Physicians’ beliefs about using EMR and CPOE: In pursuit of a contextualized understanding of health IT use behavior

https://doi.org/10.1016/j.ijmedinf.2009.12.003Get rights and content

Abstract

Purpose

To identify and describe physicians’ beliefs about use of electronic medical records (EMR) and computerized provider order entry (CPOE) for inpatient and outpatient care, to build an understanding of what factors shape information technology (IT) use behavior in the unique context of health care delivery.

Methods

Semi-structured qualitative research interviews were carried out, following the beliefs elicitation approach. Twenty physicians from two large Midwest US hospitals participated. Physicians were asked questions to elicit beliefs and experiences pertaining to their use of EMR and CPOE. Questions were based on a broad set of behavior-shaping beliefs and the methods commonly used to elicit those beliefs.

Results

Qualitative analysis revealed numerous themes related to the perceived emotional and instrumental outcomes of EMR and CPOE use; perceived external and personal normative pressure to use those systems; perceived volitional control over use behavior; perceived facilitators and barriers to system use; and perceptions about the systems and how they were implemented. EMR and CPOE were commonly believed to both improve and worsen the ease and quality of personal performance, productivity and efficiency, and patient outcomes. Physicians felt encouraged by employers and others to use the systems but also had personal role-related and moral concerns about doing so. Perceived facilitators and barriers were numerous and had their sources in all aspects of the work system.

Conclusion

Given the breadth and detail of elicited beliefs, numerous design and policy implications can be identified. Additionally, the findings are a first step toward developing a theory of health IT acceptance and use contextualized to the unique setting of health care.

Introduction

The promise of health information technology (IT) improving health care outcomes [1] can only be realized when health IT is accepted and used effectively by clinicians [2]. Yet, numerous studies show that even the most well-meaning, safety-oriented clinicians do not use available IT [3], [4], [5], override or work around it [6], [7], [8], or use only some of the available features [9], [10]. Of present interest, electronic medical records (EMR) and computerized provider order entry (CPOE) are two promising health ITs whose success has been stalled in part by problems of acceptance, underuse, and use deviating from what is expected by the organization [11], [12], [13], [14].1

Because of the importance of understanding clinicians’ acceptance and use of EMR and CPOE and the shortage of such individual-level research [3], [10], [15], this study sought to identify and describe the beliefs that might shape physicians’ acceptance and use of EMR and CPOE for inpatient and outpatient care.

Decisions to accept and use health IT are neither random nor irrational. Instead, they result from tractable motivational and decision-making processes [2] and individuals’ beliefs and experiences serve as input into those processes [16], [17]. In this study, interviews were used to elicit various acceptance- and behavior-shaping experiences and beliefs that physicians had about using EMR and CPOE. The a priori beliefs categories of interest and the questions used to elicit beliefs were based on the social-cognitive Theory of Planned Behavior (TPB) [18], [19] and various expansions thereof [20], [21] (see Table 1).

Some health IT researchers have advised the use of beliefs elicitation [22], [23] methods with categories and definitions similar to those in Table 1 [24], [25] and there has been one such study, although the elicited beliefs were not reported [25]. Therefore, this paper is the first to describe in detail results from a beliefs elicitation study of health IT, focusing on physicians’ use of EMR and CPOE for inpatient and outpatient care. A key goal of this study was to capture context-specific beliefs, or beliefs that reflect the unique aspects of IT use in health care—e.g., the particular technologies, the clinician users, the role of the patient, the collaborative and distributed process of care delivery—that distinguish it from instances of IT use in other industries [24], [26], [27], [28].

Section snippets

Methods

Beliefs about EMR and CPOE use were elicited using qualitative research interviews. The beliefs asked about were ones posited in the original TPB and recent extensions (Table 1).

Results

Themes, or commonly mentioned “modal beliefs” [22], that emerged within each category of beliefs are presented below.

Discussion

The elicited physician beliefs about EMR and CPOE summarized in the preceding text suggest several policy and design goals.

EMR and CPOE must support the outcomes deemed important by physicians. Although those include organizational benefits such as billing efficiency, physicians saw the benefit of EMR and CPOE in terms of supporting the ease and quality of personal performance [40]. Findings from the present study suggest how design and policy can support performance. Improved ease of

Conclusion

This study identified many different beliefs that physicians have about using EMR and CPOE. Those beliefs commonly identified by a large number of physicians are likely to shape whether and how those and other physicians use EMR and CPOE for inpatient and outpatient care. The study also sets up and encourages further work to be done, including further development of surveys of clinician perceptions of health IT [56], [57], and the development of valid and practical theories of health IT use

Author contributions

Richard J. Holden was responsible for study design, instrument development, data collection, data analysis, and the writing of this article.

Acknowledgements

The author thanks study participants and Geoffrey Priest, Christine Baker, and Bradley Schmidt. This research was completed as part of a doctoral dissertation under the supervision of Ben-Tzion Karsh. An anonymous reviewer provided helpful feedback. RJH was supported by a pre-doctoral training grant from the National Institutes of Health (1 TL1 RR025013-01) and a post-doctoral training grant from the Agency for Healthcare Research and Quality (5 T32 HS000083-11).

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