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1.  Barriers and facilitators to implementing electronic prescription: a systematic review of user groups’ perceptions 
We conducted a systematic review identifying users groups’ perceptions of barriers and facilitators to implementing electronic prescription (e-prescribing) in primary care.
We included studies following these criteria: presence of an empirical design, focus on the users’ experience of e-prescribing implementation, conducted in primary care, and providing data on barriers and facilitators to e-prescribing implementation. We used the Donabedian logical model of healthcare quality (adapted by Barber et al) to analyze our findings.
We found 34 publications (related to 28 individual studies) eligible to be included in this review. These studies identified a total of 594 elements as barriers or facilitators to e-prescribing implementation. Most user groups perceived that e-prescribing was facilitated by design and technical concerns, interoperability, content appropriate for the users, attitude towards e-prescribing, productivity, and available resources.
This review highlights the importance of technical and organizational support for the successful implementation of e-prescribing systems. It also shows that the same factor can be seen as a barrier or a facilitator depending on the project's own circumstances. Moreover, a factor can change in nature, from a barrier to a facilitator and vice versa, in the process of e-prescribing implementation.
This review summarizes current knowledge on factors related to e-prescribing implementation in primary care that could support decision makers in their design of effective implementation strategies. Finally, future studies should emphasize on the perceptions of other user groups, such as pharmacists, managers, vendors, and patients, who remain neglected in the literature.
PMCID: PMC3994867  PMID: 24130232
Electronic Prescribing; Systematic Review; Implementation Factors; Users' Perceptions; Primary Care
2.  Predicting the use of electronic prescribing among early adopters in primary care 
Canadian Family Physician  2013;59(7):e312-e321.
To identify the factors that can predict physicians’ use of electronic prescribing.
All primary care physicians who practised in a single geographic region in Quebec were invited to use a free, advanced, research-based electronic prescribing and drug management system. This natural experiment was studied with an expansion of the Technology Acceptance Model (TAM), which was used to explain early adopters’ use of this electronic prescribing technology.
Quebec city region.
A total of 61 primary care physicians who practised in a single geographic region where there was no electronic prescribing.
Main outcome measures
Actual use of electronic prescribing; physicians’ perceptions of and intentions to use electronic prescribing; physician and practice characteristics.
During the 9-month study period, 61 primary care physicians located in 26 practice sites used electronic prescribing to write 15 160 electronic prescriptions for 18 604 patients. Physician electronic prescribing rates varied considerably, from a low of 0 to a high of 75 per 100 patient visits, with a mean utilization rate of 30 per 100 patient visits. Overall, 34% of the variance in the use of electronic prescribing was explained by the expanded TAM. Computer experience (P = .001), physicians’ information-acquisition style (P = .01), and mean medication use in the practice (P = .02) were significant predictors. Other TAM factors that generally predict new technology adoption (eg, intention to use, perceived ease of use, and perceived usefulness) were not predictive in this study.
The adoption of electronic prescribing was a highly challenging task, even among early adopters. The insight that this pilot study provides into the determinants of the adoption of electronic prescribing suggests that novel physician-related factors (eg, information-acquisition style) and practice-related variables (eg, prevalence of medication use) influence the adoption of electronic prescribing.
PMCID: PMC3710062  PMID: 23851559
3.  Method for developing national quality indicators based on manual data extraction from medical records 
BMJ quality & safety  2012;22(2):155-162.
Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs.
We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries.
PMCID: PMC3582043  PMID: 23015098
Chart review methodologies; Health policy; Quality measurement
4.  Assessing Task–Technology Fit in a PACS Upgrade: Do Users’ and Developers’ Appraisals Converge? 
Journal of Digital Imaging  2011;24(6):951-958.
The purpose of this study was to measure users’ perceived benefits of a picture archiving and communication system (PACS) upgrade, and compare their responses to those predicted by developers. The Task–Technology Fit (TTF) model served as the theoretical framework to study the relation between TTF, utilization, and perceived benefits. A self-administered survey was distributed to radiologists working in a university hospital undergoing a PACS upgrade. Four variables were measured: impact, utilization, TTF, and perceived net benefits. The radiologists were divided into subgroups according to their utilization profiles. Analysis of variance was performed and the hypotheses were tested with regression analysis. Interviews were conducted with developers involved in the PACS upgrade who were asked to predict impact and TTF. Users identified only a moderate fit between the PACS enhancements and their tasks, while developers predicted a high level of TTF. The combination of a moderate fit and an underestimation of the potential impact of changes in the PACS led to a low score for perceived net benefits. Results varied significantly among user subgroups. Globally, the data support the hypotheses that TTF predicts utilization and perceived net benefits, but not that utilization predicts perceived net benefits. TTF is a valid tool to assess perceived benefits, but it is important to take into account the characteristics of users. In the context of a technology that is rapidly evolving, there needs to be an alignment of what users perceive as a good fit and the functionality developers incorporate into their products.
PMCID: PMC3222555  PMID: 21465295
Picture archiving and communication system (PACS); task–technology fit; radiology information systems; technology assessment; questionnaires; organizational innovation; evaluation research; models; theoretical
5.  Users’ perspectives of key factors to implementing electronic health records in Canada: a Delphi study 
Interoperable electronic health record (EHR) solutions are currently being implemented in Canada, as in many other countries. Understanding EHR users’ perspectives is key to the success of EHR implementation projects. This Delphi study aimed to assess in the Canadian context the applicability, the importance, and the priority of pre-identified factors from a previous mixed-methods systematic review of international literature.
A three-round Delphi study was held with representatives of 4 Canadian EHR user groups defined as partners of the implementation process who use or are expected to use EHR in their everyday activity. These groups are: non-physician healthcare professionals, health information professionals, managers, and physicians. Four bilingual online questionnaire versions were developed from factors identified by the systematic review. Participants were asked to rate the applicability and the importance of each factor. The main outcome measures were consensus and priority. Consensus was defined a priori as strong (≥ 75%) or moderate (≥ 60-74%) according to user groups’ level of agreement on applicability and importance, partial (≥ 60%) when participants agreed only on applicability or importance, or as no consensus (< 60%). Priority for decision-making was defined as factors with strong consensus with scores of 4 or 5 on a five-point Likert scale for applicability and importance.
Three Delphi rounds were completed by 64 participants. Levels of consensus of 100%, 64%, 64%, and 44% were attained on factors submitted to non-physician healthcare professionals, health information professionals, managers, and physicians, respectively. While agreement between and within user groups varied, key factors were prioritized if they were classified as strong (≥ 75% from questionnaire answers of user groups), for decision-making concerning EHR implementation. The10 factors that were prioritized are perceived usefulness, productivity, motivation, participation of end-users in the implementation strategy, patient and health professional interaction, lack of time and workload, resources availability, management, outcome expectancy, and interoperability.
Amongst all factors influencing EHR implementation identified in a previous systematic review, ten were prioritized through this Delphi study. The varying levels of agreement between and within user groups could mean that users’ perspectives of each factor are complex and that each user group has unique professional priorities and roles in the EHR implementation process. As more EHR implementations in Canada are completed it will be possible to corroborate this preliminary result with a larger population of EHR users.
PMCID: PMC3470948  PMID: 22967231
Delphi technique; Adoption factors; Implementation factors; Electronic health record; Health information technology; Health communication technology; Medical informatics
6.  The effects of a regional telepathology project: a study protocol 
Telepathology, which is an emerging form of telemedicine in Canada, is defined as the electronic transmission of pathological images, usually derived from microscopes, from one location to another. There are various applications of telepathology, including case referral for an expert opinion, provision of an emergency service in the absence of a resident pathologist, and education. Until now, there has been relatively little use of telepathology for core diagnostic services in the absence of a local pathologist, but this practice is likely to increase in the future. The Laval University Integrated Health Network is in the process of deploying a telepathology system, primarily to provide an intraoperative frozen section service to small hospitals in sparsely populated areas which are experiencing a severe shortage of on-site pathologists. The telepathology project involves 17 hospitals located in five regions of eastern Quebec, Canada. This paper describes the study protocol that will be used to evaluate the benefits associated with the project.
A panel of experts was first assembled by Canada Health Infoway to agree on a set of benefits indicators that could be applied to all telepathology projects across Canada. Using the set of indicators as an input, we have developed a three-step study protocol. First, a survey questionnaire will be distributed to appraise the way pathologists, pathology technologists and surgeons perceive the telepathology system and its impacts. Second, a series of semi-structured interviews will be conducted with project leaders and telepathology users at sites that are representative of all the hospitals in the Laval University Integrated Health Network. The overall aim is to better understand the expected and unexpected effects of telepathology on health care professionals and patients as well as on the regional organization and delivery of care services. Finally, a pre-post design using secondary data is proposed to evaluate a wide array of tangible benefits to the patients, the health care providers, the hospitals, and the region as a whole.
The Laval University Integrated Health Network's telepathology project is expected to yield positive and significant results that are relevant internationally. Our findings will provide valuable information on the nature and extent of benefits associated with telepathology systems intended to provide an intraoperative frozen section service to remote hospitals experiencing a shortage of specialists.
PMCID: PMC3324388  PMID: 22420301
7.  Virtual Organization of Hospital Medical Imaging: A User Satisfaction Survey 
Journal of Digital Imaging  2009;23(6):689-700.
A virtual medical imaging department is an innovative and demanding organizational model, to the extent that the underlying goal is to achieve a continuous and advanced organizational integration of human and physical resources, clinical data, and clienteles. To better understand the kind of benefits offered, we conducted a survey of three groups of users—radiologists, radiological technologists, and medical specialists—working in a five-site virtual organization. We received 127 valid questionnaires, for an overall response rate of 66%. The assessments vary according to the use made of the system. The scores for system quality and the quality of the data produced were markedly higher for intra-hospital use (respectively 7.9 and 8.7 out of 10) than for inter-hospital use (5.4 and 7.0). Despite the negative assessments they made of inter-hospital use, users maintained a positive attitude toward some type of virtual organization of medical imaging. Indeed, the score for Overall satisfaction with the system was very high, 8.9 out of 10. Moreover, the scores for Intended future use of the system were very high for both intra-hospital use (8.9) and inter-hospital use (8.7). We also found significant differences in perceptions among user groups.
PMCID: PMC3046687  PMID: 19588196
PACS integration; PACS implementation; Integrating Healthcare Enterprise (IHE); Evaluation research
8.  Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review 
BMC Medicine  2011;9:46.
Electronic health record (EHR) implementation is currently underway in Canada, as in many other countries. These ambitious projects involve many stakeholders with unique perceptions of the implementation process. EHR users have an important role to play as they must integrate the EHR system into their work environments and use it in their everyday activities. Users hold valuable, first-hand knowledge of what can limit or contribute to the success of EHR implementation projects. A comprehensive synthesis of EHR users' perceptions is key to successful future implementation. This systematic literature review was aimed to synthesize current knowledge of the barriers and facilitators influencing shared EHR implementation among its various users.
Covering a period from 1999 to 2009, a literature search was conducted on nine electronic databases. Studies were included if they reported on users' perceived barriers and facilitators to shared EHR implementation, in healthcare settings comparable to Canada. Studies in all languages with an empirical study design were included. Quality and relevance of the studies were assessed. Four EHR user groups were targeted: physicians, other health care professionals, managers, and patients/public. Content analysis was performed independently by two authors using a validated extraction grid with pre-established categorization of barriers and facilitators for each group of EHR users.
Of a total of 5,695 potentially relevant publications identified, 117 full text publications were obtained after screening titles and abstracts. After review of the full articles, 60 publications, corresponding to 52 studies, met the inclusion criteria. The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities.
This systematic review presents innovative research on the barriers and facilitators to EHR implementation. While important similarities between user groups are highlighted, differences between them demonstrate that each user group also has a unique perspective of the implementation process that should be taken into account.
PMCID: PMC3103434  PMID: 21524315
9.  Clinicians' perceptions of organizational readiness for change in the context of clinical information system projects: insights from two cross-sectional surveys 
The adoption and diffusion of clinical information systems has become one of the critical benchmarks for achieving several healthcare organizational reform priorities, including home care, primary care, and integrated care networks. However, these systems are often strongly resisted by the same community that is expected to benefit from their use. Prior research has found that early perceptions and beliefs play a central role in shaping future attitudes and behaviors such as negative rumors, lack of involvement, and resistance to change. In this line of research, this paper builds on the change management and information systems literature and identifies variables associated with clinicians' early perceptions of organizational readiness for change in the specific context of clinical information system projects.
Two cross-sectional surveys were conducted to test our research model. First, a questionnaire was pretested and then distributed to the future users of a mobile computing technology in 11 home care organizations. The second study took place in a large teaching hospital that had approved a budget for the acquisition of an electronic medical records system. Data analysis was performed using partial least squares.
Scale items used in this study showed adequate psychometric properties. In Study 1, four of the hypothesized links in the research model were supported, with change appropriateness, organizational flexibility, vision clarity, and change efficacy explaining 75% of the variance in organizational readiness. In Study 2, four hypotheses were also supported, two of which differed from those supported in Study 1: the presence of an effective project champion and collective self-efficacy. In addition to these variables, vision clarity and change appropriateness also helped explain 75% of the variance in the dependent variable. Explanations for the similarities and differences observed in the two surveys are provided.
Organizational readiness is arguably a key factor involved in clinicians' initial support for clinical information system initiatives. As healthcare organizations continue to invest in information technologies to improve quality and continuity of care and reduce costs, understanding the factors that influence organizational readiness for change represents an important avenue for future research.
PMCID: PMC3056827  PMID: 21356080
10.  Users' perspectives of barriers and facilitators to implementing EHR in Canada: A study protocol 
In Canada, federal, provincial, and territorial governments are developing an ambitious project to implement an interoperable electronic health record (EHR). Benefits for patients, healthcare professionals, organizations, and the public in general are expected. However, adoption of an interoperable EHR remains an important issue because many previous EHR projects have failed due to the lack of integration into practices and organizations. Furthermore, perceptions of the EHR vary between end-user groups, adding to the complexity of implementing this technology. Our aim is to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators influencing the adoption of an interoperable EHR among its various users and beneficiaries.
First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to the implementation of the EHR. Standardized literature search and data extraction methods will be used. Studies' quality and relevance to inform decisions on EHR implementation will be assessed. For each group of EHR users identified, barriers and facilitators will be categorized and compiled using narrative synthesis and meta-analytical techniques. The principal factors identified for each group of EHR users will then be validated for its applicability to various Canadian contexts through a two-round Delphi study, involving representatives from each end-user groups. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the implementation of EHR in the Canadian healthcare system.
Given the imminence of an interoperable EHR in Canada, knowledge and evidence are urgently needed to prepare this major shift in our healthcare system and to oversee the factors that could affect its adoption and integration by all its potential users. This synthesis will be the first to systematically summarize the barriers and facilitators to EHR adoption perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. This comprehensive and rigorous strategy could be replicated in other settings.
PMCID: PMC2673204  PMID: 19358739
11.  Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base 
Home telemonitoring represents a patient management approach combining various information technologies for monitoring patients at distance. This study presents a systematic review of the nature and magnitude of outcomes associated with telemonitoring of four types of chronic illnesses: pulmonary conditions, diabetes, hypertension, and cardiovascular diseases.
A comprehensive literature search was conducted on Medline and the Cochrane Library to identify relevant articles published between 1990 and 2006. A total of 65 empirical studies were obtained (18 pulmonary conditions, 17 diabetes, 16 cardiac diseases, 14 hypertension) mostly conducted in the United States and Europe.
The magnitude and significance of the telemonitoring effects on patients’ conditions (e.g., early detection of symptoms, decrease in blood pressure, adequate medication, reduced mortality) still remain inconclusive for all four chronic illnesses. However, the results of this study suggest that regardless of their nationality, socioeconomic status, or age, patients comply with telemonitoring programs and the use of technologies. Importantly, the telemonitoring effects on clinical effectiveness outcomes (e.g., decrease in the emergency visits, hospital admissions, average hospital length of stay) are more consistent in pulmonary and cardiac studies than diabetes and hypertension. Lastly, economic viability of telemonitoring was observed in very few studies and, in most cases, no in-depth cost-minimization analyses were performed.
Home telemonitoring of chronic diseases seems to be a promising patient management approach that produces accurate and reliable data, empowers patients, influences their attitudes and behaviors, and potentially improves their medical conditions. Future studies need to build evidence related to its clinical effects, cost effectiveness, impacts on services utilization, and acceptance by health care providers.
PMCID: PMC2244878  PMID: 17329725
12.  A Risk Assessment of Two Interorganizational Clinical Information Systems 
A risk analysis framework was used to examine the implementation barriers that may hamper the successful implementation of interorganizational clinical information systems (ICIS). In terms of study design, an extensive literature review was first performed in order to elaborate a comprehensive model of project risk factors. To test the applicability of the model, we next conducted a longitudinal multiple-case study of two large-scale ICIS demonstration projects carried out in Quebec, Canada. Variations in the levels of several risk dimensions measured throughout the duration of the projects were analyzed to determine their impact on successful implementation. The analysis shows that the proposed framework, composed of five risk dimensions, was very robust, and suitable for conducting a thorough risk analysis. The results also show that there are links between the quality of the risk management and the level of project outcomes. To be successful, it is important that the implementation efforts be distributed proportionally according to the importance of each of the risk factors. Furthermore, because the risks evolve dynamically, there is a need for high responsiveness to emerging implementation problems. Thus, implementation success lies in the ability of the project management team to be aware of and to manage several risk threats simultaneously and coherently since they evolve dynamically through time and interact with one another.
PMCID: PMC1561789  PMID: 16799130
13.  The Effects of Creating Psychological Ownership on Physicians' Acceptance of Clinical Information Systems 
Objective: Motivated by the need to push further our understanding of physicians' acceptance of clinical information systems, we propose a relatively new construct, namely, psychological ownership. We situated the construct within a nomological net using a prevailing and dominant information technology adoption behavior model as a logical starting point.
Design: A mail survey was sent to the population of users of a regional physician order entry (POE) system aimed at speeding up the transmission of clinical data, mainly laboratory tests and radiology examinations, within a community health network.
Measurements: All scales, but one, were measured using previously validated instruments. For its part, the psychological ownership scale was developed using a multistage iterative procedure.
Results: Ninety-one questionnaires were returned to the researchers, for a response rate of 72.8%. Our findings reveal that, in order to foster physicians' adoption of a clinical information system, it is important to encourage and cultivate a positive attitude toward using the new system. In this connection, positive perception of the technology's usefulness is crucial. Second, results demonstrate that psychological ownership of a POE system is positively associated with physicians' perceptions of system utility and system user friendliness. Last, through their active involvement and participation, physicians feel they have greater influence on the development process, thereby developing feelings of ownership toward the clinical system.
Conclusion: Psychological ownership's highly significant associations with user participation and crucial beliefs driving technology acceptance behaviors among physicians affirm the value of this construct in extending our understanding of POE adoption.
PMCID: PMC1447539  PMID: 16357351
14.  Determinants of User Satisfaction with a Clinical Information System 
Clinical Information Systems (CIS) implementation has faced user resistance. Consequently, we aimed to assess the acceptability of an integrated CIS.
We designed an electronic survey instrument from two theoretical models (Delone and McLean, and Technology Acceptance Model). Dimensions hypothesized to be determinant of user satisfaction were: user characteristics, CIS use, quality, usefulness, and service quality. The questionnaire was administered to physicians, nurses and medical secretaries of the Georges Pompidou European university Hospital (HEGP) in Paris.
Answers were obtained from 324 users (93 physicians, 174 nurses, and 57 secretaries). Cronbach’s alpha coefficients showed a correct reliability within each dimension. Secretaries and nurses were more satisfied with the CIS than physicians. Except for CIS use, after adjustment for confounders, female gender, perceived CIS quality, usefulness, and service quality were strongly correlated with user satisfaction.
This study reinforces the necessity of several models and dimensions to evaluate the acceptability of a complex CIS, with a specific approach for different user profiles.
PMCID: PMC1839744  PMID: 17238414

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