There are several studies that have proven the benefits of Electronic Health Record (EHR) for patient’s safety, as well as their ability to improve efficiency in primary care settings (Porterfield, Engelbert, & Coustasse, 2014). Regardless of the benefits of the implementation of EHR in primary health care settings, health care providers have moved slowly to adopt this technology (Ajami, & Bagheri-Tadi, 2013). Practitioners who do not want to adopt EHR, especially electronic prescription, can endanger patient safety. A study in Boston primary care settings found errors in 7.6 % of prescriptions that were handwritten, and half of them had the potential to harm patients (Kaushal et al., 2010). The purpose of this case report is to identify and discuss the barriers to EHR adoption and to investigate the ability of a quality improvement teaching program to improve adherence to EHR use in primary health care practice.
Problem statement: While the literature indicates all the benefits of Electronic Health Records, it is unknown if the application of a quality improvement teaching program to health care providers will improve their adherence to EHR in a primary health care setting.
Background of the Problem
The importance of the use of EHR in healthcare settings is documented well. The implementation of EHR improves patients’ safety, reduces medication errors, and improves efficiency in primary care settings (Porterfield, Engelbert, & Coustasse, 2014). However, despite the benefits of the implementation of EHR in primary health care settings, health care providers have been slow to adopt this technology (Ajami, & Bagheri-Tadi, 2013). Practitioners have presented several barriers to the use of EHR. They have had problems during the transition from handwritten to electronic prescriptions (Abramson, 2012). Some of the obstacles that practitioners encountered when implementing EHR are the complicated and challenging process, as well as the need for user computer skills, support from others, and numerous organizational and environment facilitators (Ajami, & Bagheri-Tadi, 2013).
Theoretical Foundations and Review of the Literature/Themes
Kurt Lewin developed the theory of Unfreeze-Move-Freeze. This theory emphasizes the processes that any organization should perform during change management projects (Grant, 2016). The unfreezing stage of Lewin’s theory is crucial for the following ones and ensures the success of the project (Gupta, Boland, & Aron, 2017).
The theory of planned behavior (TPB) is another change behavior theory that states that the desired behavior depends on the individual’s intention to do it (Bai Dinour, 2017). The TPB explains that if an individual believes that the behavior change will have positive outcomes, he or she will create a positive attitude to the behavior (Bai Dinour, 2017).
Transformative learning theory explores the way learners’ beliefs and assumptions can be used to lead to critical reflection (Taylor, 2013). Mezirow’s Transformative Learning Theory states that in order to see self-reflection results, learners identify their self-limiting factors to learn (Margareth et al., 2017).
Theoretical Foundations/Conceptual Framework
Primary health care practitioners are required to change their behavior to perform the transition to the use of EHR. Kurt Lewin created the Unfreeze-Move-Freeze theory to describe the processes of change management projects (Grant, 2016). It is necessary to follow the process from unfreezing to refreezing to achieve successful outcomes. The refreezing stage cannot be started if the unfreezing and the moving stages have not been accomplished (Gupta, Boland, & Aron, 2017).
The theory of planned behavior (TPB) is another change behavior theory which suggests that behaviors depend on individuals’ intention to engage in them (Bai Dinour, 2017). The plan to change behaviors follows three constructs: attitude, subjective norm, and perceived behavioral control (Bai Dinour, 2017). TPB explains that if an individual believes that he or she will have positive outcomes when they change their behavior, he or she will create a positive attitude to the behavior (Bai Dinour, 2017). This theory also explains that if an individual recognizes favorable circumstances and supports the behavior, he or she will engage in said behavior.
Transformative learning theory explores how to use learners’ beliefs and assumptions to lead to critical reflection (Taylor, 2013). Mezirow’s Transformative Learning Theory indicates that in order to obtain self-reflection results, learners identify their self-limiting factors to learn (Margareth et al., 2017). The purpose of learning is to empower learners to think critically and make decisions based on their previous experiences (Margareth et al., 2017).
Electronic Health Records in Primary Health Care Settings
The use of EHR for medication orders has the potential to increase patients’ safety and decrease medication errors (Porterfield, Engelbert, & Coustasse, 2014).
Health Care Providers and the use of EHR
Health care practitioners have the tendency to resist change and maintain what they have been doing prior to it (Abramson, 2012). It is important to assess practitioners’ perception of the use of EHR even before the selection of the new EHR. This process could decrease resistance and result in a better implementation process (Abramson, 2012). Health care providers reported that one of the barriers to the use of electronic prescribing is the high cost of the system and the maintenance fees (Lander et al., 2013).
Educational training has been shown to be an effective intervention in changing practitioners’ perceptions and behaviors in primary health care settings (Squires, Sullivan, Eccles, Worswick, & Grimshaw, 2014).
Ambulatory care clinic (Abramson, 2012; Porterfield, Engelbert, & Coustasse, 2014). Primary care settings (Jensen, & Bossena, 2016; Lander et al., 2013; (Squires et al., 2014). Geriatric clinic (Frisse, 2016).
While the literature indicates all the benefits of Electronic Health Records, it is unknown if the application of a quality improvement teaching program to health care providers will improve their adherence to EHR in a primary health care setting.
Research Question(s) and Phenomenon or Research Questions, Hypotheses, and Variables
(P) Among healthcare providers, (I) how does the implementation of a quality improvement teaching program (C) compared to not participating in the teaching program (O) influences primary care providers’ perceptions of the usability of EHR (T) within three months of participating in the program?
Quantitative (Research Questions, Hypotheses, and Variables)
- Variable 1: Quality improvement teaching program
- Variable 2: Practitioners’ perception of EHR usability
R1: How does the implementation of a quality improvement teaching program influence the perceptions of EHR usability of primary care providers?
H1: The application of a quality improvement program will improve primary care providers’ perceptions of EHR usability.
H01: There is no significant relationship between the use of a quality improvement teaching program and the improvement of primary health care providers’ perception of EHR usability.
R2: How does the improvement of primary health care practitioners’ perceptions of EHR usability influence patient safety?
H2: Improving the primary care practitioners’ perceptions of EHR usability will improve patients’ safety.
H02: There is no significant relationship between primary health care practitioners’ perception of EHR usability and patient safety.
The Significance of the Study
Even though the importance of EHR for patients’ safety and care in general has been widely discussed in the literature, primary health care providers still have to face barriers to the use of the tool. If the project concludes that there is a significant relationship between the employment of the quality improvement teaching program and practitioners’ perceptions of EHR usability, practitioners at Vega health care clinic will use EHR more often, improving patients’ safety in the clinic. The results can serve as an example for other clinics that have the same problem. Positive results of the project will also show the importance of taking into consideration behavioral and learning theories during the development of any quality improvement project that is meant to improve participants’ behavior.
Rationale for Methodology
I will use quantitative methods because I want to determine the relationship between two variables: the quality improvement teaching program (independent) and primary health care practitioners’ perceptions of EHR usability (dependent). Also, the data will be collected in a numerical form with the help of a questionnaire and electronic medical records. The questionnaire will use closed-ended questions that will provide quantifiable data (Yilmaz, 2013). Since I intend to investigate the relationships between the two variables, I will use a correlational design.
Nature of the Research Design for the Study
The project will use a correlational design to investigate the nature of the relationships or associations between the two variables instead of detecting cause-effect relationships. The dependent data will be collected before and after the intervention. The project cannot use an experimental design because I will not use a control group data, and I will not randomize the data because I will use the entire population as the sample size. A t-test will compare the means of the data sets to determine if there is a statistically significant difference
Purpose of the Study
The purpose of this quantitative correlational project is to determine the relationship between the application of a quality improvement teaching program and the enhancement of practitioners’ perception of EHR usability, as well as the advancement of patient safety. The quality improvement teaching program will be defined as a teaching program with all the information needed to improve the perception of the usability of EHR based on the literature researched.
Instrumentation or Sources of Data
I will use a pre- and post-test survey with ten questions (Likert scale) that were already employed in previous research to measure physicians’ perceptions of the usability of EHR. The survey to be used is a modified version of the Perceived Ease of Use and Usefulness Tool. It was employed in a 2008 Ph.D. dissertation that is dedicated to clinicians’ perceptions of the usability of an electronic medical record. The survey was used to measure the overall acceptance of EHR by clinicians. Permission to use this instrument was obtained from the author. In the dissertation, the survey included four items that rated the perceived usefulness, but I will only use the first part of the instrument which has a five-point Likert scale survey for the clinicians. Cronbach’s alpha tests will be done to see if the multiple-questions Likert-scale surveys are reliable. Because of the high-quality data provided by the instrument, the electronic medical record is a commonly used source of information for clinical research (Saczynski, McManus, & Goldberg, 2013). Therefore, EHR will be used to complement the post-test survey to determine how many times practitioners have been using the system. EHR will also be employed to determine how many medications errors which could affect patients’ safety before and after the instructional program have been reported.
Data Analysis Procedures
An independent t-test will be performed using the SPSS software to compare the means of the two groups of data: the practitioners’ perception of EHR usability and medication errors before and after the application of the quality improvement teaching program.
Since the study will involve human subjects, certain ethical considerations are of importance. The practitioners will be expected to take part in a quality improvement teaching program, and this procedure involves no actual risks except for those related to confidentiality and voluntary participation (Polit & Beck, 2017). The latter concern will be resolved with the help of informed consent; only the participants who sign it will be included in the research. As for confidentiality, no personal information about the participants will be gathered throughout the project, and no identifying data about them will appear in the final report. Instead, the participants will be assigned numbers to identify their survey responses and EHR information. Regarding the use of EHR in the project, it will be necessary to ensure the security of its data and avoid the disclosure of sensitive and personal information from the system. This outcome will be achieved by requesting only non-confidential information (already processed data) about medication errors and the time of EHR use. Finally, it should be noted that all the data which will be collected throughout the project will be preserved in a secure location (researcher’s place) and kept in a locked drawer (for paper surveys) and password-protected computer (for all the electronic data) for the time period that is recommended by the IRB of my educational institution. The study will only be carried out after the full IRB approval and upon obtaining the official site authorization from the Vega health care clinic, the management of which will be contacted directly. The participants will be recruited by distributing the leaflets with the information about the project in Vega. The practitioners who are interested will contact the researcher, after which the informed consent procedures will also take place in Vega’s offices.
Polit, D.F., & Beck, C.T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.