Themes, or commonly mentioned “modal beliefs” [22
], that emerged within each category of beliefs are presented below.
3.1. Behavioral beliefs: Performance outcomes
Physicians believed that in many ways EMR and CPOE use improved the ease of personal performance. One perceived improvement was that physicians could now access medical records remotely, from home, from their clinic office, or from anywhere in the hospital, without needing to search for the paper chart. Immediate access to information such as laboratory results was perceived to speed up work; as one physician put it, “I can very quickly get the nuggets of information that I need, versus … looking around and asking the personnel on the floor, ‘Where is the old chart?’ ‘Oh, it's on microfilm.’” Information was also perceived be more easily accessed or found in part due to collating and sorting functions in the software. Physicians believed that much information was available in one place, some of which was previously unavailable in paper charts, and could be accessed all at once, particularly by using the synopsis feature of the software. Retrieved information was also perceived to be legible and therefore easily understood: “There were many physicians whose notes I couldn't read or couldn't figure out most of what they said before … I can read them all now.”
Aside from making personal performance easier, physicians perceived EMR and CPOE to improve the quality of performance. In particular, they described more accurate and timelier awareness of patient status, trends, and other information, with many physicians appreciating that chest X-rays, CT scans, and other results were available in real time. Importantly, having information was thought to improve clinical decision making: “the amount of information that will be missing from my knowledge base, as I'm making … decisions about my patients, is small.” Some perceived that communication with colleagues and nurses was improved, both in general through better documentation, and through formal features such as secure EMR-based messages. Some physicians felt that CPOE improved the ordering process. Said one physician, “if you go to the EMR and you order it, you see exactly what it is that you ordered, so I think the potential for improved order accuracy.” Another physician explained that having CPOE order sets reduced reliance on memory and improved accurate ordering. Physicians using data entry/CPOE also felt that colleagues' performance improved, primarily due to more legible notes and orders.
Yet, many perceived that EMR and CPOE worsened performance and made performance more difficult and more complex. Information such as colleagues' notes, medications on the discharge list, and data from other hospitals, was described as difficult to access or find (“I'm a savvy user and even I find it cumbersome to get the information”). Some old records, notes, and test results, were simply not in the system. Additional demands and extra steps were perceived to increase physicians' burden. In particular, physicians said that CPOE required numerous clicks and screens to navigate. Selecting from options rather than directly writing out the desired order, as in the past, was seen as problematic: “when you pop in potassium, for example, I mean, they give you a whole glossary of different types of potassiums that you just … don't need.” CPOE alerts (e.g., allergy warnings) required further clicking and were perceived as blocks in performance, as were other new requirements such as someone needing to order a consult in the system before a physician could provide care. Perceived performance decrements stemmed from reduced ability to stay aware and informed, because information was sometimes missing (e.g., no problem list; missing radiological information; not being able to tell at discharge what medications were added or removed during hospitalization); clinical notes in EMR were described as less personal, less informative, and less complete than were notes in the past; and some believed that EMR made it more difficult to tell trends or take in the gestalt. Another perceived source of performance decrement was the reduced ability to see physician colleagues' thought process. Several spoke of this as a problem of “garbage in, garbage out,” for instance, “the note is only as good as the content in the note. And there's some people who put enough into the note so that I could follow their train of thought, and some do not” and “it's very hard to tell what the physician was thinking now with the way most physicians document.”
3.2. Behavioral beliefs: Productivity and efficiency outcomes
Some physicians believed that EMR and CPOE improved productivity over the previous paper-based system, stating reasons such as “it probably increases productivity, since I physically don't have to move that much around” and because “the actual sifting through data part of it is a lot better and is a lot faster.” Others believed that EMR and CPOE only initially reduced productivity, although several outpatient clinicians noted that even four years into EMR and CPOE, they were compensating for decreased productivity by working longer hours. A large number of comments about using EMR and CPOE pertained to the effect on time-efficiency. 70% believed that EMR and CPOE saved time or sped up the care process, especially when retrieving information. However, almost every physician could also provide examples of perceived inefficiencies and time loss created by EMR and CPOE use, either by causing delays (e.g., when logging on or waiting for someone to enter data) or by slowing down the process. A common example of the latter was the perceived slowness of computerized documentation and ordering processes as a result of having to use the keyboard and mouse, especially when ordering medications. Said one physician, “It's, you know, ten boxes to click instead of a quick, written-out thing [medication order] that would take, literally, three to five seconds. Now it's, you know, it might take me minutes…”
3.3. Behavioral beliefs: Patient outcomes
Physicians believed that patients were benefiting from EMR and CPOE in several ways. Quality of care was thought to increase with EMR and CPOE use by allowing physicians to access more up-to-date information more quickly, by providing reminders (e.g., “I have to attend to the fact that, you know, they're overdue for a colonoscopy”), by speeding up the delivery of care (e.g., “if a test gets done earlier in the day”), and by reducing the number of duplicate procedures that might have previously been ordered because of the difficulty of knowing which procedures had already been done (e.g., “It saves them from any unnecessary X-rays”). Reduction in duplicate tests was also believed to save patients money. Further, faster ordering and order processing was seen as a way to save patients' time and reduce their length of stay and, presumably, associated costs. Numerous patient safety benefits were believed to arise from EMR and CPOE use. For example, a physician said, “there are just so many checks now to make sure that things are done safely.” Mentioned checks included mandatory medication reconciliation, easier checking of medication history by pharmacists, and automatic checks for patient allergies and drug-drug interactions. Further, safety was thought to have improved due to improved data entry, in particular, orders that physicians described as clearer, more legible, and no longer abbreviated. Some physicians thought that patients were better informed as a result of EMR, for example because physicians could provide timely information through secure communication channels or because patients could go home with discharge reports printed from the EMR.
There were perceived EMR and CPOE use-related costs to patient outcomes as well. Of all participants, 40% (and 78% in Hospital 2) believed that EMR and CPOE use threatened patient safety due to, for example, physician over-reliance on potentially erroneous information, nurses focusing more on complying with EMR use protocol than on independently reviewing order accuracy, orders in the system not being seen or neglected, and physicians speeding through the system or ignoring CPOE alerts because they were used to false alarms. Quality of care outcomes perceived to be jeopardized by EMR and CPOE use. Mentioned reasons included perceived delays and poorer care resulting from nurses who were less familiar with EMR and CPOE not acting on orders; longer outpatient wait times as physicians spent more time on electronic documentation, and more time spent with the EMR than with the patient. Sometimes lab results arrived late in the system, even after the patient was discharged, and this was seen as harming care. Further harm was perceived because errors in the system were sometimes propagated when physicians copied and pasted blocks of information, rather than creating information from scratch.
3.4. Behavioral beliefs: Financial, organizational, and other outcomes
Physicians believed that some cost savings resulted from eliminating dictation and paper and improved billing efficiency for billing departments and for individual physicians. However, physicians also believed that EMR and CPOE use caused an inefficient use of resources. In particular, physicians believed strongly that it was or soon would be a waste of human resources to have physicians enter data: “from a pure business standpoint, it makes very little sense, you know, to have a highly paid … stressed out physician, who may or may not be a good typist, or, um, may or may not be a computer whiz, trying to do the data entry.” Other commonly mentioned undesired outcomes were the perceived intrusion of work on home life made possible by remote access and the perceived inability of EMR and CPOE to accommodate the complexity and variety of clinical needs. As two examples, some specialty-specific tools were described as lacking (e.g., for drawing retinal images of ophthalmology patients) and template-based data entry was perceived to not allow physicians to tell a rich, patient-specific story in their notes.
3.5. Behavioral beliefs: Affective outcomes
In general, responses pertained to instrumental, not affective, outcomes. This was expected, because the standard behavioral belief questions used in the interviews were not tailored to eliciting affective beliefs; such questions favor elicitation of instrumental over affective beliefs [23
]. Nevertheless, some affective reactions were described. Consistent with prior CPOE studies [11
], most (91%) were negative reactions such as frustration, irritation, and resentment (e.g., “I'm highly resentful of the fact that somebody's using me as a very overqualified typist”).
3.6. External normative beliefs
Several entities internal and external to participants' hospitals or outpatient clinics were perceived to approve or encourage physicians' EMR and CPOE use. By far the most often mentioned internal entity was the hospital administration; the outpatient clinic administration was also often mentioned. Said one physician of the hospital's encouragement of EMR and CPOE use, “that's part of their message, that this is kind of the way medicine is going, and we need to do this.” Inpatients and outpatients were also perceived to encourage system use, although 40% of physicians believed that inpatients were unaware of the system. External entities believed to approve or encourage use included political entities, particularly the government (note that Hospital 2 interviews took place in January-February 2009, during the Obama administration's push for health IT); professional organizations (e.g., American Association of Orthopaedic Surgeons, American College of Physicians); payers; and national advocacy organizations (e.g., Leapfrog Group) and regulatory agencies (e.g., Joint Commission).
Entities discouraging EMR and CPOE use were seldom mentioned; the only commonly mentioned entity was “fellow users.” Indeed, when asked about entities that disapproved or discouraged their EMR and CPOE use, over a third of physicians answered that there were none.
3.7. Personal normative beliefs
Participants identified themselves as professionals and physicians and sometimes mentioned that it was not characteristic of someone in their role to do data entry work. Other self-identifying beliefs were on a personal level (e.g., “I'm a typist,” “I'm a savvy user,” “I like computers”). Moral normative beliefs related to EMR and CPOE use were most commonly those related to the confidentiality, privacy, and security of patient records. One physician explained, “my reservations and concerns about it are mainly about, um, the ability to safeguard the information in a way that, uh, doesn't, um, expose people to possible adverse consequences as a fact … as a fact that their records are now more easily accessible by more people.” Some physicians liked that access rights were restricted to those who had care responsibilities but wanted to maintain exclusive rights to reorder medications or access raw data, rather than sharing those rights with office staff and patients. Finally, although some perceived that using EMR and CPOE was a moral obligation (e.g., “[there are now] moral obligations on physicians to embrace the record to improve patient safety”), others had no moral normative beliefs or believed that EMR and CPOE were morally neutral (e.g., “There's nothing in my Bible that, that discourages … the use of EMRs”).
3.8. Control beliefs: Controllability
For the most part, physicians believed that using EMR and CPOE was not under volitional control (e.g., “we have no choice,” “it's not an option to not use it”), because it was mandated by the organization, because some information was accessible only electronically, and generally because EMR and CPOE were believed to have become “as essential as … carrying a pen and a stethoscope,” with physicians perceived to be “reliant on the EMR now.” Some factors precluded volitional use, according to physicians. Mentioned factors were a lack of computer stations, unavailability of features or information in the partial EMR at Hospital 1, and the EMR being unavailable (“But when it's down, it is down. And nothing is available.”) Some specific actions, such as addressing CPOE allergy warnings, were also perceived as uncontrollable. Few perceived EMR and CPOE use as up to them, although a third of physicians in Hospital 2 noted that they were given the choice to dictate admission and discharge notes instead of entering them manually.
3.9. Control beliefs: Self-efficacy
Physicians reported numerous perceived barriers that might have limited their ability to use EMR and CPOE. They included perceived hardware and software barriers (e.g., non-functioning remote access software, Mac-PC incompatibility, slow operating system); system slowness and delays; environmental barriers (e.g., “The only problem now you have is finding a computer”); lack of typing proficiency; lack of understanding of how to use the system, which was perceived to be difficult to use and unintuitive; insufficient time to use the system or to learn to use it; and forgetting how to use the system after some time had passed.
Physicians also reported perceived factors that might have made it possible or easier to use EMR and CPOE. Having access to a computer and the remote access gateway were often mentioned. Physicians believed that initial training and technical support facilitated use (e.g., “[support staff] wore red vests, and they were on the floors and could be summoned by, you know, ‘Hey, could you come over and help me?’ if they were right within earshot, or you could call, and someone would come up and help you”). Post-implementation nearly half the physicians said they used a support helpline or helpdesk to facilitate their use. Other physicians said that they sought support from colleagues. Some preferred those informal helpers to the dedicated technical support staff: “probably more important have been colleagues sharing tips and kind of best practice or best use. Those are the most useful….” Other commonly mentioned perceived facilitators were environmental (e.g., having a broadband connection), technological (e.g., a customizable, consistent format), and individual (e.g., learning to use the system, motivation and adventurousness, and abilities including typing skill).
3.10. Other beliefs
Among the many beliefs about the system itself (rather than about its use), the following were most commonly mentioned. 50% of physicians noted the need for fit between the system and other elements of the work system (e.g., “you really need to customize the technology to the individual … department”), the perceived lack of fit (e.g., “it doesn't work how doctors think, basically”), and the perceived requirement to adapt in order to achieve fit (e.g., “I have to kind of change my workflow to accommodate it, rather than the other way around”). Some perceived that the system was intuitive and had other positive usability aspects, but many more described specific perceived problems as well as general usability limitations (e.g., “This is stupidly designed. This is designed by someone who is not actually taking care of patients”).
Overall, physicians at both hospitals spoke favorably about system implementation, although some at Hospital 2 believed that CPOE was implemented with problems (e.g., too hastily, without first establishing nurses' roles in the ordering process). Physicians also mentioned what they believed to be specific implementation problems, including strained physician-nurse relations, major workflow changes, and unplanned hospital expenditures. Physicians gave detailed responses about their perceptions of the roll-out, initial training and technical support, management support and commitment (most believed that their hospital was very supportive and committed), user involvement (some believed they were under-involved whereas others were content with a low level of involvement), post-implementation modifications to the system, and interactions with the vendor.
Finally, physicians described the EMR and CPOE-use-related beliefs and behaviors of their colleagues, including shortcuts and work-arounds such as phoning nurses from within the hospital and having them enter orders, thus taking advantage of nurses' obligations to put in verbal orders given over the phone. Unfortunately, space limitations preclude more thorough discussion of this and other categories of “other beliefs” in the present paper.