Physicians’ beliefs about using EMR and CPOE: In pursuit of a contextualized understanding of health IT use behavior
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).
References (58)
- et al.
Understanding technology adoption in clinical care: clinician adoption behavior of a point-of-care reminder system
Int. J. Med. Inform.
(2005) - et al.
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety
J. Am. Med. Inform. Assoc.
(2008) - et al.
Technology implementation and workarounds in the nursing home
J. Am. Med. Inform. Assoc.
(2008) - et al.
Implementation and use of an electronic health record within the Indian Health Service
J. Am. Med. Inform. Assoc.
(2007) - et al.
Types of unintended consequences related to computerized provider order entry
J. Am. Med. Inform. Assoc.
(2006) - et al.
Effects of scanning and eliminating paper-based medical records on hospital physicians’ clinical work practice
J. Am. Med. Inform. Assoc.
(2003) - et al.
Some unintended consequences of information technology in health care: the nature of patient care information system-related errors
J. Am. Med. Inform. Assoc.
(2004) - et al.
Differing faculty and housestaff acceptance of an electronic health record
Int. J. Med. Inform.
(2005) The theory of planned behavior
Org. Behav. Hum. Decision Process.
(1991)- et al.
The effects of creating psychological ownership on physicians’ acceptance of clinical information systems
J. Am. Med. Inform. Assoc.
(2006)
EHR safety: the way forward to safe and effective systems
J. Am. Med. Inform. Assoc.
Turning off frequently overridden drug alerts: limited opportunities for doing it safely
J. Am. Med. Inform. Assoc.
Physician and nurse satisfaction with en electronic medical record system
J. Emerg. Med.
Evaluating informatics applications—some alternative approaches: theory, social interactionism, and call for methodological pluralism
Int. J. Med. Inform.
Grounding a new information technology implementation framework in behavioral science: a systematic analysis of the literature on IT use
J. Biomed. Inform.
Development and psychometric evaluation of the Impact of Health Information Technology (I-HIT) Scale
J. Am. Med. Inform. Assoc.
Evaluating user interactions with clinical information systems: a model based on human–computer interaction models
J. Biomed. Inform.
Information technology comes to medicine
N. Engl. J. Med.
A theoretical model of health information technology usage behaviour with implications for patient safety
Behav. Inform. Technol.
A review of medical error reporting system design considerations and a proposed cross-level system research framework
Hum. Factors
Getting physicians to accept new information technology: insights from case studies
CMAJ
Physicians’ decisions to override computerized drug alerts in primary care
Arch. Intern. Med.
Physicians and electronic health records: a statewide survey
Arch. Intern. Med.
Role of computerized physician order entry systems in facilitating medication errors
JAMA
Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research
Interpersonal Behavior
Attitudes, Personality, and Behavior
Analyzing additional variables in the Theory of Reasoned Action
J. Appl. Soc. Psychol.
Evaluating and extending the Theory of Planned Behaviour
Cited by (132)
Impact of an electronic health record on task time distribution in a neonatal intensive care unit
2021, International Journal of Medical InformaticsCustomer relationship management systems (CRMS) in the healthcare environment: A systematic literature review
2020, Computer Standards and InterfacesPrescriber perceptions of medication-related computerized decision support systems in hospitals: A synthesis of qualitative research
2019, International Journal of Medical InformaticsCitation Excerpt :A large proportion of users’ perceptions were categorized into the human domain, in particular, the subdomain of system use. Expectations that medication-related CDSS improves safety [27,29,31,33,34,36,37] and efficiency [27,29,36] were consistently identified as facilitators of CDSS uptake. Factors associated with resistance to using CDSS included mistrust of the information [26,28,34], CDSS recommendations conflicting with prescribers’ professional autonomy [33,34,36], and personal prescribing preferences [28,35].
Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record
2018, International Journal of Medical InformaticsThe Impact of Digital Hospitals on Patient and Clinician Experience: Systematic Review and Qualitative Evidence Synthesis
2024, Journal of Medical Internet Research