the researcher creates designs that answer the research question instead of

selecting a standard design based on the research question (Johnson & Onwuegbuzie,

2004). Johnson and Onwuegbuzie (2004) recommend using contingency theory when

applying a mixed-methods approach to a study. Contingency theory is the preferable

theory under quantitative, qualitative, and mixed methods approach as it is the

researcher’s responsibility to examine the contingencies and make decisions about the

approach design (Johnson & Onwuegbuzie, 2004).

Research Design

Research design is a logical plan or blueprint of the research study starting with

the research question and ending with conclusions about the questions (Yin, 2014). Yin

(2014) identifies 5 components of a research design: 1) the research question, 2) the

54
research proposition, 3) the units of analysis, 4) the logical linking of the data to the

propositions, and 5) the criteria for interpreting the findings. Schram (2006) stated that

the research design selection process should be based on the researcher’s belief of which

option would best address the research problem, the research question, and the purpose of

the study. Schram (2006) recommended that the decisions about why, where, around

what concerns, and from what perspective the researcher will be conducting the study

should be considered. Ways of looking include observing, asking, and examining what

others have done are similar among the different qualitative designs but ways of seeing

which include underlying intent, guiding concerns, focus, and perspective are not so

similar (Schram, 2006). Several research designs were considered for this study.

Phenomenology

Phenomenology investigates the meaning of the lived experience of a small group

of people related to a phenomenon. Phenomenological researchers focus on what

inexperience means for the person who had lived the experience and provide a

comprehensive description of that experience. Phenomenologist collects data through

long in-depth interviews and critical self -reflection of the researchers. Phenomenology

research does not build theory but offers insights into the world of the study participants

(Schram, 2006).

Grounded Theory

Grounded theory proposes a methodological stance and a set of tools designed to

develop a theory based on the study of social situations rather than being an actual theory.

A distinguishing factor of grounded theory is the specific analytic strategies, not the data

collection methods. Grounded theorists begin analysis as soon as there is data and start

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coding and theorizing based on the data collected, making this a fluid process as more

data is collected the theorizing made go in a different direction. Most grounded theory

research relies on fieldwork primarily interviewing to generate data that is used to

analyze human behavior and social interactions (Schram, 2006).

Research questions in grounded theory are directed towards an understanding of

how a process or change over time influences participant's perceptions (Schram, 2006).

Grounded theorists regard their theories as qualifiable, modifiable, and open to

negotiation. Grounded theorists ground their theories in data and validate the statements

of the relationship between concepts during the research process. The purpose is to create

new and theoretically expressed understandings and to also ground that theory and data

where theory and data are interpreted in a systematic way (Strauss & Corbin, 1998). The

aim of this study was not to build theory but to understand how family practice

physicians decide to accept and use a replacement EMR system to better prepare for

future EMR changes, so grounded theory would not be an appropriate research design for

this study.

Ethnographic Research

Ethnography was derived from anthropology and qualitative sociology. Culture is

the central concept for ethnographic research design where the interactions and actions of

the group create their social norms. Ethnographers typically study groups, communities,

and organizations by immersing themselves in this setting and using different data

collection methods (Marshall & Rossman, 2011). This research study did not look at the

culture of an organization but the lived experiences of those within the organization;

therefore, ethnography was not an appropriate research design for the study.

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Case Study

A qualitative case study research design is a focused holistic (global) description

and analysis of a bounded phenomenon such as a person, a process, or a social unit

(Merriam, 1998a). A case study design allows the researcher to study a case while

retaining a holistic and real-world perspective (Yin, 2014). A case study design is also

used to gain an in-depth understanding of a situation and meaning to those involved in

the situation. The interest is in the process, context, and discovery of the situation

(Merriam, 1998b).

The scope of a case study research was an empirical inquiry with an in-depth

investigation of a contemporary phenomenon within its real-world context especially

when the boundaries between the phenomenon and context may not obvious (Yin, 2014).

Case study research should be used when how or why explanatory research questions are

asked, the researcher has no control over the behavioral events, and the focus of the study

is on a This study used a qualitative research method to gain a more in-depth

understanding of the phenomena under investigation. Transitioning EMR systems is

becoming more common in the health care industry and comes with its own set of

challenges and barriers. The goal of this study was to understand the decision- making

process of family practice physicians to accept and use a replacement system, the

challenges and barriers physicians faced, and the emotional impact of this change may

help health care leaders and policymakers better understand some of the potential drivers

and challenges of EMR acceptance and use when transitioning or upgrading EMR

systems.

The results of this qualitative instrumental case study will not be generalizable to

57
a larger population but could be generalizable to an organization with similar

characteristics to this case. This study looked at the decision-making process of accepting

and using a replacement EMR system from the family practice physicians’ perspective.

In-depth interviews provided thick descriptions of the physician’s experience, what they

were thinking, and how they were feeling. The qualitative method was the most

appropriate method to answer the research questions posed in this study.

Some limitations of qualitative research include the lack of generalizability. The

research findings are so in-depth they refer to the specific participant population.

Subjectivity is another limitation of qualitative research where the researcher has some

influence on the findings of the study. Bias can be reduced but never eliminated because

of the nature of qualitative research. Bias is made explicit in qualitative research designs

(Watkins & Gioia, 2015).contemporary as opposed to a historical event (Yin, 2014).

Baxter and Jack (2008) stated that when considering how to define the case one needs to

consider the research question. Baxter and Jack (2008) also stated that questions need to

be answered by the researcher to determine the case; what do I want to analyze: an

individual, a program, a process, or the differences between organizations?

Merriam (1998) characterizes qualitative case studies as particularistic,

descriptive, and heuristic. Particularistic because case studies focus on a particular event,

situation, program, or phenomenon. Descriptive because the result of the study is a thick

description of the phenomenon under study. Heuristic because case studies shed light on

the reader’s understanding of the phenomenon under study (Merriam, 1998b). The

decision to use a case study design depends on what the researcher wants to know.

Conclusion

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 The literature was able to identify the factors that influenced adoption as well as

the barriers and challenges since the first EMR implementations. Many of the same issues

that were encountered with the implementation of the COSTER5 (Barnett et al., 1982)

and the HELP (Pryor et al., 1982) have continued and are still issues today. There has

also been much learned about factors influencing adoption and use. What was not present

in the literature were the answers to this study’s research questions. The fact that a single

solution has not yet been identified for EMR acceptance and use emphasizes the

complexities of such an endeavor.

Chapter Summary

Several research methods and designs have been used to try to approach the issue

from multiple angles. Surveys have been used to investigate factors influencing EMR

adoption (Steininger & Stiglbauer, 2015; Sherer et al., 2016; Shanafelt et al., 2016;

Jamoom, Paterl, Furukawa, & King, 2014) or test theoretical frameworks (Gan, 2015).

TAM is a theoretical framework that has been used by several researchers (Gagnon et al.,

2014; Johnson, Zheng, & Padman, 2014) and UTAUT has many of the same factors as

TAM. Many of the studies found in the literature are of quantitative methodology so

conducting a qualitative study will add knowledge to the literature.

Chapter 3 discusses the research method and design. Discussions about the

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

sample are included. The recruitment and informed consent process is outlined.

Confidentiality, geographical location, instrumentation, and field testing are discussed.

Steps to achieve trustworthiness are outlined including transferability, credibility, and

confirmation, and dependability. Acknowledgment of the researcher’s bias, data

59
collection, and data analysis are also discussed.

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 Chapter 3

Research Methodology

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The decision-making process focused on the acceptance and use of

the replacement EMR system and the drivers and challenges faced by family practice

physicians during the transition with a goal of accelerating acceptance and use of future

EMR replacement systems. This study took place in an ambulatory care setting in a large

healthcare system in northeast Indiana to explore factors family practice physicians

believe to be drivers and challenges of acceptance and use when transitioning EMR

systems. In-depth interviews, participant observation, and archival documents were used

to help understand family practice physicians’ decision-making process to accept and use

a replacement EMR system. The results of the study may be useful in understanding the

complexities of family practice physician's acceptance and use of EMR systems and to

potentially expedite the adoption of future upgrades or EMR system changes.

Chapter 3 contains a detailed discussion on method, design, appropriateness of

design, research question, population, sampling, informed consent, confidentiality,

geographic location, personal bias, data collection, instrumentation, data analysis,

trustworthiness, and summary to help explore how family practice physicians perceive

the use of EMRs. Method and design appropriateness were discussed as well as the

population and sample for the participants of the study. Data collection procedures and

rationale for those procedures are also discussed. Field testing of the interview questions

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was addressed in this chapter. The data from the study was then explored and examined

in Chapter 4.

Research Method and Design Appropriateness

Researchers have three research methods to choose from that will best fit the

goals and objectives of their research study qualitative, quantitative, or mixed methods.

The focus of qualitative studies is on the process, meaning, and understanding which

produces data that is richly descriptive (Merriam, 1998). The focus of quantitative

research is to find closure of a particular issue, be able to replicate and reconfirm findings

to have certainty, use data to explain, predict, or control outcomes, and refute competing

explanations of research findings (Schram, 2006). Mixed methods research design is a

combination of both qualitative and quantitative methods. This research study used a

qualitative research framework that was appropriate for the study goal of understanding

how family practice physicians decide to accept and use a replacement EMR system to be

better prepared for future transitions.

Schram (2006) recommended that the decisions about why, where, around what

concerns, and from what perspective the researcher will be conducting the study should

be considered. Qualitative studies look for an in-depth inquiry to understand the

phenomenon of interest from the participant's perspectives, emic (Merriam, 1998). Ways

of looking include observing, asking, and examining what others have done are similar

among the different qualitative designs but ways of seeing which include underlying

intent, guiding concerns, focus, and perspective are not so similar (Schram, 2006).

Several research designs were considered for this study, but a qualitative instrumental

case study seemed to be the perfect fit.

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 An instrumental case study is a descriptive tool that was used to explore the

decision-making process of family practice physicians to accept and use a replacement

EMR system. This research study also focused on a single case to learn as much as

possible about the participants overcoming barriers and challenges related to transitioning

between EMR systems within a specific multi-specialty group practice in Northeastern

Indiana. Also, the psychological impact of transitioning EMR systems was explored to

better understand some of the decision-making processes described by the participants.

When looking at other qualitative research designs, an instrumental case study

was the best fit for the purpose of this research study. Phenomenology is used when the

researcher aims to provide meaning that is fundamental to the experience (Schram, 2006),

which was not the purpose of this study. Grounded theory aims to develop a theory that is

derived from and grounded in data or to expand upon or modify existing theory (Schram,

2006), not the purpose of this study. Ethnography studies human groups to understand

how they work together to create a culture (Marshall & Rossman, 2011), not the purpose

of this study.

Research Questions

The central question was:

Q1: How did family practice physicians form their decision to accept and use a

replacement EMR system?

Two sub-questions used to explore additional factors inherent in transitioning between

EMR systems:

S1: How did family practice physicians overcome barriers and challenges

associated with transitioning EMR systems?

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 S2: How did family practice physicians feel emotionally during the transition?

Population and Sample

Population

The population is defined as a group of individuals limited to a geographical

region or institution that has one common characteristic (Martínez-Mesa et al., 2014).

The medical group chosen for this study employs 1,050 people, 158 are physicians, 40

are family practice physicians, and 14 of the 40 are female physicians. The accessible

population included all 40 practicing family practice physicians employed by the medical

group in Northeastern Indiana who are over the age of 21 and where the use of the EMR

system is required, and where the current EMR system was replaced with a new system.

Excluded from the target population were those family practice physicians who are under

the age of 21, have not transitioned EMR systems, are not licensed, or who are not

currently practicing medicine.

Sample

The sampling method that was used for this study was purposeful sampling. The

power of purposeful sampling is in the selection of information-rich cases for in-depth

study (Gentles et al., 2015). Stake (1995) suggests bounding a case by time and activity,

similar to inclusion and exclusion criteria in quantitative studies. Saturation is often used

as a criterion for sample size in qualitative studies (Malterud et al., 2016). Saturation

occurs when no new data, no new themes, no new coding, and the ability to replicate the

study (Fusch & Ness, 2015).

Eight family practice physicians were interviewed to describe the challenges and

barriers associated with transitioning EMR systems and emotional experience. The same

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physicians who were interviewed were also be observed to cross-reference the data

collected in the interview. Minutes from implementation meetings were reviewed to add

depth to the interviews and participant observations. Castellanos (2016) conducted an

instrumental case study and had 15 participants; data saturation occurred at 8 participants.

The multispecialty medical group practice selected as a research site provided an

information-rich environment as they recently transitioned EMR systems and the

experience is fresh in their minds. Each family practice physician is a unique individual

who brings various ideas and perceptions of their experience transitioning EMR systems.

Since the use of the new EMR system was required, selected physicians would be

familiar with the system and its use. The recent transition to a replacement EMR

provided an information-rich environment for this case study. Permission to use the site

was obtained by the practice administrator (Appendix A). The authorized party permitted

the researcher to use the premises to conduct the study. The permission also requested the

researcher to be able to recruit participants from the premises. The permission also

requested authorization to use the name of the premises when publishing the results of the

study. The premises declined the use of their name when publishing the results of the

study but did authorize the researcher to recruit participants from the premises.

Recruitment

A purposive sample consisted of 8 family practice physicians. Physicians were

selected based on age category starting at 21 years old and in categorical increments of

years and gender, important themes in the UTAUT model. The age splits for the study

and demographic survey included: a) 21-34, b) 35-44, c) 45-54, d) 55-64, and e) 65years

and older. Physicians were asked in-depth questions. Interviews were conducted with a

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minimum of 10 family practice physicians or until the point of saturation, saturation point

was reached at 8 participants. Face-to-face interviews were conducted at the participant’s

private office within the clinic or via Google Meets for virtual interviews conducted due

to COVID-19 restrictions. Participant observations were conducted on those participants

interviewed to compare what was said to what is observed. The study was limited to

family practice physicians who practice in a multi-specialty group in Northeastern

Indiana and had prior experience with an EMR system.

Prospective participants were introduced to the study with a phone call to their

office and follow-up email outlining the study with the informed consent attached to see

if they will be willing to participate (Appendix B). Contact information was be obtained

from the company’s employee directory, as permitted. For recruits who agreed to

participate, interviews were scheduled to be held at their office or via Google Meets for

virtual face-to-face interviews at a date and time of their convenience. The interviews

where be limited to one hour but most lasted around 30 minutes.

Informed Consent and Confidentiality

Informed Consent

The informed consent form (Appendix C) was collected from every participant.

Participants interested in being a part of the study were explained the purpose of the

study. Participants were informed that the data collection methods of this study consisted

of semi-structured interviews, participant observations, and archival documents regarding

the EMR transition from the organization. Interviews were scheduled at the participant’s

private office within the clinic and were scheduled for an hour but took about 30 minutes.

Participants were informed about the nature of the research, that participation is

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voluntary, that they can stop participation at any time, participants were provided the

researcher’s contact information to contact with questions about the study and detailed

information about their commitments as participants of the study. Participants were

informed of any foreseeable risks or discomforts as a result of participation in the study,

given a statement that no financial compensation will be made for participation, and

described how the confidentiality of the records identifying the participants will be

maintained.

Informed consent was discussed at the initial phone call when soliciting

participants and discussing their potential participation in the study. Potential participants

who verbally agreed to participate in the study were emailed a copy of the informed

consent to review before their interview. The informed consent was also discussed before

the start of the interview to make sure the participant had not changed their mind or if

they have any questions regarding the consent form. Signed consent was collected from

every participant just before the completion of the demographic survey and the beginning

of the interview. If face-to-face interviews are not possible because of COVID 19

restrictions or comfortability of the participant, informed consents were collected via

email before the virtual Google Meets interview.

A discussion about withdrawing from the study at any time occurred at the initial

phone call and again at the interview site and included as part of the recruitment protocol

(Appendix B) and interview guide (Appendix D) where the participant can notify the

researcher via email of their desire to withdraw from the study. Participants were

informed that the interviews will be audio-recorded, audio and video recorded for virtual

interviews, and hand field notes will be taken. All data collected on participants was

67
confidential and will be destroyed by burning the data flash drive after three years.

Informed consents were stored in a fireproof safe in a locked room at the researcher’s

residence and were stored separately from raw data.

Confidentiality

Data was kept secure. Data files were kept on an encrypted flash drive that is

password protected. Data files, paper documents, and notes were kept in a fireproof safe

locked in a room at the researcher’s residence. Informed consents were kept in a separate

fireproof safe from the raw data in a room at the researcher’s residence. Those who

agreed to participate in the study received a copy of the consent form to review before

their interview. A copy of the consent form was presented to the participant at their

scheduled interview for signature before the start of the interview, or via email for virtual

visits. All data will be destroyed after three years by burning.

Recordings were kept in a secure file on an encrypted flash drive. All recordings

will be kept for three years at which time the files will be deleted, reformatted, and the

flash drive burned. Interviews were conducted via web conferencing due to COVID-19,

the interviews were audio and video recorded with the participant's permission and the

participants received a copy of the recorded interview, a feature of Google Meets.

Important data such as facial expressions were void of the face-to-face interview

experience due to the requirement of facial coverings. Web conferencing allowed an

alternate means to have a similar experience to a face-to-face meeting and provided for

facial expressions to be visible. The web conferencing format chosen was Google Meet

which has a recording feature that records the audio and video components of the

interview.

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 Every effort was made to protect the privacy and confidentiality of the

participants. Interviews were conducted in the private office within the clinic of the

participants and data will be stored on encrypted flash drives. To provide confidentiality

to the participants the researcher used an archival numbering system and interviews were

conducted outside of regular business hours. All data will be destroyed after three years

by burning the flash drive.

Geographic Location

A Multi-specialty group located in Fort Wayne, IN, was the data collection site.

The sample for this case study was a multi-specialty ambulatory clinic in Northeastern

Indiana where family practice physicians were faced with the decision of whether or not

to accept and use the replacement EMR system that was implemented in the second

quarter of 2019. This location was selected as it is within close proximity to the

researcher. The site was purposeful to the study as they just recently transitioned EMR

systems.

Instrumentation

The researcher is the instrument in qualitative studies (Marshall & Rossman,

2011). Data was collected through semi-structured face-to-face in-depth interviews,

demographic surveys (Appendix E), participant observations, and organizational

documents. A recruitment protocol (Appendix B), interview guide (Appendix D), and an

observation guide (Appendix F) were used to help identify appropriate questions to ask,

specific activities and events to observe, and maintain consistency throughout the data

collection process by adhering to these tools. The documents requested from the

organization were documents regarding the EMR transition, training manual, training

69
agenda, minutes from meetings with the EMR vendor.

Field Test

The researcher field-tested the interview protocol and a demographic

questionnaire to evaluate the appropriateness and ambiguity of the questions being asked.

They were tested by presenting them to a group of 5 multi-specialty physicians. The field

test participants are not part of this research study sample population but have already

transitioned to the replacement EMR system. The field test participants provided their

feedback on how best to refine the research questions and questionnaire which was

incorporated; no data was collected which is different from a pilot test.

Trustworthiness

Trustworthiness is a qualitative approach to validity. Trustworthiness is the

degree to which we can depend on and trust the research findings. Trustworthiness

includes the concepts of transferability, credibility, confirmability, and dependability

(Shank, 2006). Qualitative research studies have been viewed as less scientific than

quantitative studies because of the lack of established quality guidelines, those views are

improving as the studies become more trustworthy.

Transferability

Transferability is the degree to which the findings of one study can be transferred

to a different setting or a different population (Shank, 2006). The primary tool for

establishing transferability is in the use of adequate and detailed thick descriptions in

identifying all of the relevant details of the research process (Shank, 2006). Thick

descriptions were obtained through field notes, interviews, observations, and

interpretations during data collection also describing the context, location, and people

70
studied, and transparency regarding analysis and trustworthiness.

Credibility

Credibility is the degree of belief in the research findings. Credibility can be

established by prolonged exposure to the research participants to get to know them and

how they act (Shank, 2006). The researcher has worked with many of the physician

participants in the sample as their controller and later as their practice administrator

during the first transition from paper to EMR and is very familiar with their personalities

as they are with the researchers.

Member-checking is a technique used to enhance the credibility of research

results (Birt et al., 2016). Member-checking is a process where interview transcripts are

returned to the participants for review for accuracy and reduce biases from the researcher.

Researchers with a constructivist epistemology allow the participants to add or delete

items from the transcript (Birt et al., 2016) which is the epistemology of the researcher of

this study and will conduct member-checking in the same manner. Transcripts of the

interviews were delivered in a sealed envelope to the participant for review and

modifications. Participants had a week to review and return any changes to the

researcher.

Reflexive journaling is another technique used to establish credibility. The

researcher conducted a reflexive journal throughout the entire research process to help

provide an audit trail of events. The journaling included details on how data were

collected and how decisions were made throughout the data collection and analysis

process (Merriam, 1998). Reflexive journaling was also used to record the researcher’s

experiences, insights, hunches, questions, methodological and analytical concerns during

71
the data collection and analysis process.

This study utilized triangulation as a credibility tool by collecting data from

interviews, participant observations, and organizational documents and comparing the

findings. Triangulation is the use of multiple methods or data sources in qualitative

research to develop a comprehensive understanding of the phenomena (Carter et al.,

2014). Findings as a result of interviews, observations, and documents are more

convincing than findings from just one or two of these sources (Hancock & Algozzine,

2011). Triangulation is also important to credibility because the more various data

sources communicate the same findings the more credible they become (Shank, 2006).

Confirmability/Dependability

Confirmability deals with the details of the methodology used. Confirming that

enough detail has been provided to enable an analysis of the data collection process and

analysis of such data. A methodological audit trail addresses the issues of the type and

nature of the raw data, how data was analyzed, and how categories and themes were

formed (Shank, 2006). The researcher kept an audit trail of each detail of the data

collection and analysis of the data to meet the requirements of confirmability and

dependability.

Dependability is the ability to know where the data from a study came from, how

it was collected, and how it was used (Shank, 2006). An audit trail is a key strategy for

ensuring dependability. An audit trail tracks the path between the data collected and how

the data was used (Shank, 2006). An audit trail was maintained for this research study.

The audit trail outlined the decisions made throughout the research process to provide a

rationale for the methodological and interpretive judgments of the researcher (Houghton

72
& Keynes, 2013).

Researcher’s Acknowledgement of Biases

The researcher has worked with some of these participants in multiple capacities.

From 1999 – 2007 the research was employed by some of the members of the sample, in

their previous practice, as their controller. The researcher was reunited with some

members of the sample from 2013 -2016 in the capacity of the practice administrator.

During this time, the group was transitioning from paper charts to an EMR.

The researcher is still part of the same parent organization but in a different

capacity and has no influence nor authority over the participants of this study. The

researcher serves as the Chief Quality Officer which is a supportive role and poses no

threat to the potential participants as the researcher is not part of their reporting structure.

The focus of the quality department is on closing gaps in care, making sure patients who

need certain screenings, annual visits, or lab work are identified and reported to the

physicians for follow up. The quality department supports the physician’s offices by

helping the physicians and staff use the EMR so the work they are doing can be captured

for reporting purposes.

Strong relationships have been built over the years and some of the participants

will have no problem sharing information. There are some newer members of the group

who had little interaction with the researcher and others that are new and have not met the

researcher. This is a physician-led organization where elected physicians from the group

sit on the Physician Management Committee (PMC) and vote on all aspects of change

within the organization, clinical and operational.

The researcher reports to the network Chief Quality Officer, not through the

73
medical group. Therefore, there will be minimal risk posed to the participants. A conflict

of interest will not exist since the researcher is not part of the operations team. Interviews

will be audio-recorded and transcribed, member checking will be used to verify the

participant’s words and to reduce potential bias. Participant observation should provide

real-life data as the presence of the researcher in the office will not be unusual. Risk has

been mitigated by obtaining data access and use permission as well as premises,

recruitment, and name permission.

Data Collection

The case was a group of family practice physicians practicing within a

multispecialty medical group in Northeastern Indiana who have recently transitioned to a

new EMR system. The study was conducted after 15 months of transitioning from a

legacy EMR to a replacement system. Data triangulation was achieved by conducting

semi-structured interviews, participant observation, and reviewing organizational

documents such as meeting minutes, training plans, and training agenda documents

regarding the replacement system implementation. The study of the physicians was

instrumental in understanding the EMR transition process which is why an instrumental

case study was appropriate for this study. A demographic survey was used as

demographic data are important elements for the UTAUT model used in this study.

The interviews were conducted at the participant’s private office within the clinic

office or via virtual interviews using the Google Meets platform. The number of

participants is not as important in a qualitative study as it is in a quantitative study and

interviews will continue until the point of data saturation. Data saturation occurs when no

new data or themes are being revealed by the participants and is an indicator of rigor in

74
qualitative studies (Morse, 2015). Data saturation occurred after 8 interviews.

The data collected was organized and managed using NVivo software to help

categorize theoretical propositions on the participant’s decision-making process. The

theoretical propositions were useful to assist in gaining a better understanding of family

practice physician’s decision-making process of EMRs so acceptance and use efforts of

replacement EMR systems are more expeditious. This study also explored the

psychological impact of transitioning EMRs systems to better understand the effect on

physicians.

Some of the limitations of case study research are lack of rigor compared to other

studies and lack of generalizability, (Yin, 2014). This study used a qualitative research

method to gain a more in-depth understanding of the phenomena under investigation.

Transitioning EMR systems is becoming more common in the health care industry and

comes with its own set of challenges and barriers. The goal of this study was to

understand the decision- making process of family practice physicians to accept and use a

replacement system, the challenges and barriers physicians faced, and the emotional

impact of this change may help health care leaders and policymakers better understand

some of the potential drivers and challenges of EMR acceptance and use when

transitioning or upgrading EMR systems.

Interviews

Semi-structured face-to-face or virtual via GoogleMeet (due to COVID-19

restrictions) in-depth interviews, demographic surveys, participant observations, and a

review of organizational documents of the EMR transition process provided the depth of

data needed to describe such a complex phenomenon. The study explored perceptions,

75
thoughts, feelings, and emotions as the participants experience the EMR system

transition, providing the richly descriptive data that was needed to answer the research

questions. Semi-structured interviews were conducted at the participant’s private office

within the clinic or virtually via Google Meets where the researcher explored how the

participants made their decision to accept and use the replacement EMR system, how

they overcame the challenges and barriers inherent in transitioning to a new system, and

how they felt emotionally while going through the transition.

Semi-structured interviews work well in case studies (Hancock & Algozzine,

2011). Researchers ask predetermined but open-ended questions to which the responses

provide data to assist in answering the researcher’s study questions. Semi-structured

interviews ask follow-up questions to look deeper into the participant’s issues of interest

(Hancock & Algozzine, 2011). Semi-structured interviews are designed to allow

participants to express themselves openly and freely so they can define the world from

their perspectives (Hancock & Algozzine, 2011).

This research study was conducted using an instrumental case study design where

data was collected through semi-structured interviews which allows the participants to

share their stories. Using semi-structured interviews allowed the researcher to provide

little direction into what was discussed while allowing the participant to share as much or

as little about the questions being asked. Participants were encouraged to answer the

questions truthfully to help provide valuable findings.

Merriam (1989) stated that interviews are necessary when we cannot observe how

people behave, feel, or how they interpret the world. Face-to-face interviews were

conducted at the participant’s private office within the clinic which was both audio-

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recorded, and audio and video recorded when Google Meet was utilized. In addition, the

researcher took handwritten notes within the face-to-face interviews. A recruitment

protocol (Appendix B) and an interview guide (Appendix D) were used for this study.

The researcher provided questions that were semi-structured and within the context of the

theoretical framework.

The interviews were audio-recorded, or audio and video recorded via Google

Meet, with permission. Notes were also taken to record observations at the interview.

Audio records were transcribed using Nuance voice recognition software, Dragon

Anywhere. Participants were asked to review their transcribed interview for accuracy,

member checking. The answers to the research questions were used as data to analyze

information on how family practice physicians form their decision to accept and use a

replacement EMR system.

Participant Observation

Data was also collected through participant observation (Appendix F). This

included observations of how the actions of the physicians compared to what was shared

in the interview. Participant observations were scheduled with the participant just after

the interview; patient exam rooms were not included in the observation. The observation

was specific to how the participant used the system in practice and if actual use

corresponds to responses from the interview to see if what was told in the interview is

what happened in practice. The researcher also looked for “workarounds” implemented,

assessed the organizational and technical infrastructure, and looked for any emotional

responses from the participants while using the EMR.

Careful objective notes about the observations and conversations were made in

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field notes in a field notebook file. Participant observation enabled the researcher to

frame a context around each participant's experience adding more depth to the case.

Access to the facility was granted to the researcher (Exhibit G) so the researcher had

access to these offices and operations. Special attention was given to the timing of the

documentation to see when it occurred, this limited observational data to no more than

one clinic hour per participant. The researcher looked to validate the information

provided in the interview with actual practice.

Archival Data

Documents regarding the EMR transition were collected in the form of training

manuals, training agendas, and meeting minutes with the EMR vendor (Appendix G).

Training manuals were used to learn how much information and in what manner the

information was communicated to the physician. The options were; step-by-step,

screenshots, or descriptions. The training agenda was used to see what specific topics

were covered in the training sessions. Meeting minutes were used to provide a

background on how the decisions were made to roll out the new EMR system. The

archival data results were used to provide context to the learning environment of the

physicians.

The use of interviews, observations, and documents enabled data triangulation

which enhanced the reliability of the results (Fusch & Ness, 2015). Yin (2018) states that

one of the major strengths of case study data collection is the opportunity to use different

sources of evidence. Any case study finding or conclusion is likely more convincing and

accurate if based on several different sources of data (Yin, 2018).

Data Analysis

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 Interview recordings were transcribed using Nuance voice recognition software,

Dragon Anywhere, and the transcripts were loaded into NVivo software. Relevant data

from organizational documents were also loaded into NVivo software, as well as

participant observation notes. Once all the data was loaded, the initial cycle data coding

methods were applied to the data. Attribute coding was applied to the data as an initial

cycle coding method which provided participant information and contexts for analysis

and interpretation (Saldaña, 2016).

Attribute coding coded all the basic descriptive information from the study such

as fieldwork setting (name, city, country), participant characteristics or demographics,

data formats including interview transcripts, field notes, documents, and date and time

(Saldaña, 2016). After attribute coding, the first cycle coding method was used to further

define the data. Descriptive coding is a first cycle coding method that assigns basic labels

to data to provide an inventory of the topics and is recommended for use by novice

researchers (Saldaña, 2016). The next step applied a second cycle coding method, and

focused cycle coding was used to develop major categories or themes from the data.

Coding is an iterative process and was repeated several times in both the first and

second cycles. After these iterations, several categories or themes were revealed. Those

themes were applied to the theoretical framework to see if additional concepts could be

added to the model based on the data collected. The researcher used the coded data to

find themes that emerged from the transcribed recordings from the participant's

interviews.

The results of this qualitative instrumental case study will not be generalizable to

a larger population but could be generalizable to an organization with similar

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characteristics to this case. This study looked at the decision-making process of accepting

and using a replacement EMR system from the family practice physicians’ perspective.

In-depth interviews provided thick descriptions of the physician’s experience, what they

were thinking, and how they were feeling. The qualitative method was the most

appropriate method to answer the research questions posed in this study.

Summary

Chapter 3 included a review of the study’s methodology, a discussion of the

research method and design appropriateness, and a review of the research questions of the

study. The research question was the basis for much of the information in chapter 3.

Discussions also included the study population and sample, the importance and

requirements of informed consent and confidentiality, the geographic location of the

study, instrumentation used, and field test to test instruments. Trustworthiness was also

discussed as it related to the proposed data collection and analysis process followed by

the specific data collection and analyses.

Chapter 4 provides the analysis and results of the data collected. Qualitative

themes are identified and details of the interviews, participant observation, and archival

documents will be presented. The specific details of the data collection process are

described.

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 Chapter 4

Analysis and Results

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The results from the data collection methods were used to identify

themes or patterns related to family practice physicians’ decision-making process to

accept and use a replacement EMR system. Drivers and challenges faced during the

transition were also identified. Additionally, the emotional experience of such a transition

was explored. This chapter will include the data collection process, the demographics of

the participants, the data analysis, and the results of the study.

Research Questions

The research questions were the focus:

RQ: How did family practice physicians form their decision to accept and use a

replacement EMR system?

SQ1: How did family practice physicians overcome barriers and challenges

associated with transitioning EMR systems?

SQ2: How did family practice physicians feel emotionally during the transition?

Data Collection

Data collection was completed between July 28, 2020, and September 3, 2020.

The informed consent was discussed with each participant during the recruitment process.

Each prospective participant was emailed the consent for review and consideration of

participation. The collection of the signed informed consent was completed at the

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beginning of each interview. For those participants being interviewed virtually, the

informed consent was collected via email one participant interoffice mailed the consent in

a sealed envelope.

Each participant was asked at the beginning of the interview if they had any

questions regarding the informed consent. The fact that the data will be reported in

aggregate and everything said during the interview will be confidential was reiterated.

None of the participants had questions about the informed consent and informed consent

was obtained before each interview.

The semi-structured interviews were guided by the developed interview guide

(Appendix D). The questions outlined in the original interview guide were slightly

modified with feedback from the field test. One recommendation was to change the

wording of one of the questions to make it more open-ended. Another recommendation to

was include questions regarding how the next transition should be done to make it easier

and what they wished they had known before transitioning. The question about emotions

was modified to reflect past tense since the transition happened over a year ago.

The face-to-face semi-structured interviews were recorded with permission from

the participants. The semi-structured interviews were recorded using a voice memo on

the researcher’s cellphone, then downloaded as an audio file, and saved on an encrypted

flash drive. The audio files were deleted from the cell phone at the end of each interview

day.

The semi-structured interviews were transcribed using Dragon Anywhere, an app

that was downloaded to the researcher’s cellphone. The transcript was copied from the

App and pasted onto a word document. No identification of the participants was used in

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any of the files or the transcript. Each transcript was deleted from the App and the word

document was saved to the encrypted flash drive.

Virtual semi-structured interviews were conducted using the Google Meets

platform. Google Meets offers the ability to record web-meetings. With permission from

the participants, the semi-structured interviews were recorded. A feature of Google Meets

is to send a copy of the recording to all participants of the meeting; in this case, the

participant received a copy of the recording. The interviews were transcribed by using

both the closed captioning feature of the Google Meet platform and Dragon Anywhere

App. A copy of the transcript was given to the participant to review and make any

necessary modifications.

Copies of the transcripts were hand-delivered to the participants in a sealed

envelope. No modifications were requested. All participants agreed to be recorded either

audio for the face-to-face semi-structured interviews or audio and video for the virtual

semi-structured interviews. The face-to-face semi-structured interviews did not produce

as much visual data as the virtual interviews due to the participants and researcher

wearing face masks to stop the spread of the COVID-19 virus, a 2020 world pandemic.

The participants’ faces were covered so facial expressions were not visible losing some

nonverbal communication queues. Virtual interviews produced the most data.

COVID-19 has changed how the entire world socializes and interacts. The United

States government acted quickly to the 2020 COVID-19 crisis and the impact on

healthcare. The US government lifted several of the restrictions placed on Telehealth

visits enabling healthcare providers to provide and patients to receive necessary care

without potentially exposing them to the COVID-19 virus. The vulnerable patient

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population were those 65 years and old and the Medicare program allowed health care

providers to use audio-only or audio and video telehealth visits. Telehealth visits

increased due to the COVID-19 pandemic making it easier to conduct virtual interviews

as participants were familiar with using Google Meets, a CMS-approved telehealth

platform.

Participant observation was conducted on all participants of the study. The

observations were discussed during the informed consent process and the observations

were scheduled sometime after the semi-structured interview. Observation of

participant’s workflow occurred in the participant’s clinic, excluding patient exam rooms,

and lasted about 30 minutes. Dates and times were scheduled at the participant’s

convenience.

Some of the participants wanted to stop in the middle of seeing patients show how

they used the EMR, what buttons they clicked, what notes or dot phrases they brought

into their documentation but observations were limited to their natural day to day

workflow. Observations were not conducted in the exam rooms which limited the user

activity that could be observed. Staff was asked some questions regarding the documents

they provided the physicians. Participant observation was used to compare what the

participant said in their interview about EMR use to their actual practice.

COVID-19 restrictions did not prevent participant observations but did put the

researcher at risk as patients with the suspected COVID-19 virus were being seen during

some of the observations. Appropriate personal protective equipment (PPE) was not

issued to the researcher as the researcher did not hold a position within the organization

that was patient-facing, a requirement due to a limited supply of PPE. The researcher

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donned a cloth mask while observing clinic workflows.

Archival data in the form of training manuals, training agendas, and meeting

minutes with the EMR vendor were used to see how the participants were exposed and

trained on the new system. Training manuals were used to see what information was

provided to the physician to expose them to what the new system would look like. The

training agenda was used to see what specific topics and features of the system were

covered during training. Meeting minutes were used to see what the roll-out plan was for

the new system. The archival data showed a context of the learning tools provided to the

participants to prepare them for the transition.

Demographics

All participants were asked to complete a demographic questionnaire (Appendix

E). The demographics of the 8 participants (Table 1) included 4 males and 4 females. The

ages of the participants ranged from 21 – 64 years of age. Years of experience of

participants using the EMR ranged from 2 - 11+ years of age. The amount of time needed

to become comfortable with using the system ranged from weeks to years. Only 1

participant felt using the EMR was voluntary. Reasons are given for not being voluntary

included being the standard of care, governmental mandates, and organizational

expectations to use an EMR.

Table 1
Demographic Survey Results

Age Group Comfortable using EMR Years of Experience

21-64 weeks – years 2-11+ years

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 All participants were family practice physicians employed by a medical group in

Northeastern Indiana who were over the age of 21, where the use of the EMR system is

required, and where the current EMR system was replaced with a new system. The

medical group is part of an integrated network that shared information between 6

hospitals and 4 medical groups. Three of the participants have had always used an EMR,

one was on an EMR during residency and moved to paper and back to an EMR, and 4

were on paper and transitioned to an EMR eight years ago. Of the 8 participants, only 2

used scribes.

Data Analysis
Data from the semi-structured interviews were transcribed and coded by hand line

by line and then coded in NVivo to find emerging themes. Bracketing in the form of

journaling was conducted during the data collection process as well as the analysis

process. The researcher's experiences from previous EMR changes were journaled as an

outlet for expression.

The coding process began with characterizing the data. Data for analysis only

included participants' responses none of the researcher's comments or questions, off-topic

comments were not included in the coding. The data to be analyzed was then cut into

meaningful segments based on responses to the open-ended interview questions. Once the

data was characterized and sorted, the coding process could begin. The coding design

followed in this research was that of Johnny Saldana which includes first cycle and

second cycle coding.

Figure 2

The Seven-Step Coding Process

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 Attribute
Coding

Descriptive
Coding

First Cycle
Coding

SubCoding

Initial
Coding

First to Second
Eclectic Coding
Cycle Coding
x Emotion Coding
Method
x Versus Coding

Pattern Coding
Second Cycle
Coding

Theming the
Data

Seven steps were used to analyze the data collected from semistructured

interviews and participant observations (Figure 2). Archival data was introduced during

the Pattern coding process. The data went through an iterative process to help break down

the data into pieces using Nvivo and using the tools within the Nvivo product to help with

analysis. This iterative process is a way to break down the corpus of the data into pieces

87
that focus on specific aspects of the data to assist the researcher to analyze the data from

different perspectives.

Step 1: Assigning attributes. The participant interview transcripts were coded

using Attribute Coding from the demographic survey they completed at the beginning of

the interview. Coding attributes allow for comparative data analysis based on any of the

attributes from the survey. Attributes coded included gender, age range, years of

experience using an EMR, whether the participant felt using the EMR was voluntary, and

how long it took the participant to become comfortable using an EMR system (Appendix

E). All of these data points can be compared with other participants in the study to allow

for a deeper understanding of the findings. Attribute coding allowed for first and second-

cycle data comparisons in tables by demographic variables providing for a more robust

analysis.

Step 2: Listing and preliminary grouping. The semi-structured interview

questions were arranged based on the theoretical framework and the research questions of

this study. The responses were coded based on applicability to the questions using

descriptive or topic coding. The process started with coding the first interview and

became easier with subsequent interviews. Each line of the first transcript was read and

important words or phrases were coded.

The second transcript was a little easier to code as similar words or expressions started to

develop and categories started to form. Each subsequent transcript got easier to code as

codes had developed from the previous review and fit into similar categories. Each

transcript was read line by line and coded first using descriptive coding and then initial

coding to be able to breakdown the data for further analysis. After the transcripts were

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coded the observation data was incorporated into the NVivo dataset.

The original interview transcripts entered into NVivo were edited to incorporate

data from the observations. Observation data was entered in the space above the actual

transcript. Once this data was entered into NVivo it was coded using descriptive and

initial coding allowing or computer-assisted analysis. Only one category emerged,

“Actual Workflow” with 7 subcategories for analysis.

After the transcripts and observations were coded and loaded into NVivo a more

detailed analysis could take place. Categories and subcategories using sub coding

emerged which reduced the total number of categories to 23 for a total of 4, see

Codebook (Appendix H). The final piece of data incorporated into the analysis was the

training material and notes from the vendor. These documents were reviewed against the

data from the interviews and observations. The documents outlined what was to be

covered in training, verifying access before go-live, and standard workflows.

Eclectic coding was used to assist in the transition from first cycle coding to

second. Eclectic coding uses a combination of two or more First Cycle Coding Methods.

The Eclectic coding method used for this transition incorporated Emotion Coding, and

Versus Coding.

Emotion coding was performed on the codes originally coded to the emotions

category during the description and initial coding processes. Every participant had

mentioned some sort of emotional experience during the EMR transition and emotions

had 50 references coded. Emotions were further evaluated for terms like ANGER,

ANGRY, or MAD. These terms are consequential emotions that are triggered by

emotions of EBARRASSENT, ANXIETY, or SHAME. The terms and triggers were

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evaluated during the coding process.

Versus coding was the last of the eclectic coding methods used. Versus coding

identified dichotomies expressed by the participants. This was an important element to

try to correlate some of the emotions being experienced during the transition. Identifying

struggles between the participants and their work environment is important.

Step 3: Reduction and elimination. Data were coded to see what patterns if any

existed in the data. NVivo has several queries available to assist in helping to identify

patterns.

Patterns could be found using word frequency, identifying the most frequently

used word in the dataset, or text search identifying who said a specific word, or

crosstabulations combining queries and attributed data to intersect. Word clouds and

other visualizations within the NVvio product are possible using patterns of data.

Pattern coding provided another analysis of the data to further categorize the

codes identified, merge codes, and eliminate those that are no longer needed. This

iterative process is necessary to reassess the importance of the data remaining and how it

can be arranged to give the participants a voice. Three themes and eight subthemes

emerged including recommendations for future transitions.

Findings

Theme 1: Accepting and using an EMR Means Continuity of Care

Of the physicians who participated in this study, 75% expressed that their

decision to accept and use a replacement EMR system was based on the quality of care

gained by patients from being able to share patient records within the medical group,

from the hospitals within the network, and the interface of ancillary testing. One of the

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physician’s comment,

I knew that it was necessary I knew that for to provide better health

healthcare for our patients within this particular network it was it was [sic]

imperative that we go to a new EMR that would actually communicate with

the entire network and so I wasn't having to constantly call my own

hospitals to try to get reports from the ER visits and things like that so…

Another physician shared “Well our inpatient [and] outpatient are both on the

same system, which is great”. Having a shared medical record enables physicians to have

a better understanding of the issues their patients are having, if they were in the hospital,

what happened while they were in the hospital. Referencing EMRs functional integration,

Physician E commented on a recent patient hospitalization,

I have a better understanding of like what has taken place with that patient

over the last couple of weeks with the hospitalization and visiting of any

specialist or therapist because it's all available to me. At that very moment I

can click a button and I can say here's your whole hospital H&P in your

discharge summary. And the changes they made and right here here's the CT

that you had and the MRI in the hospital. I mean I before we will often be

like well the patients here can you call the hospital can you get it faxed over

and it would come in [an] hour and a half later in the patient was already

gone you know so I think this is better. It's been very nice I mean it's nice to

login there and I can automatically see what cardiology said about them last

week and the medications they added, and I can see who's prescribing which

medications.

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 When family practice physicians send their patients to a specialist, they do not

have to wonder what the specialist said or what tests were done because they are all

available in the medical record. Participant G shared “the only thing I find that has really

improved patient care with EMR's it’s nice having the notes from the other doctors.” The

two physicians who did not mention the benefit of having access to hospital records have

only ever used an EMR and their EMR was integrated with a hospital, thus making this

feature commonplace.

Another example of continuity of care facilitated by the EMR is the ability to

identify preventative services patients need or have received. An integrated EMR

provides alerts to family practice physicians for their patients needing services such as

their annual care visits, flu shots, breast cancer screenings, colorectal cancer screenings,

and other preventative services. Many times, interfaces integrate the results of such

screenings into the EMR reducing costs related to faxing and staff having to scan into the

EMR. Participant E stated,

It's [healthcare] all driven by quality of care now. I think the EMR's really

been driving more towards how do we [or] how are we able to obtain the

necessary documentation to prove our quality of care, and what patients are

having done, and are the physicians convincing these patients or getting

them to do the appropriate things to better their health? In the long run, and

you can argue is that what medicines all about? You know are we finally

trying to really target the things that need to be done for these patients

because we've identified the things that are most important to prolong your

life and hopefully decrease hospitalizations.

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 Many insurance companies are asking health care organizations to capture

increasingly more quality measures at an increasingly higher rate. Family practice

physicians have a heavy burden to collect or, as the gatekeepers, make sure others have

collected needed quality measures for their patient population. The burden placed on the

family practice physicians to collect quality measures was expressed by Participant H

stating, “You know, I'm sure the subspecialists are doing some but I don't see that they're

doing half of what we're being asked to do”. Having an integrated EMR system has made

the data collection process easier as Participant B shared “HEDIS, it would be more

difficult even to look for things on paper.” However, collecting all of this data in the

EMR takes time. When Participant C was asked how transitioning to the new EMR

impacted their job performance the response was,

Well for me it impacted it [job performance] hugely because we weren’t

able to do any of the like quality stuff in it. I don't feel like it made me I

mean less productive for sure because you know it took a while to get built

back up and get things done.

Some of the features of the EMR were not available when the group went live on

the EMR. The alerts for needed preventative services were not available so identifying

those patients who needed services was a manual process, relying on reports provided by

the insurance companies. The delay in the availability of these features caused some

frustrations. For example, Participant A,

There are so many things that they say this is coming this is coming this is

coming well that is fine but none of it is here now and so none of it is

functional now. So, like all these quality things oh well they will all roll

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 out in the future. Ok but I still care if my patient’s get colonoscopies now,

and I still care if they get mammograms now and there is it is not in the

system. The system is not built now to help me do that so the interim times

when the system isn’t fully functional is really hard as a provider and as

clinical staff and I feel like patient care suffers because of it.

Having quality features that once worked and then were removed was also

frustrating as expressed by Participant F:

The area that became very frustrating early on and it's the same today you

had these quality you [sic] had that quality Mpage where you could see

where things could be tracked and it was broken. So all of a sudden we're

going to get all our numbers from day one going and get all this good and

then well the quality piece doesn't work. And then we're going to take the

Mpage off altogether and then a year later, we're still not there. I think

that's where the emotional side has been very disappointing. I felt like If

we're going to roll out an EMR, I get that it takes probably three months to

get enough information in it to turn on some of the dashboards to make

any of it make sense. But most providers they like judgment they liked

reports. They like to know that what they're doing counts. And so if you

know there's a graph or there's you know a check mark that's green or

yellow or red based on how good they're doing it drives change it drives

motivation. And when that doesn't exist, they get stale they get frustrated

then they withdraw. And we're there.

The participants identified some of the benefits of transitioning to an EMR system

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where notes from other physicians, care settings, or testing are integrated. Capturing

quality data was another benefit of using an EMR. Frustrations were expressed about not

all of the available features of the EMR worked or worked and were later removed.

Barriers and challenges are inherent when transitioning EMRs and the participants shared

theirs.

Theme 2: Overcoming Barriers and Challenges Means Addressing Them

Transitioning EMR systems is an extraordinarily complex process. Decisions

need to be made on how the old data will be accessed or integrated with the new system,

when to implement the system, and how users will be trained. The organization where the

participants worked decided they would import the patient’s problem list, medications,

and pathology reports from the old system into the new. The EMR system transition was

done in a phased approach, the participants’ practice was the last group to go-live.

Subtheme 1: The challenge of importing old records. The phases started in

October 2018 and ended with the participant’s practice in April 2019. Using a phased

approach and delaying go-live dates, the historical data was loaded before the first go-live

in October 2018 causing the data to be outdated by April 2019 implementation.

Participant C expressed their frustration with the historical data load and stated,

Frustrating because we had our go-live pushback so many times that they

downloaded the med list and problem list from almost a year and a half

prior; so literally by the time we got them there wasn't I mean everybody's

medicines were obsolete like they have been changed a billion times. So it

was like basically having to do it yourself.

Bringing in data from an old system into a new system can be risky because the

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data must be mapped exactly for it to populate in the correct field in the new system. This

practice experienced mapping issues as do many system conversions as shared by

Participant F,

So you're told your patient med lists will be able to be collected from your

past EMR and brought over into the current EMR. And so they do that

basically through a linking and so ah, that sounds good except for

sometimes in the file they ended up with three or four versions of the same

medicine. You're learning that just because they say that it links [it does]

not always or you have multiple issues with past medical history where

you'll have coding that doesn't actually come over correctly or it comes

over as just a text file but isn't actually a usable piece of information in the

new system. So I think there's several different pieces where the errors

occur that creates that unknown when you end up working in the new

system for what's going to happen. My newest opinion is most of the time

I don't want the interface. I think you start from scratch. It [interfacing]

creates a lot of extra work that if you just done it up front it would be

better. One of our conversions we would have that and so if there were

multiple first name versions then that individual in the new EMR would

get that many charts.

Another Participant found that the problem list that was converted from the old

system into the new had errors, “Now some people have diabetes in their record and now

you have to say whether they're not [or] whether they are because that was information

that I don't know where it came from.” One of the ways the participants overcame chart

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errors from data migration was to access the old records.

Approximately 62% of the Participants, found that they were accessing the old

system to update charts in the new system. Participant C shared, “That was painful in

itself because we didn't have charts there [previous EMR conversion] but we also didn't

have anything in Cerner had no charts so we still had to access our old system and bring

stuff in.” Using annual wellness visits as a patient encounter to update the data in the new

system was how Participant B approached this challenge, “I thought that things were to

be transferred to Cerner but it's not so you know that's very difficult for now until next

year when I do my annual wellness visits.” Participant D also utilized the old records and

stated, “It sucks because we have to go back and find all of the old records.”

Some participants did not have access to the old system and were frustrated. The

organization was not purchasing any more user licenses for the old system but added a

link called HRV that would provide a .pdf of old chart notes. As noted by Physician C,

the HRV featured had issues and would not always launch. Having to access the old chart

is what many of the participants said they did to overcome the challenge of not having

patient’s old records in the new system; however, they also had a challenge of finding

information in the new system.

Subtheme 2: Findings records in the new system. Finding filed documents in the

new system was a challenge expressed by 75% of the participants. Participant B

conveyed how difficult it is to find documents that have been filed in the new system

either by someone scanning or the interface,

They're [documents] not filed according to [subject], for example if you're

looking for an x-ray they are all on top of each other [documents] and

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 that's difficult for us really difficult to find things that you need. Say if you

want to find an abdominal ultrasound that was done like a year ago you

have to scroll down, there is [no] place like Allscripts before that

radiology you can find all the radiology in one spot [radiology folder]. [In

Cerner] everything [document types] x-ray, hospital records, if you go to

the hospital you probably depending on how many times your you were in

there you got … an endoscopy and then the next day you got a chest x-ray

the next day you have a cath so it's like filed on top of each other and then

your nurse…notes you [via messenger or I get] … a phone message

[which gets filed] on top [of all the other documents, chronologically]. If I

send a text its on top so it's harder [to find documents]. The Cerner

[system makes] is harder to find things that you need. If you have a 15-

minute time slot [for an appointment] I don't have time to scroll those

things or… I'll just say [to the patient] I will look for [it] and I will call

you if I need that test again.

All documents are filed chronologically in a file folder called documents in the

new system. There are document types and limited filters for sorting. Concurring with

Participant B, Participant C added that medical documents can be obscured as all

documents are filed in the same place, thus “every piece of paper that they sign is all in

[documents].”

The inability to find important patient information was also expressed by

Participant H, “it's hard for me to find labs at times.” Recalling important documents is

ineffective if there is not continuity of how documents are filed as noted by Participant D,

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“There needs to be a continuity … when we have different providers’ notes that are

scanned in … to be a way for us to easily coordinate all of those as opposed to just a big

dump basket.”

The lack of consistency in how documents were filed harmed their ability to find

important documents. The lack of consistency may have resulted from the training

received for this new system.

Subtheme 3: Lack of consistency in training. Every participant expressed their

disappointment with the training received. Some of the issues included having training

too far in advance of go-live, not having access to a training environment, and the lack of

knowledge from the trainers seemed to be the number one issue. Having the training a

year in advance was not effective. In reference to the timing of the training, Participant G

commented,

They had the teaching sessions prior, but they really weren’t all that

effective I mean they were not effective at all to be honest with you. They

were a year before … so the teaching sessions were not effective; but what

was effective was just being on the EMR, learning it that way.

Learning from using the system was a sentiment shared by others. Participant D

noted,

It's kind of like you got to learn on the fly and go through your step-wise

protocols as you go through your day and having somebody there to to

[sic] help guide you along in real time is really when you learn the

systems. You can only learn so much through simulation. You have to

really have the day in, and day out grind to really learn and figure out the

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 system.

At-the-elbow resources became scarce after a few days and physicians found it

difficult to get needed help. Participant A expressed their frustration with the inability to

locate a needed resource:

I feel like the support they have is really intensive the first like 2 to 3 days

and then you are searching for help. And I think it is important to have

those longitudinal check-ins because on the first couple of days you are

just trying to figure out how to put in orders, how to get patients in the

office, order what they need to order, and get them out.

Some technical issues encountered included not having access to the

system in advance to train or having the wrong access. Access to features in the

system is based on job codes and where services are provided. A family practice

physician who no longer rounds in the hospital will only have access to chart in

the ambulatory space of the system. Those family practice physicians who still

round in the hospital will have access to both the ambulatory and acute space for

charting. Documents are visible irrespective of place of service, ambulatory can

see acute and acute can see ambulatory. Participant C was given access as a

hospitalist instead of a family practitioner who rounds in the hospital:

I think Cerner was horrible because we had the worst training ever I mean

the training was horrible and I wasn't nervous about going on it I was fine

because I thought well it's just another system but our training was

horrible. My training was all bad because they had me down as being

hospitalist only and so I went through all the training just for hospital stuff

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 and we kept trying to like do stuff in the [clinic] like they would tell us

like you know go here and do this I had no idea what they were talking

about. It was really challenging and frustrating because I thought that

somebody dropped the ball big time there.

Some of the participants did not find the trainers or at the elbow support trainers

from the vendor very knowledgeable and just fumbled through the system. Some of the

participants were familiar with EMR systems and had some high-level questions which

the trainers could not answer. As reported by Participant F, “I had lots of high-end

questions and my trainer was like, well you click this button, and you do this button and

then that's how that works. That was about the extent of the training.” When asked if they

thought the trainer knowledgeable, Participant F replied, “not for me, no. I ended up

having a physician trainer. He came in from England and we talked, and I think he spent

two days with me and that part was super helpful.” Participant C also ended up having a

physician trainer come to the office for one-on-one training. Several participants

commented on trainers’ lack of knowledge because they were not physicians themselves.

Participant D summarized:

I think the lack of help was or the lack of helpfulness was because they

weren't Physicians that were using or providers that were using the

program…there are certain things that just aren't important and there are

other things that are way more important and you don't really know that

until you are a provider and going through the EMR all day long every day

and what, what [sic] is an appropriate workflow.

The lack of knowledgeable trainers was described as frustrating to physicians.

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Describing they’re at the elbow support team, Participant G reflected as:

There were some people in here they were not as well trained or as helpful

as we had hoped. I think they were a bunch of college kids or kids right

outta college. I think they kinda treated it like it was summer camp or

something and so I mean they just didn't have a whole lot of knowledge.

Some of the physicians were very determined to figure out this system on their

own making use of public social media sites like Participant C:

I would just go to YouTube and learn how to do I pretty much self-taught

myself because I don't think we had a really good resource and no one else

really knew a whole lot so no one had used it [before].

Archival documents were reviewed to see what the training plan was for

the transition. Physicians were offered a 4-hour training session in a classroom

setting. Those physicians who worked only in the ambulatory setting also had a 4-

hour training session. Those physicians who provide services in the acute and

ambulatory setting were provided modified training with 2 hours acute and 2-hour

ambulatory. The favorites would then be listed on a landing page so the physician

could just click on the item instead of having to search for the item in the

database. A training manual was created with “job aids” that provided instruction

with screenshots.

Favorites fair was a 2- hour one-on-one training session with a trainer who

helped the physicians build templates, and label their favorite notes, codes, and

orders. Favorites are items physicians use frequently like labs, imaging studies,

order sets, or medications to make it easier for the physician to place orders and

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bill charges. Physicians spent hours building templates. The system came with

standard templates, but physicians chose to build their own. At go-live, physicians

had at-the-elbow support to support them and their staff as they used the system

for the first time. Physicians were supported for three weeks.

Subtheme 4: Timing of go-live. Data migration, filing of documents, and

training were challenges the participants had faced, another was the timing of the

implementation. The timing of the roll-out of the new system was during spring

break for 3 out of the eight participants. These physicians already had plans to be

out the week of spring break. The plans were made when the original go-live date

was earlier in the year and would not have interfered with their spring break

plans. These participants lost a week with the vendor trainers at-the-elbow support

as stated by Participant E:

I was not a big fan of the timing that we rolled this out. It was done over

spring break which I thought maybe some may argue that it was a great

time because there were a lot of providers and people who were out the

office and it allowed the trainers to spend more with one-on-one time with

those people who were remaining but I, as one of the physicians who was

gone during the first week that we went live, I really felt like I came in

behind the eight ball with the go-live and the trainers were kinda already

felt like everyone had already had a week under their belt but there were

… eight or 10 of us docs who were like no this is our day number one and

so we did have one less week of having trainers in our office because we

were gone the first week.

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Implementing this transition during spring break gave those physicians who were out one

week less of at the elbow support as mention by Participant B:

So they were already [providing support] for a week when I came. So, I

only had I think two weeks right because the tech support were there for

three weeks. So I only had two weeks. You [had] a lot of our questions

they didn't know the answers [to]. So they would get somebody to come

and fix it. …there's a lot of ways [of] how to go into [the system and

navigate] it so; so one person might tell you a different way on how to get

to the information you want do.

Having multiple ways to accomplish a goal was a common frustration

among the participants which made it difficult for them to understand the flow

because trainers would rotate and the new trainer would teach them a different

way to accomplish their goal.

Subtheme 5: Lack of support. The ticketing system to log issues was a

barrier to the physicians. When issues with the system were encountered, a call

needed to be placed with the support line established during go-live. The support

tech answering the phone would ask for a variety of pieces of data, sometimes

including screenshots. This could be a lengthy process and at the end of the call,

the caller would be given a ticket number and the caller’s email address would be

logged with the ticket so they could get updates on the issue.

Several of these tickets would be closed without resolution. The process of

reporting the issue again was making the call and supplying the requested

information, sometimes multiple times for the same issue. The ticketing process

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was frustrating as Participant A shared:

I had like a running sticky note of how much time I had spent [logging

tickets] because you talked to one person [who could not help and sends

the call to someone else]. [I was] like oh I need to talk to someone else?

… I stopped the sticky note as an hour and a half of different

conversations [transpired]. And then after 30 days the case example

expires and so they're like, oh sorry, there’s there's [sic] nothing we can do

about it. And then they send you a lot of emails. … I mean emails are fine,

but yeah, I mean it's an excessive amount of emails … with tickets.

Especially if it's not resolved quickly like the COVID bar, I bet I got I

don't know 75 emails you know about [the status of] it. And then they're

like well give us your user experience rate your experience, you know take

the survey and I'm like, ah, you know what I mean? Yeah, and then it's

even frustrating when they close your ticket, and it's not been resolved.

The lack of support on the ground and then the ticketing process from the

vendor resulted in physicians stopping to report issues and logging tickets and

finding workarounds as expressed by a participant:

[It is] My fault because we don't really have time [for technical issues]. If I

have technical difficulties on my computer most of the time, I just ignored

I by-pass it ... But sometimes [issues] keep coming [up] like little things

and I take a picture. … I just don't want to deal with it anymore because

you know if I … have to stop what [I am] doing it might take 30 minutes

of your time while you're seeing patients [to address the issue with tech

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 support] so yeah most of the time I just deal with it.

Subtheme 6: Workarounds. Disruptions in a physician’s day can set their

schedule back so they find ways to get through their day. Workflow changes happen

during the day as shared by Participant A:

If something doesn't work, there's usually something that you can do to

change or alter it to make it fit for you better. There's workarounds. So it's

just being comfortable with knowing that it's not always going to work

how using it should work, but it'll work.

Several workarounds were observed during participant observations. Staff would

print the last office note, the medication list, and any recent tests done and put in the slot

for the physician to grab as they walk into the exam room. Some of the participants used

preprinted forms that listed frequently ordered tests and referrals. The physician would

mark any tests or referrals needed for the patient on the form and hand the form to the

receptionist who would enter the orders and make the referrals into the EMR. Using

ancillary staff to enter orders and make referrals, the physician could continue to see

patients and not be delayed by entering the orders or referrals themself. A nurse was

observed taking handwritten intake assessment notes during a telehealth encounter

instead of entering the information into the EMR. The nurse then verbalized the

assessment to the physician who entered the information into the system.

One office handed their front office staff their billing sheet so the front staff could

enter the appropriate visit codes to be billed along with the above-mentioned documents.

A physician was observed having to request their clinical staff to log into the old EMR to

get a lab result. The word “cumbersome” was mentioned by three participants to describe

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entering information into the system. Participant H stated, “The iPhone … does pretty

well with anticipating what I need and what I do but our EMRs don't.”

Half of the participants found the system easy to use. The other half, 2 had scribes

so they did not speak to the ease of use and the remaining two felt like it took more clicks

to complete an encounter than in their old system. Switching EMRs gives rise to a

concern of the unknown as expressed by Participant F,

If order comes back, if a lab comes back, if there's an error message that

occurs all of these different variables of what you're exposed to over and

over and over. It makes it really tricky sometimes to know what the proper

way to do something is and it creates this unknown and we don't always

have the resource to figure out. I get slowed down by trying to double and

triple check things [so] that I know that

what I did will happen. And so you can't keep that same level of

productivity when you don't trust your system.

The participants were asked, based on their transitioning experience, what they

would recommend for future EMR transitions.

Subtheme 7: Physicians’ recommendations for future transitions. The

participants were asked what they would do differently for future EMR transitions. Some

of the recommendations included more IT resources, consistency in training and entering

data into the system, and better organization of documents. Others thought more

physician input in the choice of system and they felt that having a physician train them

was more beneficial. A couple of participants had a physician come to their office and

within that short interaction, they learned more than all the training prior. Participants had

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shared that the trainers are IT people who do not understand the needs of a physician.

Some of the other recommendations were to freeze salaries during this time so the

physicians can focus on learning the system and not have to worry about lost income. A

training environment was not provided prior to go-live which several of the participants

shared that they learned the system by using it and the classroom training was not that

helpful. Most of the participants felt the at-the-elbow support was beneficial but only for

a few days. The recommendation is to have the trainers come back a few weeks later to

see how the system is being used and offer recommendations for efficiencies. There was

also a recommendation to stick with a go-live date and have course room training over a

weekend to not interfere with the office and seeing patients.

There were conflicting recommendations when it came to interfacing the old

records from the previous system. Some of the participants had voiced frustration that the

old records were not incorporated into the new system. Other participants have had

experience changing EMR systems and recommended not interfacing the old data

because of the risk of data not being mapped correctly which causes several issues. The

recommendation is to just start from scratch and do more chart preparation work in the

new system. Not trusting the system, not being able to find documents, having to access

the old system to get old records, and creating workarounds when the system isn’t

working as expected can take an emotional toll when transitioning EMR systems.

Theme 3: Transitioning is an Emotional Experience

Words used by the participants describe their impending EMR transition included

“expected anticipation,” “a challenge,” “hopeful,” “excited,” “matter of fact,” “anxiety,”

“stress,” and “frustration.” An emotion that some of the participants felt during the

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transition was anxiety. Anxious about missing something important as expressed by

Participant D, “where my anxiety of new systems comes in is that it's just, it runs the risk

of missing things when you take care of your patients.” However, stress and frustration

leading to stress were the terms used by 75% of the participants.

Some of the participants were frustrated early in the process when features did not

work as expressed by Participant F, “when efforts to improve quality cannot be tracked or

trended, it drives change it drives motivation and when that doesn't exist, they get stale

they get frustrated then they withdraw”. When speaking about physicians’ motivations

Participant F shared their personal feeling on the matter, …”If it wasn't for me being

involved on the quality team side, I would have shut down and I would have recoiled into

my office took care of patients and went home. “Participant F had a lot of experience

transition EMR systems and was able to use prior experience to help drive change within

the organization but as was mentioned many of the other physicians disengaged.

One of the participants observed was very much disengaged from the EMR

transition and conformed the system to how they had always practiced instead of

changing to conform to the new system. As this participant shared, “I made all my own

templates. Here [they are] all the templates I made for myself. This took probably 100

hours to do [all] this [but] now it makes my life easier.”

The participants were familiar with transitioning to an EMR system. Some of

them remember what they went through in 2012 when they went from paper charts to an

EMR. That experience framed their attitude for this transition as expressed by Participant

H:

I think … emotionally wise, it's very frustrating. … I'll tell you every time

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 … we switch computer … [systems] and it's only been twice for me … I

struggle with Tourette's. … I just want to cuss all the time because it's so

frustrating …. And I'm like most folks, I don't like things that change but

especially when it doesn't do what you need to do. It slows you down …

[especially] if you have to stop in the middle of the morning because

there's a problem and you have to call [IT] support. …I've got five people

[patients] stacked up. … [and IT support], they don't understand. … we

can't stop for problems. … [Computer problems] can derail a whole day

and …, that's one of the biggest stresses.

The transition experience for some participants was first hopeful about the

new system, stressful during the transition, and resignation when encountering

system glitches. System glitches as described by participant G, “if it goes down

will figure it out, if it's slow you just wait, [laughing] what else are you gonna

do,” added to their stress level. Another stress for some of the participants who

were on a productivity compensation model was the loss in income.

Subtheme 1: Decreased compensation. Several participants were on a

productivity compensation model, so their stress stemmed from a reduction in salary as

Participant E stated,

How many times are we gonna do this? Let's do this one more time and

were done. Don't keep coming to us every couple of years and throwing a

whole new system at us and having us take a month of significant pay cuts

just to learn the new system. But at the end of the day I knew it would be

nice, I knew it would be better, I know we needed it, so it's kind of

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 investment. I was hopeful that going to the new system would increase my

productivity … but um I can't say that it has.

Productivity, availability, and income were also factors for Participants C and D.

The financial exposure experienced by these physicians makes them want to learn the

system quicker which exhausts them with all the extra hours they put in to learn the

system to minimize their financial loss.

Besides the feeling of stress, some of the participants were also angry. Anger due

to embarrassment, “I literally was so frustrated I would go home and cry I am like I must

be the dumbest person like everybody else can use the system I can't even use the

system.” Some providers experienced embarrassment in front of patients:

You know just looking like an idiot in front of your patients that stressful very

stressful. You know I don't know that people really understand how stressful, you

don't want to get in there [exam room] and be like it's not working I can’t get this

to work you know. And you know you want your patients to have confidence in

you as a physician you don't want to walk in there and be like oh my gosh.

Providers were angry that they could not do their job efficiently, having to focus

on a computer screen instead of on the patient. Some of the emotions expressed may have

been a result of the explicit or implicit expectations placed on the physicians. Comments

such as, “administration, they want us to do this in two days … this task in seven days so

it's an expectation” or “the expectation was that we would just go to four hours of

training and we would rock the system that was the expectation that wasn't the reality.”

Other statements such as, “when to accomplish one thing takes three or four minutes

when the expectation is that it'll take 10 seconds.”

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 The physicians may have felt a little animus about the lack of volunteerism to use

the replacement EMR as was expressed, “I mean I felt like it was a blanket expectation

from our network administration that this is just what needed to happen.” Another

participant shared, “we did the new system because we were told we were going to so I

mean there was not really a voluntary thing.” Concurring with the previous statement

another participant stated, “we did it because you know the new system is being rolled

out so … if you're gonna work for [this organization] … you're gonna use Cerner so I

mean that that was the influence.

Several emotions were expressed from the participants during the EMR transition such

as; anxiety for potentially missing test results, frustration when features of the new

system did not work, stressed about potentially taking a reduction in compensation, anger

from the embarrassment of struggling to use the new system in front of patients. The

physicians expressed some animosity against the organization for feeling forced into the

new system, not feeling supported by the organization with unrealistic goals and

expectations, and for the organization implementing a new system that failed to meet all

the physicians’ needs.

Summary

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The central research questions that guided the study were: How did

family practice physicians form their decision to accept and use a replacement EMR

system? The two sub-questions that helped to explore additional factors inherent in

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transitioning EMR systems included: how did family practice physicians overcome

barriers and challenges associated with transitioning EMR systems; and how did family

practice physicians feel emotionally during the transition?

This research was conducted using semi-structured interviews, participant

observation, and the review of archival data. Interviews were transcribed and data was

entered in NVivo qualitative data analysis software which assisted in the data analysis.

The data analysis process produced three themes: 1) Accepting and Using an EMR means

Continuity of Care; 2) Overcoming Barriers and Challenges means Addressing them,

with subthemes of (a) The Challenge of importing old records, (b) Finding records in the

new system, (c) Lack of Consistency in Training, (d) Timing of go-live, (e) Lack of

Support, and (f) workarounds (g) Physicians’ recommendations for future EMR

transitions; 3) Transitioning is an Emotional Experience with the subtheme (a) Decreased

compensation. Chapter 5 will discuss the study’s findings and include limitations and

conclusions and recommendations to leaders and practitioners as well as future research.

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 Chapter 5

Conclusions and Recommendations

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The decision-making process focused on the acceptance and use of

the replacement EMR system and the drivers and challenges faced by family practice

physicians during the transition with a goal of accelerating acceptance and use of future

EMR replacement systems. The problem statement for this study called for an

understanding of the different challenges in transitioning EMR systems than from paper

and how physicians’ perceptions of the EMR system affect adoption and use.

This study took place in an ambulatory care setting in a large healthcare system in

northeast Indiana to explore factors family practice physicians believe to be drivers and

challenges of acceptance and use when transitioning EMR systems. In-depth interviews

of eight participants, participant observation, and archival documents were used to help

understand family practice physicians’ decision-making process to accept and use a

replacement EMR system. The results of the study may be useful in understanding the

complexities of family practice physician's acceptance and use of EMR systems and to

potentially expedite the adoption of future upgrades or EMR system changes. Chapter 5

will discuss the findings of the research study, the limitations of the study,

recommendations to leaders and practitioners, as well as recommendations for future

studies.

Research Questions

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The research questions were the focus:

RQ: How did family practice physicians form their decision to accept and use a

replacement EMR system?

SQ1: How did family practice physicians overcome barriers and challenges

associated with transitioning EMR systems?

SQ2: How did family practice physicians feel emotionally during the transition?

Discussion of Findings

The findings presented in Chapter 4 addressed the research questions. The key

finding in this research study is a family practice physician’s decision to accept and use a

replacement EMR system is based on the perception that the use of the new EMR system

will improve the quality of care delivered to the patient. This chapter includes discussions

of the key findings from the eight semistructured interviews, the participant observations,

and archival data. Five major findings emerged from the study:

1. Quality of care gained for the patients was what 75% of the participants

expressed as their motivating factor to decide to use a replacement EMR

system.

2. All of the participants reported that a lack of IT support was a barrier to

EMR acceptance and use.

3. All participants identified challenges in transitioning to a replacement

EMR system.

4. All participants were observed to have developed workarounds.

5. All participants noted transitioning to a replacement EMR system was an

emotional experience.

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 Each of these major findings will be compared and contrasted with the literature

from the literature review in Chapter 2 and a discussion of each will follow.

Theme 1: Accepting and Using an EMR Means Continuity of Care

Quality of care gained for the patients was what 75% of the study participants expressed

as their motivating factor to decide to accept and use a replacement EMR system which is

consistent with the literature. As one participant shared, “it was [sic] imperative that we go

to a new EMR that would actually communicate with the entire network and so I wasn't having to

constantly call my own hospitals to … try to get reports from the ER visits and things like that

…”. Likewise, a research study conducted by Michel-Verkerke et al. (2015) in the

Netherlands found that almost all of the care providers interviewed stated that integration

and availability of patient information as important elements to delivering high-quality

care. This also supports the UTAUT model that predicts that performance expectancy is

the strongest predictor of intention to use technology (Venkatesh et al., 2003).

The lack of interoperability among EHR systems was found to cause frustration

and skepticism among physicians relative to the value of EHRs (Meigs & Solomon,

2016). Frustration was also expressed by the participants of this study when they could

not locate patient information in the chart that came from outside their network. In

addition, Meigs and Soloman (2016) concluded that there was a need for more evidence

to support the assertion that EMR use leads to improved quality of care to “counter the

physicians’ ambiguity or uncertainty regarding the perceived usefulness of this

technology”(p.8). One of the participants of this study shared that they received a thank

you card from a patient because they encouraged the patient to get a mammogram and the

patient thanked the physician for saving her life because they were able the catch the

tumor early. The EMR system alerted the physician that this patient was due for a

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mammogram and the physician placed the order and informed the patient.

Based on several studies, extended use of EMR systems leads to improvement in

performance benefits (Raymond et al., 2015). Krousel-Wood et al. (2017) conducted a

baseline study with a follow-up study 12-24 months after implementation and found that

positive perceptions of the benefits of an EMR system had significantly increased for the

entire study population. Similarly, the current research study found that the participants

were satisfied with the improved performance in the benefits of the replacement EMR

system. The participants of the current study have been using the new system for about

18 months and have had time to experience the benefits of the replacement EMR system,

confirming previous research findings.

Theme 2: Overcoming Barriers and Challenges Means Addressing Them

Ayanso et al. (2015) found that physicians are willing to change and adapt to new

ways of caring for patients if it improves outcomes for the patient. There are several

barriers to switching EMR systems. Some of the barriers identified in the literature

included interoperability with no standard protocol for data exchange, training and

maintenance and upgrades, staff shortages, privacy, lack of infrastructure, missing data,

cost, too time consuming, perceived lack of usefulness, the transition of data, facility

location, implementation issues, user/patient resistance, lack of technical assistance, and

medical errors (Kruse et al., 2016). One significant barrier related to switching EMRs

identified in the literature is the cost (Andresen et al., 2017). The cost was not a factor for

the participants of this study; however, they shared many of the other barriers identified.

Consistent with prior research, interoperability with no standard protocol for data

exchange was identified as a challenge by the current research participants as they were

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not always able to locate medical information about their patients from facilities outside

of their current network. Training and maintenance was another barrier these participants

shared with findings in the literature. The training was a significant barrier for the

research participants of this study. Other similar barriers experienced by the current

research participants included: lack of infrastructure, missing data, too time consuming,

the transition of data, lack of technical assistance, and the potential for medical errors.

Subtheme 1: The Challenge of importing old records. One of the risks associated

with transitioning EMR systems is the inability to retrieve old data (Andresen et al.,

2017). One solution to bringing data over from a previous EMR system is interfacing.

Interfacing is very complex and not a viable option for some data elements. Bentley et al.,

(2016) stated that interfacing is especially problematic for applications requiring

frequently updated data such as medications, allergies, and problems. The participants of

this study shared their frustration about the data that was interfaced, data was outdated,

created duplicate entries, and attaching problems to the wrong patient. In accordance with

Saleem et al.’s study, participants were frustrated with unanticipated challenges with data

conversion from switching EMR systems and had to access legacy data (Saleem et al.,

2018). In addition, in the current study, the participants were not only frustrated with not

having their legacy data interfaced, but they were also frustrated about not being able to

find information in the new system.

Subtheme 2: Finding records in the new system. Indexing of files and folders in

the EMR has caused issues for the participants and their ability to locate documents. One

study found the same problem after they switched EMR systems and created a multi-

disciplinary committee to simplify and facilitate the readability of the EMR architecture

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(Ologeanu-Taddei et al., 2016). Bardach et al., (2017) also found a provider’s difficulties

locating documents exacerbated by a lack of standardization in EMR use. Information

retrieval is critical for rapid and effective access to patient information such as diagnosis

results, treatment plans, and patient summaries (Yang et al., 2015). The lack of

standardization could have been the result of a lack of consistency in training.

Subtheme 3: Lack of consistency in training. The lack of consistency of the

training was directed toward the trainers that were there to help the participants during

their go-live. Similar to the participant’s experience, Halas et al. (2015) shared that their

study also found that the trainers were not training the same way and would get off track.

In addition, Halas et al. (2015) revealed that training was too long and not helpful

because it did not focus on specific patient scenarios so trainees could not follow along.

Some organizations used the same methodology and approach from training across all

disciplines and customized the content and duration for each discipline (Bentley et al.,

2016). According to the findings of several studies, a variety of training methods, types,

and levels of training is more effective than having a single method (Younge et al., 2015).

The need for training methods was evident by the responses from the participants where

some found value in the training sessions where others did not; they preferred a different

method. One approach to training was to train staff within the organization to be super

users who would go out and train the rest of the team.

Subtheme 4: Timing of go-live. The timing of the go-live for the study

participants was changed several times. The participants had their classroom training

approximately a year before their go-live. The recommendation for large-scale go-lives is

for training to occur 2 to 8 weeks before implementation; training more than 8 weeks

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from go-live will likely not be remembered (Pantaleoni et al., 2015). The fact that

training occurred a year before go-live for the current research participants may have

contributed to some of them not finding value in the classroom training that was offered

as confirming the findings of Pantaleoni et al. (2015).

Subtheme 5: Lack of support. All of the participants in the current research study

reported that a lack of IT support was a barrier to EMR acceptance and use. Similarly, the

Halas et al. (2015) study found that on-site support was lacking. The study site for Halas

et al. (2015) did offer a practice environment for new users to get exposure to the system;

however, it was not accessible remotely requiring users to be on-site. The participants of

the current study were not offered a practice environment to become familiar with the

program before go-live, which was a frustration.

A study conducted by Lambooij et al. (2017) found that IT support yields a

successful EMR implementation. Likewise, Cucciniello et al. (2015) shared that EMR

systems are complex systems serving different stakeholders, and implementations should

be viewed as much as a change management exercise as an IT program. The current

study and similarly the Halas et al. (2015) study both demonstrate that just having IT

support is not enough for a successful EMR implementation. The type and quality of

support are other factors that need consideration when implementing an EMR system,

regardless if it is a new or a replacement system.

Subtheme 6: Workarounds. Similar to the study conducted by Megis et al. (2016)

the participants of this study were observed using workarounds to the EMR workflow.

The most utilized workaround was to document on paper and to later transcribed it into

the EMR. The nurses would print the last patient visit, any recent labs or X-rays, and a

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medication list and place it in the slot on the exam room door. Some participants used a

prepopulated form with a listing of commonly ordered tests and diagnosis codes and

would complete the form and hand it to a staff member to enter into the system.

According to Megis et al. (2016) that though this tactic assisted in avoiding disruptions

for the provider while seeing the patient, this strategy added to the provider’s workload;

using paper.

Bhattacherjee et al. (2018) found that those who hate IT or view it as an intrusion

to their workflow may develop workarounds. It is important to find out why there is a

need for workarounds to improve workflows and enhance education for EHR use (Evans,

2016). Workarounds may be a byproduct of the UTAUT direct determinant of intention

to use technology, effort expectancy, and why despite the extra efforts needed to

complete a patient encounter, physicians are still intending to use the system (Venkatesh

et al., 2003). The participants' encountered several barriers and challenges switching their

EMR system but have also offered recommendations for future transitions.

Subtheme 7: Physicians’ recommendations for future transitions. The

participants of this study have each offered recommendations for future transitions such

as having physician input, more IT resources, consistency in training and data entry,

physician trainers, and organization of documents. Recommendations from the literature

include EMR designers finding features in the EMR that are most and least satisfying to

users and whose usage improves and disrupts performance (Raymond et al., 2015).

Penrod (2017) recommended using the results from their study to evaluate the current

state and the future state of EMR transitions to provide a foundation for future success.

The full benefits of the EMR are not realized until the system is fully utilized and an

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optimization phase will help to refine workflows, enhance the system, and add

functionality and should be part of the go-live implementation (Bentley et al., 2016).

There is much to learn about EMR transitions and the emotional toll this change takes on

the providers.

Theme 3: Transitioning is an Emotional Experience. People respond to their

emotions with either an adaption strategy or a vacillating strategy and these coping

behaviors are reflected in IT use patterns (Stein et al. (2015). Furthermore, if physicians

perceive aspects of their job as burdensome, anxiety-provoking, or dissatisfactory, such

as using the EMR, they risk reduced job satisfaction (Carlton et al., 2016). Saleem et al.

(2018) stated that health care organizations should expect to see physician satisfaction

decrease with a new EMR for up to two years after implementation. Jacobs et al. (2015)

shared that managers wanting to increase implementation effectiveness should focus on

creating an environment supportive of the change and provide an incentive program

highlighting expectations, support, and rewards for EMR use.

Every participant in this current research study had an emotional response to the

EMR change. Some participants felt anger because they did not want the embarrassment

of looking incompetent in front of their patients as they struggled to use the new EMR.

Others experienced anxiety thinking that they would somehow miss a critical finding

because of a glitch in the system. The emotional experience expressed by the participants

confirms the findings that transitions are psychological events and supports the three-

phase Transitional Model of Bridges et al. (2016). A supportive environment from the

organization would be difficult to promote if the physicians are negatively impacted,

financially, by the EMR change.

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 Subtheme 1: Decreased compensation. Some of the participants in this study

were on a productivity type of compensation where they get paid for the work they

perform. The EMR transition caused a schedule reduction of about 50% for a few weeks

and 6 days of training out of the office which reduced the physician's compensation

which increased their anxiety. McAlearney et al. (2015) shared that some of the barriers

physicians have to an EMR implementation are lack of participation in the selection

process, the lack of consideration to the impact on physician compensation, reduced

productivity during training, a lack of physician champion for the innovation, and lack of

supportive leadership. The impact of an EMR transition is a reduction in total outpatient

visits and the number of work Relative Value Units (wRVUs) generated by the provider;

however, a steep rise in the level of care and the wRVU per visit increased at the end of

the study’s sample period (Meyerhoefer et al., 2016). Other organizations have allotted

administrative time so physicians were not financially impacted for training (Bentley et

al., 2016). The financial impact should be a consideration when organizations decide to

transition EMR systems.

Limitations

The present study was limited in several ways. First, the generalizability of the

research findings was limited by the fact that only one type of EMR was referenced in

one type of organizational context. Second, the purposeful sample might not be

representative of the entire population of family practice physicians limiting the

generalizability to one health care organization. Thirdly, the study only included EMR

users in the ambulatory care setting and did not include EMR users in the hospital.

Fourth, the case was selected based on the maximization of information gained and

123
accessibility. Fifth, this study only focused on perceptions of family practice physicians

working in the United States, though adoption is a global problem. A final limitation was

that this design does not allow for inference of cause. However, conducting an

instrumental case study at the research site allowed for an in-depth investigation.

Recommendations to Leaders and Practitioners

The purpose of this qualitative instrumental case study was to explore the

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

EMR system. The decision-making process focused on the acceptance and use of a

replacement EMR system and the drivers and challenges faced by family practice

physicians during an EMR system transition; to accelerate acceptance and use of future

EMR replacement systems.

The general problem was, despite previous EMR use, transitioning to a different

EMR system or upgrading the current system has unique and significant challenges that

differ from transitioning from paper records (Edsall & Adler, 2015). Edsall and Adler

(2015) found that the number one challenge in switching EMR systems was the time

investment followed by productivity loss, difficulty learning the new system, cost to

switch systems, data loss in the conversion, difficulty using the new system, and lastly

the loss of functions of the old system. Understanding those differences are important

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

replaced (Edsall & Adler, 2015).

Understanding the key decision-making factors of family practice physicians

related to EMR acceptance and use could be used to better develop and plan future EMR

transitions to help expedite acceptance and use. The benefits gained from an EMR system

124
are only accomplished by getting the greatest number of physicians using an EMR

system (Lakbala & Dindarloo, 2014) and increases exponentially with prolonged use of

the system (King et al., 2014). Recommendations based on the three themes and the eight

subthemes that emerged from this research study are in Table 2:

Table 2

Recommendations to Leaders

THEME RECOMMENDATION

Highlight the features of the new system

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

Develop a multidisciplinary quality training

Theme 2: Overcoming Barriers and program that addresses workflows and
Challenges means Addressing them. standards for data input and filing of
outside records.

The recommendation by the participants as

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

Work with physicians so that a standard

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

Recommendations from the participants

and the literature are to offer a variety of
types of training but make sure the trainers
Subtheme 3: Lack of consistency in are well trained themselves and consistent
Training. in the information and processes they train.

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 Another recommendation is to try to stick
to the go-live date to ensure training occurs
Subtheme 4: Timing of go-live.
between 2 to 8 weeks before go-live for
optimal retention.

It is highly recommended to have a

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

The literature recommends identifying any

workarounds and improve workflows or
Subtheme 6: Workarounds.
enhance EMR education on use to
eliminate workarounds.

Based on the findings of this research and

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

Be prepared to address some of the

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

A supportive environment with realistic

goals and expectations of performance
should be created and maintained by
Subtheme 1: Decreased compensation. leadership. Develop a plan to address the
financial impact an EMR transition has on
physicians who are on a productivity
compensation model.

Recommendations for Future Research

The old EMR system that this group transitioned from did not have an ambulatory

medical record system that interfaced with the hospital. The ability to share medical

126
records and ancillary testing seemed to be a driver to acceptance and use based on what

the participants expressed. The story from waiting an hour and a half for hospital reports

to being able to access them with a click of a button must also give the patients a sense of

comfort knowing that their family practice has all their medical history and is informed.

Improvements in interoperability are increasing as well as innovations in EMR systems.

More research is needed to determine a best- practice in the EMR transition to help

expedite adoption and use.

Recommendations for future research would be to conduct a survey based on the

findings of this study to explore a larger population of providers. Likewise, conduct a

comparative study with other types of health care providers or with allied health

professionals for a multidisciplinary perspective. Similarly, conduct a comparative study

with other health systems that have transitioned EMR systems. Further investigation is

needed into the strong emotional impact these EMR transitions have on physicians to try

to mitigate them in future transitions.

Chapter Summary

The purpose of this qualitative instrumental case study was to explore the

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

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

Northeastern Indiana. The problem statement for this study called for an understanding of

the different challenges in transitioning EMR systems than from paper and how

physicians’ perceptions of the EMR system affect adoption and use. The research

questions were the focus:

RQ: How did family practice physicians form their decision to accept and use a

127
 replacement EMR system?

SQ1: How did family practice physicians overcome barriers and challenges

associated with transitioning EMR systems?

SQ2: How did family practice physicians feel emotionally during the transition?

Five major findings emerged from the study; 1) quality of care gained for the

patients was what 75% of the participants expressed as their motivating factor to decide

to use a replacement EMR system, 2) all of the participants reported that lack of IT

support was a barrier to EMR acceptance and use, 3) all participants identified challenges

to transitioning to a replacement EMR system 4) all participants were observed to have

developed workarounds, and 5) all participants noted transitioning to a replacement EMR

system was an emotional experience. The themes from Chapter 4 were compared and

contrasted with the literature from Chapter 2 and included in Chapter 5. The study

findings have contributed to a better understanding of the experiences and emotions of

physicians transitioning EMR systems. Consideration needs to be given to the emotional

impact EMR transitions have on physicians.

128
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Appendix A

144
145
 Appendix B

Recruitment Protocol

PARTICIPANT RECRUITMENT

Researcher: Hello, this is Diana Berich Brieva. I am calling because I am conducting a

research study in partial fulfillment of my doctorate degree in Health Administration

from the University of Phoenix. The title of my research study is FAMILY PRACTICE

PHYSICIANS’ ACCEPTANCE AND USE OF A REPLACEMENT ELECTRONIC

MEDICAL RECORD SYSTEM: AN INSTRUMENTAL CASE STUDY. The purpose of

this qualitative instrumental case study will be to explore the decision- making process of

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

specialty ambulatory clinic located in a metropolitan area of Northeastern Indiana. The

decision-making process will focus on the acceptance and use of the replacement EMR

system and the drivers and challenges faced by family practice physicians during the

transition with a goal of accelerating acceptance and use of future EMR replacement

systems.

You were selected because you are a family practice physician who is at least 21

years of age and practicing at a multi-specialty medical group in Northeastern Indiana

who transitioned to a replacement EMR system in 2019. Your participation will involve

either a face-to-face or virtual Google Meet (due to COVID-19 restrictions) interview

that should not last longer than an hour. With your permission, I would like to audio or

audio/video (Google Meet) record the interview so that I capture your words accurately.

If you are uncomfortable with an audio or audio/video recording, I will take hand notes.

For your convenience and confidentiality, face-to-face interviews will be conducted in

146
your private office at the clinic and after work hours.

Participation will also include (pending COVID-19 restrictions) being observed in your

clinic, excluding patient exam rooms, for about an hour to see how you are currently

using your electronic medical record. Observations will be documented in field notes and

stored electronically. Date and time of observation will be at your convenience.

If you have any questions about the research study, please call me at 260-417-4985

or email me at dberich@email.phoenix.edu.

147
 Appendix C

INFORMED CONSENT: PARTICIPANTS 21 YEARS OF AGE AND OLDER

Dear Participant (__________________________),

My name is Diana Berich Brieva and I am a student at the University of Phoenix working
on a Doctorate in Health Administration degree. I am doing a research study entitled
FAMILY PRACTICE PHYSICIANS’ ACCEPTANCE AND USE OF A
REPLACEMENT ELECTRONIC MEDICAL RECORD SYSTEM: AN
INSTRUMENTAL CASE STUDY.

Participation in this study will provide useful information to lawmakers, electronic

medical record (EMR) system developers, and health care administrators on the
challenges, drivers, and emotional factors involved in EMR transitions for physicians.

The purpose of this qualitative instrumental case study will be to explore the decision-
making process of family practice physicians transitioning to a replacement EMR system
at a multi-specialty ambulatory clinic located in a metropolitan area of Northeastern
Indiana. The decision-making process will focus on the acceptance and use of the
replacement EMR system and the drivers and challenges faced by family practice
physicians during the transition with a goal of accelerating acceptance and use of future
EMR replacement systems.

Your participation will involve either a face-to-face or virtual Google Meet (due to
COVID-19 restrictions) interview that should not last longer than an hour. With your
permission, I would like to audio or audio/video (Google Meet) record the interview so
that I capture your words accurately. If you are uncomfortable with an audio or
audio/video recording, I will take hand notes. For your convenience, face-to-face
interviews will be conducted in your private office at the clinic. Participation will also
include (pending COVID-19 restrictions) being observed in your clinic, excluding patient
exam rooms, for about an hour to see how you are currently using your electronic
medical record. Observations will be documented in field notes and stored electronically.

You can decide to be a part of this study or not. Once you start, you can withdraw from
the study at any time without any penalty. Should you withdraw from the study, all the
data collected from you will be destroyed within 24 hours. The results of the research
study may be published but your identity will remain confidential and your name will not
be made known to any outside party.

148
In this research, there are no foreseeable risks to you.

Although there may be no direct benefit to you, a possible benefit from your being part of
this study is to help fill gaps in the literature of the decision-making process of family
practice physicians in ambulatory care settings and help health care leaders and
policymakers better understand some of the potential drivers, challenges, and emotional
factors of EMR acceptance and use when transitioning or upgrading EMR systems.

If you have any questions about the research study, please call me at 260-417-4985 or
email me at dberich@email.phoenix.edu. For questions about your rights as a study
participant, or any concerns or complaints, please contact the University of Phoenix
Institutional Review Board via email at IRB@phoenix.edu.
As a participant in this study, you should understand the following:

1. You may decide not to be part of this study or you may want to withdraw from
the study at any time. If you want to withdraw, you can do so without any
problems by emailing me at dberich@email.phoenix.edu.
2. Your identity will be kept confidential.
3. Diana Berich Brieva, the researcher, has fully explained the nature of the
research study and has answered all of your questions and concerns.
4. Interviews may be recorded. If they are recorded, you must give permission for
the researcher, Diana Berich Brieva, to record the interviews. You understand
that the information from the recorded interviews will transcribed using Nuance
Dragon speech recognition software. The transcript of the interview will be
shared with you to review for accuracy. The data will be coded to assure that
your identity is protected.
5. Data will be kept secure. Data files will be kept on an encrypted flash drive that
is password protected. Data files, informed consents, paper documents and notes
will be kept in a fireproof safe locked in a room at the researcher’s residence.
Informed consents will be stored separately from raw data in a fireproof safe in a
locked room at the researcher’s residence. The data will be kept for three years,
and then destroyed by burning.
6. The results of this study may be published.

“By signing this form, you agree that you understand the nature of the study, the possible
risks to you as a participant, and how your identity will be kept confidential. When you
sign this form, this means that you are 21 years old or older and that you give your
permission to volunteer as a participant in the study that is described here.”

( ) I accept the above terms. ( ) I do not accept the above terms. (CHECK
ONE)

149
Signature of the research participant ______________________________ Date
____________

Signature of the researcher _____________________________________ Date

____________

150
 Appendix D

Interview Guide

1. Ask participant to review and sign informed consent.

BEGINNING THE INTERVIEW – REVIEW INFORMED CONSENT

Researcher: Hello. I want to thank you for taking the time to meet with me today and

allow me to interview you as part of my research project. Your participation will

involve either a face-to-face or virtual Google Meet (due to COVID-19 restrictions)

interview that should not last longer than an hour. With your permission, I would like

to audio or audio/video (Google Meet) record the interview so that I capture your

words accurately. If you are uncomfortable with an audio or audio/video recording, I

will take hand notes. Participation will also include (pending COVID-19 restrictions)

being observed in your clinic, excluding patient exam rooms, for about an hour to see

how you are currently using your electronic medical record. Observations will be

documented in field notes and stored electronically.

You can decide to be a part of this study or not. Once you start, you can withdraw

from the study at any time without any penalty. Should you withdraw from the study,

all the data collected from you will be destroyed within 24 hours. The results of the

research study may be published but your identity will remain confidential and your

name will not be made known to any outside party.

RISKS OF PARTICIPATION

In this research, there are no foreseeable risks to you.

151
BENEFITS OF PARTICIPATION

Although there may be no direct benefit to you, a possible benefit from your being

part of this study is to help fill gaps in the literature of the decision-making process of

family practice physicians in ambulatory care settings and help health care leaders

and policy makers better understand some of the potential drivers, challenges, and

emotional factors of EMR acceptance and use when transitioning or upgrading EMR

systems.

QUESTIONS

If you have any questions about the research study, please call me at 260-417-4985 or

email me at dberich@email.phoenix.edu. For questions about your rights as a study

participant, or any concerns or complaints, please contact the University of Phoenix

Institutional Review Board via email at IRB@phoenix.edu.

PARTICIPANT’S RIGHTS

As a participant in this study, you should understand the following:

1. You may decide not to be part of this study or you may want to withdraw from

the study at any time. If you want to withdraw, you can do so without any

problems by emailing me at dberich@email.phoenix.edu.

2. Your identity will be kept confidential.

3. Diana Berich Brieva, the researcher, has fully explained the nature of the research

study and has answered all of your questions and concerns.

152
 4. Interviews may be recorded. If they are recorded, you must give permission for

the researcher, Diana Berich Brieva, to record the interviews. You understand that

the information from the recorded interviews will be transcribed using Nuance

Dragon speech recognition software. The transcript of the interview will be shared

with you to review for accuracy. The data will be coded to assure that your

identity is protected.

5. Data will be kept secure. Data files will be kept on an encrypted flash drive that is

password protected. Data files, informed consents, paper documents, and notes

will be kept in a fireproof safe locked in a room at the researcher’s residence. The

data will be kept for three years and then destroyed by burning.

6. The results of this study may be published.

DURING THE INTERVIEW

Researcher: I want to be engaged with you and listen carefully to what is being said.

The tape recorder will allow me to listen intently without braking eye contact. I may

periodically need to take notes and they will be quick jots as to not distract the you

while speaking.

Researcher: After the interview I will check the recording to make sure everything

was captured. I will spend time filling in notes about my observations before I leave

to make sure everything is fresh in my mind. I may ask you to review my notes to

ensure I have accurately captured what was said.

2. Ask participant to complete demographic survey

153
3. 1st Question: Would you please share with me your experience with accepting and
using an electronic medical record system in your clinic and how you prepared for the
transition to the new system? How were you able to overcome barriers and challenges
inherent in EMR system acceptance and use?

Performance Expectancy:
Effort Expectancy:
Social Influence:
Facilitating Conditions:

Does the response from question 1 answer the below questions; if not, please ask these
supplemental questions:
A. Performance Expectancy: Please share with me your experience of any increased
job performance because to the EMR system?

B. Effort Expectancy: Please share with me your experience on the ease of using the
system?

C. Social Influence: Please share with me your perception of others expectation of

you on use of the system; was anyone specific influential?

D. Facilitating Conditions: Please share with me your thoughts on the organizational

and technical infrastructure to support the EMR system?

4. 2nd Question: Would you please share with me how you have been feeling
emotionally about this impending EMR system change?

CONCLUDING THE INTERVIEW

Researcher: I want to thank you again for your time today. Should you have any

questions or concerns about the study after I leave here today please feel free to reach me

at reach me at 260-417-4985 or email me at dberich@email.phoenix.edu.

Participant #_______________
For researcher use only

154
 Appendix E
Demographic Survey

The theoretical framework for this study is the Unified Theory of Acceptance and Use of
Technology (UTAUT) which identifies certain demographic characteristics as mitigating
factors in the model. Those demographic characteristics are included below:

Please CIRCLE the most applicable response.

1. Gender: MALE FEMALE

2. Age (in years): 21-34 35-44 45-54 55-64 65+

3. Years of experience using an electronic medical record (EMR) (in years):

<2 years 2-5 years 6-10 years 11+ years

4. Do you feel use of the EMR system is voluntary: Yes No

5. How long do feel it took for you to become comfortable with using an EMR system?
(Please fill in with the appropriate number in the respective time frame)

__________ Days _________ Weeks __________ Months __________ Years

155
 Appendix F

Observation Guide

Name of Observer: ________________________ Role of Observer: Participant

Observer

Location: _____________________________________ Date:

_______/________/_______

Start Time: _____:____ am or pm End Time: _____:____ am or pm Duration:

______mins

Pseudonym of participant: ____________________________________

What to Observe - Research Questions: (specific focus of observation based on research

questions highlighted and underlined and participant’s responses to interview questions
within the context of Performance Expectancy, Effort Expectancy, Social Influence, and
Facilitating Conditions; UTAUT Model)
x How did family practice physicians form their decision to accept and use a
replacement EMR system?, (Acceptance and use of the system will be observed
by how the participant uses the EMR system and if any “workarounds” have been
created. Workarounds such as documenting on paper and scanning the paper
document instead of entering the data in the system or the physician having the
staff print documents out of the EMR instead of using the system as designed
will be the focus. Also looking for increased job performance and ease of using
the system, performance expectancy and effort expectancy)
x How did family practice physicians overcome barriers and challenges

156
 associated with transitioning EMR systems?, (Barriers and challenges, if any,
identified by the participant during the interview will be the focus during the
observation. Also looking for how the organizational and technical infrastructure
supports the EMR system, ie hardware, software, network connections, end-user
support, and interfaces to name a few, facilitating conditions.)
x How did family practice physicians feel emotionally during the transition?
(Focusing on any emotions exhibited while using the EMR system, frustrations,
excitement, etc. and any collaborations with other physicians or staff on
navigating the system, social influence.)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

______________________________________________________

Reflections – initial impressions and interpretations of activities and events under

157
observation.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

______________________________

158
Appendix G

159
160
 Appendix H

Coding Interviews
Codes

Name Description Files References

Acceptance and Use of an Effort Expectancy, Performance 0 0

EMR System means Expectancy, and Social Influence
Continuity of Care

Effort Expectancy Participant's perception of how easy the 8 38

new system is to use

cumbersome A term used by several participants 3 4

regarding the new system

Experience Accepting Participants shared their experience 8 45

and Using EMR accepting and using EMR systems

Performance How has the new system impacted job 8 43

Expectancy performance

Social Influence The expectation of others to use the 7 26

system was anyone specifically helpful
during the transition

Expectation of Participant's perception of expected use of 6 10

Use the system

Next Transition Advice for the next transition 8 51

Old Records Advice on what to do with old records for 5 17

next transition

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

differently differently looking back

Overcoming Barriers and How were barriers and challenges 8 39

Challenges means overcome
Addressing Them

161
Name Description Files References

Actual Workflow 0 0

Charting How was charting done 5 6

Documentation When and where is the physician 7 10

by Physician documenting into the patient's chart

Gives nurses Giving verbal orders instead of entering 1 1

verbal them
instruction

Pace What was the pace of the clinic like 3 5

Paper What type of paper documents are being 7 9

supplements used

Scribe What tasks are the scribes performing and 2 8

where

Telehealth Visit What is the workflow for a telehealth visit 1 1

Benefits of the new What were some of the benefits the 6 12

system participants found in the new system

Facilitating Participant's thoughts on how the 8 48

Conditions organizational and technical infrastructure
supported the new EMR system

Communication How information about the system is 5 18

shared

Latency Slowness and/or wifi connection issues 6 10

Connectivity experienced by participants
Issues

Old Records Access/availability/interface of old records 3 10

Training Participant's experience with training to 8 69

prepare for the new system

Consistency Records are getting filed into the new 6 13

in Filing system

162
Name Description Files References

Elbow Participant's experience with the elbow 7 19

Support support for the first three weeks of go-live

Favorite Participant's experience with the vendor's 4 6

Fair favorites fair

Spring Go-live occurred during spring break for 3 3

Break some participants

Workarounds What workarounds, if any, are being used 2 3

Transitioning is an Participant's sharing how they felt 4 9

Emotional Experience emotionally transitioning EMR systems

Anger 2 4

Embarrassment Looking inept in front of patients 2 2

Offended 1 1

Anxiety 6 10

Disappointment 2 3

Excitement 2 3

Exhausted 1 1

Hopeful 1 1

Resentment 2 2

Resolve 1 1

Stress 5 9

Frustration 7 21

Loss in Loss of pay/production was the result of 4 7

Pay_Productivity transitioning systems for some participants

Versus Coding 1 1

163
Name Description Files References

Administration 1 1
vs Physician

Expectation vs 1 1
Reality

Our Needs vs 1 1
System
Capabilities

164