Electronic Health Record Implementation Research Articles

Understanding the arena of smoldering crises: a longitudinal study of discursive struggles after implementing a new IT health care platform

PurposeThe aim of this paper is to study the development of a smoldering crisis over time. The focus is on a nationwide news media and online news communication related to a smoldering crisis running in the Danish healthcare system since 2016: the problematic implementation of a large-scale electronic health record (EHR), technology entitled Sundhedsplatformen (SP), in the hospitals of the capital region of Denmark.Design/methodology/approachBased on insights from crisis communication theories and in particular rhetorical arena theory (RAT), traces of SP smoldering crisis and patterns of discursive strategies are identified and explained from a longitudinal perspective to explain the communicative complexity that characterizes this smoldering crisis. To build an understanding of how this smoldering crisis is perceived, followed and kept alive, an analysis of (de)legitimation discursive strategies employed strategically by various actors and voices in news articles is conducted in relation to four communicative themes: issue identification, warnings, blame attribution and potential solutions.FindingsIt has been found that a legitimacy deficit emerges communicatively through specific (de)legitimation strategies during this smoldering crisis. New insights into RAT (Frandsen and Johansen, 2017) are also provided.Practical implicationsThis study is not only of theoretical relevance, but it is also of practical relevance for public relation professionals who aim to identify characteristics of starting smoldering crises as well as to find strategic responses to the ongoing challenges and the developing over time of smoldering crises.Originality/valueNew insights into RAT (Frandsen and Johansen, 2017) are provided.

Systematic review of electronic health records to manage chronic conditions among displaced populations

ObjectivesThe objective of this study was to assess the impact of electronic health records (EHRs) on health outcomes and care of displaced people with chronic health conditions and determine barriers...

Communicating Level of Certainty Associated with Human Factors Findings and Recommendations in Healthcare

While there is a need for human factors engineering (HFE) in health systems design, the pace of operations in most healthcare systems often requires deviation from optimal HFE practices. We must provide sufficiently useful and usable findings to the design team and stakeholders to support project decisions while also tempering their expectations and properly calibrating their level of certainty around the findings and recommendations. As members of an HFE team in a series of projects related to the implementation of a new electronic health record (EHR) in a large healthcare system, we describe some early efforts with project teams and initial missteps that limited the effectiveness of HFE work. We also describe communication strategies we are piloting that appear to achieve better results in terms of project team engagement, stakeholder buy-in, and validity and utility of findings.

Physician experience with the Epic electronic health record (EHR) system: longitudinal findings from an emergency department implementation.

In June 2019, The Ottawa Hospital launched the Epic electronic health record system, which transitioned all departments from a primarily paper-based system to an electronic system using a 1-day "big bang" approach. We sought to evaluate emergency physicians' satisfaction with system implementation and perception of its impact on clinical practice in an academic emergency department (ED) setting. Four electronic surveys were distributed to staff during pre-implementation (1-month prior [May 2019]) and post-implementation (1-month [July 2019], 9-month [March 2020], and 20-month [February 2021]) time periods. 5-point Likert scales were used to rate agreement with statements. Responses were compared using the Cochran-Mantel-Haenszel trend test to assess for significant differences. Response rates were consistent, ranging between 41 and 51%, with the exception of +9months which was 27%. The majority of respondents were staff, working 8-15 shifts/month, with ≤ 10years in practice. General satisfaction and confidence improved substantially from pre-implementation to 20 months post-implementation. Personalization sessions were perceived as not effective and lacking in quality, particularly immediately after Epic launch. Although clinical workflow tasks got easier, there were sustained challenges in efficiency and patient flow, including number of patients seen/hour, time spent after shift-end, and time spent on post-shift documentation. Although satisfaction and system confidence improved over time, there were sustained difficulties in overall efficiency long after implementation, with opportunities for future optimization. Training was lacking in terms of relevance to emergency physician workflow. These factors should be considered in future electronic health record implementations in ED settings.

Implementing Electronic Health Records in Primary Care Using the Theory of Change: Nigerian Case Study.

BackgroundDigital health has been a tool of transformation for the delivery of health care services globally. An electronic health record (EHR) system can solve the bottleneck of paper documentation in health service delivery if it is successfully implemented, but poor implementation can lead to a waste of resources. The study of EHR system implementation in low- and middle-income countries (LMICs) is of particular interest to health stakeholders such as policy makers, funders, and care providers because of the efficiencies and evidence base that could result from the appropriate evaluation of such systems.ObjectiveWe aimed to develop a theory of change (ToC) for the implementation of EHRs for maternal and child health care delivery in LMICs. The ToC is an outcomes-based approach that starts with the long-term goals and works backward to the inputs and mediating components required to achieve these goals for complex programs.MethodsWe used the ToC approach for the whole implementation’s life cycle to guide the pilot study and identify the preconditions needed to realize the study’s long-term goal at Festac Primary Health Centre in Lagos, Nigeria. To evaluate the maturity of the implementation, we adapted previously defined success factors to supplement the ToC approach.ResultsThe initial ToC map showed that the long-term goal was an improved service delivery in primary care with the introduction of EHRs. The revised ToC revealed that the long-term change was the improved maternal and child health care delivery at Festac Primary Health Center using EHRs. We proposed a generic ToC map that implementers in LMICs can use to introduce an optimized EHR system, with assumptions about sustainability and other relevant factors. The outcomes from the critical success factors were sustainability: the sustained improvements included trained health care professionals, a change in mindset from using paper systems toward digital health transformation, and using the project’s laptops to collect aggregate data for the District Health Information System 2–based national health information management system; financial: we secured funding to procure IT equipment, including servers, laptops, and networking, but the initial cost of implementation was high, and funds mainly came from the funding partner; and organizational: the health professionals, especially the head of nursing and health information officers, showed significant commitment to adopting the EHR system, but certain physicians and midwives were unwilling to use the EHR system initially until they were persuaded or incentivized by the management.ConclusionsThis study shows that the ToC is a rewarding approach to framing dialogue with stakeholders and serves as a framework for planning, evaluation, learning, and reflection. We hypothesized that any future health IT implementation in primary care could adapt our ToC approach to their contexts with necessary modifications based on inherent characteristics.

Examining the adoption and implementation of behavioral electronic health records by healthcare professionals based on the clinical adoption framework

BackgroundWhile various quantitative studies based on the Unified Theory of Acceptance and Use of Technology (UTAUT) and Technology Acceptance Models (TAM) exist in the general medical sectors, just a few have been conducted in the behavioral sector; they have all been qualitative interview-based studies.ObjectiveThe purpose of this study is to assess the adoption dimensions of a behavioral electronic health record (EHR) system for behavioral clinical professionals using a modified clinical adoption (CA) research model that incorporates a variety of micro, meso, and macro level factors.MethodsA questionnaire survey with quantitative analysis approach was used via purposive sampling method. We modified the existing CA framework to be suitable for evaluating the adoption of an EHR system by behavioral clinical professionals. We designed and verified questionnaires that fit into the dimensions of the CA framework. The survey was performed in five US behavioral hospitals, and the adoption factors were analyzed using a structural equation analysis.ResultsWe derived a total of seven dimensions, omitting those determined to be unsuitable for behavioral clinical specialists to respond to. We polled 409 behavioral clinical experts from five hospitals. As a result, the ease of use and organizational support had a substantial impact on the use of the behavioral EHR system. Although the findings were not statistically significant, information and service quality did appear to have an effect on the system's ease of use. The primary reported benefit of behavioral EHR system adoption was the capacity to swiftly locate information, work efficiently, and access patient information via a mobile app, which resulted in more time for better care. The primary downside, on the other hand, was an unhealthy reliance on the EHR system.ConclusionsWe demonstrated in this study that the CA framework can be a useful tool for evaluating organizational and social elements in addition to the EHR system's system features. Not only the EHR system's simplicity of use, but also organizational support, should be considered for the effective implementation of the behavioral EHR system.Trial Registration: The study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No.: B-1904-534-301).

Clinician Perceptions of Transition From Legacy Electronic Health Record to MHS GENESIS: A Pilot Study.

The implementation of a new electronic health record (EHR) presents significant challenges as users navigate a new interface. Our institution was an early adopter of MHS GENESIS (MHSG), the MHS's new EHR. This study investigated provider perceptions of usability and the prevalence of burnout during an EHR transition from the Legacy system (LEHR) utilizing online, anonymous surveys before implementation and at several points post-implementation. Clinician satisfaction, perceptions of EHR impact on safety, communication, reliability, and chart completion were assessed on five-point Likert scales. Usability was assessed using the validated System Usability Scale (SUS). Burnout prevalence was assessed using a validated single-item measure. Data were gathered via online, anonymous surveys before implementation and at 1, 3-6, and 9-12 months post "Go-Live." Of 367 clinicians, 56 responded to the baseline survey; on average, 29% of responses were positive (i.e., satisfied or very satisfied) with LEHR. Following implementation, an average of 47%, 37%, and 47% of responses were positive for MHSG at 1 months (n = 42), 6 months (n = 55), and 12 months (n = 30), respectively. The mean SUS for LEHR was 48 (on a scale of 1-100); for MHSG, the mean SUS was 48 (1 month), 41 (6 months), and 44 (12 months). The burnout rate was reported as 39% (baseline), 26% (1 month), 33% (6 months), and 37% (12 months). Perceptions of system usability, physician satisfaction, and burnout were not remarkably different between the two systems. Study results imply a need for further investigation as to why most clinicians continue to be unsatisfied with MHSG and wish to return to LEHR and whether or how this EHR transition contributed to burnout or if other factors are more contributory in this population. Future studies could also explore whether changes in the clinician interface, training, or implementation process impact clinician satisfaction, burnout, and desire to return to LEHR, or if these measures change with longer follow-up or in more varied populations.

From Old to New: Process of Integrating PACU Phase 1 Documentation and Workflow from Old Electronic Health Record (EHR) System to New Electronic Health Record (EHR) System

<h3>Background Information</h3> In 2019, a new Electronic Health Record (EHR) was implemented to standardize and streamline access of patient health records across the health care system. Meaningful use of EHR provides benefits such as safety, quality, and efficiency in patient-care delivery. The adoption of the new EHR system has created significant disruption in the complex workflow of busy units, as well as frustration to users specifically in the usability functions of the new EHR system. This project will outline strategies and processes to ensure that resources are equipped to handle its complexity by employing methods to assist user for seamless transition from an old EHR system to new EHR system in phase 1 PACU. <h3>Objectives of Project</h3> •Identify and create a framework of key elements to bridge the gap in nursing documentation •Provide educational tools focusing on the change in workflow and documentation of clinical pathways •Create an audit tool to address nursing documentation compliance <h3>Process of Implementation</h3> Identified super users to serve as unit resources. Staff training included mandatory learning modules, post-tests, and unlimited practice simulations. All PACU workflow and clinical pathways were reviewed and revised to ensure the necessary "must haves" were included in the new platform. Created tip sheets of new workflow processes. An audit tool was created to address nursing compliance issues and cover key elements of workflow and documentation of clinical pathways. Leveraged use of lean methodology through daily huddle discussion of issues and generating ideas. <h3>Statement of Successful Practice</h3> The goals of the EHR implementation were achieved by familiarizing users with the new system through education, hands-on training, and constant follow through via lean methodology. Success was measured by rate of resolution of issues which achieved 100% by February 2020. Completion rate of RN documentation audits exceeded the set goal by 12.4%. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing the appropriate education and hands-on training served as of great value for successful implementation. The tip sheets created by the team improved effectiveness of user workflow and was spread to several PACU facilities within the healthcare system & vendor for their education and training.

Designing a Flow-based Mechanism for Accessing Electronic Health Records on a Cloud Environment

Electronic health record (EHR) implementation not only to facilitate doctor-patient communication reduces paper consumption but also allows the rapid exchange of medical records, integrating patients’ medical information from different locations. However, the costs of establishing massive and repetitive systems, constructing databases, and maintaining and exchanging data, as well as the energy consumption underscoring such an operation, represent substantial costs for a medical institution. Therefore, it is important to develop a cloud solution for EHRs and to provide a platform where resources are truly shareable. This study investigates the feasibility of cloud EHR services provided by trusted third parties. However, not only do medical records stored in an access environment with multiple users potentially endanger patient privacy, but also, without well-designed access control, such an environment may beget excessive unnecessary data access, which is costly and hinders cloud computing. To address the dual challenge of protecting patient privacy and allowing cloud computing, this study proposes the doctor–patient workflow and implements a web-based system. This mechanism ensures patients’ data security and addresses the demand of EHR cloud sharing, i.e., controlling EHR access authorities. The proposed method can protect the privacy of patients’ medical records on the cloud and grant users with minimum granularity access, thereby creating a system with the advantages of data security and cloud computing. This study proposes the doctor–patient workflow as the access control mechanism of cloud medical records, which minimizes the granularity of access. In addition, the access authority of the workflow dynamically changes with the environment, which ensures patients’ access to their medical records and defines the appropriate timing of cloud data access operations, thereby preventing unnecessary energy consumption. In practice, considerable contributions can be made to the establishment of access control and promotion of the cloud environment for medical records.

EVALUATING THE IMPACT OF ELECTRONIC HEALTH RECORD SYSTEMS ON REDUCING MEDICATION ERRORS: A STUDY AT LADY READING HOSPITAL, PESHAWAR

Medication mistakes significantly threaten hospitals, leading to adverse events and increased healthcare costs. Electronic health records (EHRs) have been introduced to reduce the frequency of errors and mitigate these issues. This study aimed to determine if the EHR system reduced medical errors at Lady Reading Hospital (LRH) in Peshawar, Pakistan, thereby enhancing patient safety. A retrospective study was conducted from January 3, 2021, to July 3, 2021. The assessment involved a detailed analysis of medication error incidents at LRH, recorded during this period, involving 200 patients. Data from the Department of Pharmacy were collected and analyzed concerning the occurrence, types, and possible contributing causes of medication errors. The results showed a significant reduction in medication error rates following the implementation of the EHR system. The number of medication errors decreased from 80 incidents to 30 occurrences. Specifically, overall mistakes dropped from 25 to 5, omissions from 15 to 10, and wrong medication reports from 20 to 8. The most common types of errors included dosage errors (accounting for 50 incidents), followed by wrong medication (30 incidents), and omissions (25 incidents). Factors contributing to these errors included communication gaps (20 incidents), transcribing errors (15 incidents), and inadequate training (10 incidents). An evaluation of the severity of these errors revealed 15 minor, 25 moderate, and 10 severe problems. Implementing the EHR system significantly enhanced patient safety by improving communication and providing continuous access to accurate patient information. The findings indicate that EHRs are a crucial component of hospital drug safety, significantly reducing medication errors. Integrating electronic record-keeping facilitates medication management processes, provides real-time information access, and improves communication among healthcare professionals. However, addressing other aspects of system malfunctions and ensuring effective system distribution is essential for successful EHR implementation in healthcare facilities. Future research should focus on designing longitudinal studies to evaluate the long-term safety of medications, the use of EHR systems, and strategies to further improve patient care quality.

“Note Bloat” impacts deep learning-based NLP models for clinical prediction tasks

One unintended consequence of the Electronic Health Records (EHR) implementation is the overuse of content-importing technology, such as copy-and-paste, that creates “bloated” notes containing large amounts of textual redundancy. Despite the rising interest in applying machine learning models to learn from real-patient data, it is unclear how the phenomenon of note bloat might affect the Natural Language Processing (NLP) models derived from these notes. Therefore, in this work we examine the impact of redundancy on deep learning-based NLP models, considering four clinical prediction tasks using a publicly available EHR database. We applied two deduplication methods to the hospital notes, identifying large quantities of redundancy, and found that removing the redundancy usually has little negative impact on downstream performances, and can in certain circumstances assist models to achieve significantly better results. We also showed it is possible to attack model predictions by simply adding note duplicates, causing changes of correct predictions made by trained models into wrong predictions. In conclusion, we demonstrated that EHR text redundancy substantively affects NLP models for clinical prediction tasks, showing that the awareness of clinical contexts and robust modeling methods are important to create effective and reliable NLP systems in healthcare contexts.

Systematic Assessment of the Interoperability Requirements and Challenges of Secure Blockchain-Based Electronic Health Records

A peer-to-peer (P2P) decentralized information-sharing network is used to share data and maintain security, privacy, and integrity standards called blockchain. In this case, information sharing and updating require regular simplification. The presented systematic review mainly focuses on the interoperability of electronic health records (EHRs) using blockchain. Correspondingly, 18 blockchain-based solutions were selected to address the interoperability challenges of EHRs. The limitation of solutions includes reliability, privacy, integrity, sharing, and standards. This systematic review contains six phase’s research question, research phase, article selection, abstract-based keyword, data extraction, and progress tracking. Various Web resources such as Google Scholar, Web of Science, and IEEE are used to extract the relevant manuscripts. Primarily, 18 articles were selected to present the interoperable requirements of EHRs using blockchain, standards of blockchain-based EHRs, and solutions for interoperability of EHRs using blockchain. The conducted study explains the best available interoperable blockchain-based EHR standards, implementations, applications, and challenges.

Electronic health records and blockchain interoperability requirements: a scoping review.

ObjectiveThe purpose of this study was to conduct a scoping review of publications that explored blockchain technology in the context of interoperability and challenges of electronic health record (EHR) implementations. We synthesize the literature regarding standards and security, specifically regulation, regulatory operability, and conformance to standards. We review open practitioner questions that were not addressed in the studies as directions for further research.Materials and MethodsWe conducted a literature search in the OVID databases (Medline and Embase) on terms blockchain, implementation, interoperability, EHRs, security, and standards. The search resulted in 152 nonduplicate, peer-reviewed manuscripts, of which 15 were relevant to our objective and included for synthesis.ResultsBased on the search results, we analyzed the adoption of blockchain technology in the healthcare systems and challenges to EHR implementation of blockchain. From the synthesized research, we categorized and reported compelling factors of blockchain for EHR integration using current knowledge on blockchain research standardization and architectural challenges.DiscussionOur research showed promise in implementing blockchain technology associated with EHRs, especially with Health Information Exchanges. The studies relevant for both EHR (n = 5) and blockchain (n = 10) reported compelling factors and limitations of the architecture. Security (n = 4) and interoperability (n = 4) features were reported as compelling requirements with lingering challenges. Standardization literature (n = 3) reported implementation challenges.ConclusionThis study shows promise in implementing blockchain technology within EHR systems. The adoption is increasing; however, multiple implementation challenges remain from architectural perspectives (eg, scalability and performance), to security challenges (eg, legal requirements), and standard perspectives including patient-matching problems.

EHR Integrated Urine Culture Algorithm Is an Effective Diagnostic Stewardship Strategy

<h3>Background</h3> Diagnostic stewardship can be a high-impact, low-effort strategy to optimize clinical outcomes through implementation of evidence-based guidelines and electronic health record (EHR) decision support. Published practice guidelines indicate appropriate indications for diagnostic urine cultures for evaluation of urinary tract infection. <h3>Methods</h3> A multidisciplinary team reviewed current evidence-based practice guidelines and developed a urine culture algorithm including a list of approved indications and updated urinalysis (UA) reflex to culture criteria. The protocol was implemented into the electronic health record, including requirements for the providers to list an approved indication for urine culture, and updated UA reflex criteria. Number of urine cultures tested, number of catheter-associated urinary tract infection (CAUTI) events, and CAUTI rate was assessed pre and post protocol implementation. <h3>Results</h3> Urine cultures, CAUTIs, and CAUTI rates were reviewed for one year prior to implementation and one year after implementation, 03/2019-02/2020 and 03/2020-02/2021. Comparing the baseline year of data to the year after implementation revealed that the implementation of the urine culture algorithm resulted in a 23.5% reduction in the amount of urine culture tests completed (p<.001). A 15.9% CAUTI reduction and a 23.3%5 CAUTI rate reduction were also obtained. <h3>Conclusions</h3> Diagnostic stewardship can be an important part of an infection prevention program. The implementation of an evidence-based urine culture algorithm resulted in a statistically significant reduction in urine culture tests. A reduction in CAUTI events and CAUTI rates were also obtained. Integrating the algorithm into the electronic medical record and obtaining input from a multidisciplinary team were key components to achieving successful implementation.

Addressing the Challenges of Electronic Health Records Using Blockchain and IPFS.

Electronic Health Records (EHR) are the healthcare sector’s core digital strategy meant to improve the quality of care provided to patients. Despite the benefits afforded by this digital transformation initiative, adoption among healthcare organizations has been slower than desired. The sheer volume and sensitive nature of patient records compel these organizations to exercise a healthy amount of caution in implementing EHR. Cyberattacks have also increased the risks associated with non-optimal EHR implementations. An influx of high-profile data breaches has plagued the sector during the COVID-19 pandemic, which put the spotlight on EHR cybersecurity. One objective of this research project is to aid the acceleration of EHR adoption. Another objective is to ensure the robustness of the system to resist malicious attacks. For the former, a systematic review was used to unearth all the possible causes why the adoption of EHR has been anemic. In this paper, sixty-five existing proposed EHR solutions were analyzed and it was found that there are fourteen major challenges that need to be addressed to reduce friction and risk for health organizations. These were privacy, security, confidentiality, interoperability, access control, scalability, authentication, accessibility, availability, data storage, data ownership, data validity, data integrity, and ease of use. We propose EHRChain, a new framework that tackles all the listed challenges simultaneously to address the first objective while also being designed to achieve the second objective. It is enabled by dual-blockchains based on Hyperledger Sawtooth to allow patient data decentralization via a consortium blockchain and IPFS for distributed data storage.

Electronic health records using a resource advantage theory perspective: an interdisciplinary literature review

PurposeWarren Buffett asserted that the greatest issue confronting American business and the economy is rising health-care costs, which have risen to 17% of gross domestic product. Public policymakers, health-care providers and other stakeholders grapple with cost-containment and increased health-care delivery efficiencies. There exists a paucity of theory-driven research addressing how information technology vis-à-vis electronic health records (EHR) may supply a managerial mechanism for increasing bottom-line hospital performance, thereby attaining competitive advantage.Design/methodology/approachA systematic interdisciplinary literature review motivated by resource advantage theory (RAT) offers a conceptual foundation for analyzing the financial, informational and physical workflows that are core elements of supply chain management in a hospital.FindingsRAT links how EHR impacts profitability, competitive advantage and macromarketing factors in hospital supply chains. The literature review provides a research synthesis of the implementation and adoption of EHR to reveal its impact on a hospital’s competitive advantage. Although legislative initiatives like the 2009 Health Information Technology for Economic and Clinical Health Act and the Affordable Care Act encourage EHR adoption, there remains a reluctance for hospitals to do so.Originality/valueThe extant literature precedes the relevant legislation, has incomplete data or focuses solely on patient outcomes.

Electronic health records post-implementation challenges in selected hospitals: A qualitative study in the Central Region of southern Ghana.

Electronic health records (EHRs) are useful tools in healthcare settings but implementation in low and middle-income countries (LMIC) face challenges. To explore post-implementation challenges affecting the deployment of EHRs and their use in selected health facilities in Ghana. Using a qualitative research approach, 21 in-depth interviews were conducted with health workers in two hospitals in the study area in Ghana, in February and June 2020. Purposive sampling was used to select participants. All interviews were audio recorded, transcribed, and coded into themes using QSR Nvivo12 software to aid thematic analyses. Post-implementation challenges were grouped into lack of technological, logistical and managerial support, and inadequate training. Inadequate equipment was the most reported post-implementation challenge that affected EHR use. Unreliable Internet and network connectivity was a source of frustration, which caused staff to develop negative attitudes towards use of the system. Lack of funding stalled implementation of the system and limited its use to critical care units only. It was also the reason replacement of equipment delayed. While EHR post-implementation challenges facing health facilities are surmountable, managerial support, backed with the requisite logistical and technical support is needed. It is not enough to rely on funding; health institutions should prioritise emerging EHR post-implementation challenges in their operating budgets. A national framework is needed to guide effective and sustainable EHR implementation across the country.

Adolescent Consent and Confidentiality: Complexities in Context of the 21st Century Cures Act.

Adolescent Consent and Confidentiality: Complexities in Context of the 21st Century Cures Act.

Electronic health record implementation and healthcare workers\u2019 work characteristics and autonomous motivation\u2014a before-and-after study

BackgroundTechnological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers’ autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored.MethodsA quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE).ResultsA total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation.ConclusionsOur study showed that healthcare professionals’ perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers’ autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers’ values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

Implementation of a Web-Based Tool for Shared Decision-making in Lung Cancer Screening: Mixed Methods Quality Improvement Evaluation.

BackgroundLung cancer risk and life expectancy vary substantially across patients eligible for low-dose computed tomography lung cancer screening (LCS), which has important consequences for optimizing LCS decisions for different patients. To account for this heterogeneity during decision-making, web-based decision support tools are needed to enable quick calculations and streamline the process of obtaining individualized information that more accurately informs patient-clinician LCS discussions. We created DecisionPrecision, a clinician-facing web-based decision support tool, to help tailor the LCS discussion to a patient’s individualized lung cancer risk and estimated net benefit.ObjectiveThe objective of our study is to test two strategies for implementing DecisionPrecision in primary care at eight Veterans Affairs medical centers: a quality improvement (QI) training approach and academic detailing (AD).MethodsPhase 1 comprised a multisite, cluster randomized trial comparing the effectiveness of standard implementation (adding a link to DecisionPrecision in the electronic health record vs standard implementation plus the Learn, Engage, Act, and Process [LEAP] QI training program). The primary outcome measure was the use of DecisionPrecision at each site before versus after LEAP QI training. The second phase of the study examined the potential effectiveness of AD as an implementation strategy for DecisionPrecision at all 8 medical centers. Outcomes were assessed by comparing absolute tool use before and after AD visits and conducting semistructured interviews with a subset of primary care physicians (PCPs) following the AD visits.ResultsPhase 1 findings showed that sites that participated in the LEAP QI training program used DecisionPrecision significantly more often than the standard implementation sites (tool used 190.3, SD 174.8 times on average over 6 months at LEAP sites vs 3.5 SD 3.7 at standard sites; P<.001). However, this finding was confounded by the lack of screening coordinators at standard implementation sites. In phase 2, there was no difference in the 6-month tool use between before and after AD (95% CI −5.06 to 6.40; P=.82). Follow-up interviews with PCPs indicated that the AD strategy increased provider awareness and appreciation for the benefits of the tool. However, other priorities and limited time prevented PCPs from using them during routine clinical visits.ConclusionsThe phase 1 findings did not provide conclusive evidence of the benefit of a QI training approach for implementing a decision support tool for LCS among PCPs. In addition, phase 2 findings showed that our light-touch, single-visit AD strategy did not increase tool use. To enable tool use by PCPs, prediction-based tools must be fully automated and integrated into electronic health records, thereby helping providers personalize LCS discussions among their many competing demands. PCPs also need more time to engage in shared decision-making discussions with their patients.Trial RegistrationClinicalTrials.gov NCT02765412; https://clinicaltrials.gov/ct2/show/NCT02765412