Electronic medical records and computerized physician order entry: examining factors and methods that foster clinician it acceptance in pediatric hospitals

The healthcare industry and others have acknowledged the potential for information technology systems (IT) such as electronic medical records (EMR) and computerized provider order entry (CPOE) to improve quality of patient care and especially patient safety. Thus the US government, businesses, and other groups are advocating adoption of these systems by hospitals and other care providers. This research study endeavors to examine the factors that contribute to clinician acceptance of EMR and CPOE systems and apply this new knowledge to ensure that methods used to implement these systems foster clinician acceptance and other aspects of system success. A review of lessons from past EMR/CPOE successes and failures demonstrates two factors commonly observed in implementations that achieve positive (versus negative) outcomes: (1) designing a system that is usable by clinicians in the clinical work context, and (2) adequately preparing users to adopt changes associated with the implementation. Based on this, a framework for User-Centered Implementation (UCI) is presented. This framework combines methods from user-centered design and change management to provide an implementation methodology that addresses these factors during implementation and improves the likelihood that positive outcomes are achieved. Next, this study examines clinician acceptance of an EMR/CPOE system implemented in a pediatric hospital system, Children's Healthcare of Atlanta (Children's). Children's was selected for this research because they have employed an implementation approach founded in user-centered implementation principles and methods. The study examined physician, nurse, and other staff perceptions about the system's usefulness (performance expectancy (PE)) and ease of use (effort expectancy (EE)) both prior to and following system implementation. The pre- and post-implementation models demonstrate that the factors that influence PE change over time. Compatibility with work practices was important both prior to and following implementation. Prior to implementation, users who perceived a greater need for the system and felt that their needs were represented in the design process also had higher expectations of the impact the system would have on their job performance. After implementation, PE ratings were influenced primarily by characteristics of the system. These characteristics included how well the system supported clinical decision making, facilitated sharing information, and how easy it was to use (EE). One aspect of the rollout process, the support provided by super users, also had a positive impact on PE and EE after implementation. This finding highlights the importance of having front-line support resources available on the units. Because Children's employed a UCI-based implementation approach, it was expected that good levels of user acceptance of the EMR/CPOE would be achieved. Study results indicate Children's implementation achieved positive perceptions of system ease of use (EE). However, this ease of use did not consistently translate to favorable ratings of the systems' impact on individual job performance. Post-implementation PE ratings remained neutral or positive for most user subgroups, a finding likely related to the fact that during this intermediate stage of the implementation both the paper chart and EMR must be used. Managing these dual locations for patient information may be contributing to predominantly neutral, rather than positive, PE ratings since this limits the ability of the system to contribute to gains in personal efficiency and effectiveness. The findings on factors that influence PE and EE, two aspects of technology acceptance, and the PE and EE levels achieved with Children's EMR were applied to provide further guidance for using UCI to achieve clinician acceptance of EMR systems. Designing EMR/CPOE systems that are usable within the clinical work context is important because it enables clinicians to focus time and energy on the patient, rather than on using the system. Accomplishing this in practice is difficult given the complexity of these systems and the dynamic clinical care processes they must support. However, the UCI framework presented here can be effectively applied to EMR/CPOE implementations to ensure the usability, utility, and, consequently, acceptance of these systems.