Essays on the Impact of Implementing Electronic Health Records in a Hospital Setting

Abstract

The healthcare sector faces considerable challenges in the continuous search for better, safer, and more efficient patient care. One of these challenges is the need to increase and speed up digitalization within the healthcare sector to be able to meet the needs of today and tomorrow. In 2013, the Belgian governments initiated an e-health action plan, consisting of more than twenty action points, with the purpose of stimulating the use of technology in health care. Due to the strong resilience of the sector, the action plan was revised in 2015 leading to more ambitious criteria and the formulation of some new action points, including an accelerator program for integrated hospital Electronic Health Records (EHRs). Together with the potential benefits an integrated EHR can offer in terms of quality of care, information-sharing, hospital accreditation, etc., the action plan led to a major transformation in the Belgian hospital landscape as the majority of them have recently implemented or are still implementing integrated EHRs. This doctoral dissertation closely examines the impact of implementing an integrated EHR in a Belgian hospital from multiple angles using primary data with the purpose of advancing both the health and economic literature on the topic. The limited literature on the impact of integrated hospital EHRs has shown EHRs have the potential to improve quality of care, patient safety, efficiency, information-sharing, etc. However, the extent to which these benefits are achieved is highly variable between healthcare institutions. One of the critical success factors for a hospital to fully exploit the potential of the EHR is to achieve acceptance of the EHR among hospital staff as the daily end-users of the technology. To date, however, little insight has been gained in which determinants are important in achieving EHR acceptance and a positive attitude of staff towards the new EHR. Based on an extensive literature review, a series of workshops, and pilot studies, we introduced a new model to examine the acceptance of an integrated EHR in a hospital setting. Using primary survey data and partial least squares structural equation modelling (PLS-SEM), we estimated the model to gain insight into the drivers of hospital staff’s attitude towards the EHR and the complex set of relations between these drivers. The results show the importance of administrative simplification due to the EHR, adequate and sufficient training, and open, complete, and timely communication by the hospital management to achieve EHR acceptance. Additionally, we show prior experiences with information technology in daily life facilitate the acceptance and use of the EHR in the work context. A second gap in the EHR acceptance literature is the limited use of analyses of change over time as 90% of the technology acceptance literature is crosssectional. While this approach delivers insight into EHR acceptance at a given point in time, it does not account for the implementation stage or time effects which may be of significant importance in truly understanding EHR acceptance and help hospital management to differentiate its policy depending on the implementation stage. By means of a repeated cross-sectional design, consisting of one survey wave before and two waves after the implementation, and partial least squares multigroup analyses (PLS-MGA), we were able to identify significant variations in the model’s relations. First, we find a significant trade-off over time between effort expectancy and performance expectancy. This means that, as time progresses, effort expectancy becomes less important in explaining staff’s attitude towards the EHR while performance expectancy becomes more important in explaining staff’s attitude. More specifically, we show that in the first stage of the implementation trajectory the ease of use of the EHR is more important to hospital staff, while in the later stages, when the EHR is implemented, the usefulness and performance of the EHR in their daily work routine gains significantly more importance. Furthermore, we also demonstrate that the attitude of staff towards technology in general in daily life (off the job) to be mainly an important factor in the first stages of the implementation trajectory as its effect decreases significantly over time. These findings demonstrate that hospital management and EHR suppliers should adapt their policy to the implementation stage of the EHR and the importance for future technology acceptance research to opt for a design enabling analyses of change over time. Besides the barriers and enablers to EHR acceptance, a major gap in the literature is the impact of the EHR on healthcare’s most valuable resource: healthcare staff. Using a repeated cross-sectional research design, we examined the impact of the EHR implementation on thirteen outcomes categorized in three clusters: staff wellbeing, staff-patient interactions, and staff interactions. The repeated crosssectional design enables us to perform a before-after analysis of the clustered set of outcomes and consisted of three survey waves: (1) baseline survey wave before EHR implementation, (2) first follow-up survey wave 11 months after EHR implementation (short term impact), and (3) second follow-up survey wave 19 months after implementation (medium term impact). The results show a negative impact of the EHR on staff well-being, staff-patient interactions, and staff interactions in the short term after which the outcomes improve again towards the baseline level. Hence, we demonstrate the existence of an implementation dip in the outcomes in the short term after which the EHR has been implemented in the hospital. This implementation dip is characterized by lower staff well-being (e.g. job satisfaction, motivation, burnouts, etc.), quality of care, patient safety, and lower quality of interactions between staff members and should therefore be kept as little in magnitude and short in time as possible. Adequate training, transparency in the decision-making, and end-user involvement before and after the EHR implementation are critical success factors in achieving this objective. By taking a stakeholder perspective on the impact, we demonstrate the impact is experienced differently among the various stakeholders in the hospital. Nurses, older staff members, and more experienced staff members feel most negatively affected on the short and medium term by the implementation of the EHR. In contrast, head nurses, younger and less experienced staff members feel least impacted by the EHR. To gain more insight into which of these outcomes are associated to the three major staff well-being outcomes (i.e. job satisfaction, motivation, and burnout likelihood), we built a framework around these three outcomes and the remaining set of outcomes using correlational analyses. Before the EHR was implemented, the results show job satisfaction and motivation are significantly correlated with a highly similar set of outcomes (i.e. job qualification, quality of communication to patients, quality of communication to colleagues, and quality of care). In addition, workload is also significantly correlated with job satisfaction. Surprisingly, burnout likelihood is correlated with a smaller set of outcomes (i.e. workload, probability of making administrative errors, and the quality of communication to colleagues). The impact of the EHR implementation on the framework is relatively modest, which shows the robustness of the model over time. Overall, we can conclude that the main difference between the situation before and after the implementation of the EHR is the increased importance of the staff-patient interactions outcomes in the correlational framework at the expense of the outcomes in the staff well-being cluster. Additionally, by taking a stakeholder perspective, the analyses show considerable differences in the framework between the different professions working in the hospital. The general framework provides the best fit for nurses and the worst fit for secretaries. Due to the major impact of the EHR on the organization of the administrative processes within the hospital and the importance of administrative efficiency in achieving a successful EHR implementation, we examined one particular outcome in more detail: the impact of the EHR implementation on hospital staff’s red tape. While examining this impact fills a major gap within the EHR literature, it is also of significant importance within the red tape research field as red tape research within a healthcare context is to date, despite its significant relevance in the sector, very scarce. To examine this impact we employed a repeated crosssectional research design consisting of three survey waves over time of which the first was conducted before the EHR was implemented and the two remaining waves were performed after the EHR had been implemented (i.e. 11 and 14 months after implementation). Due to the complexity of the red tape phenomenon, especially in healthcare, we used multiple instruments to gain insight into the impact on red tape. First, respondents were asked to report the time they spend on administration, patient care, and communication to colleagues in every survey wave. The results show a significant increase in the time spent on administration at the expense of the time spent on patient care. Second, in the second survey wave respondents were asked to complete a set of self-reported comparative red tape questions in comparison to the situation before the EHR had been implemented. The set consisted of one general comparative question and several comparative questions on a task level. The results clearly show hospital staff experienced a substantial increase in red tape, both in general and on a task level, with more than three quarters of hospital staff indicating having experienced an increase in red tape. Third, we performed observations at carefully selected departments during the survey waves and organized workshops with hospital staff after survey completion with the purpose of validating and explaining the survey results. Both the observations and workshops confirmed the previous results from which we can conclude there is a substantial increase in red tape in the hospital due to the implementation of the EHR. Fourth, we included two validated red tape instruments originating from the public administration research field in each survey wave: the General Red Tape (GRT) scale and the relatively new Three Item Red Tape (TIRT) scale. Due to the accumulating criticism on the GRT scale and the recentness of the TIRT scale, this research design provided an excellent opportunity to test the validity of both scales by examining whether both instruments pick up the previously discussed increase in red tape. Surprisingly, the results of the TIRT scale demonstrate a significant increase of red tape, while the results of the GRT scale do not show a significant change in red tape. This raises questions on the validity of the GRT scale as it seems not to be able to capture the increase in red tape in the hospital. Based on the existing literature, we suggest the reason for this phenomenon is the bottom-up intraorganizational research design in contrast to the predominantly used top-down interorganizational approach in the red tape literature. More specifically, this means it is too difficult for staff, in contrast to managers, to evaluate red tape in the entire organization and that as a result the GRT scale results lack accuracy. While these results seem to advocate for a more extensive use of the TIRT scale, especially in bottom-up intraorganizational research, the TIRT scale does show empirical weaknesses in its design. Therefore, in future red tape research in a healthcare setting, alternatives should be explored to examine red tape perceptions and measure the impact of organizational change on red tape. Finally, we examined one specific point of criticism towards the GRT scale in more detail, which is aimed at the definition for red tape accompanying the GRT scale. Scholars claim the definition’s wording is too negative, which triggers respondents to give a more negative response on the scale itself. An alternative for the GRT definition is the definition of the European Commission (EC) for red tape, which is considered to be more neutral. By randomly assigning each respondent to either the GRT scale with the GRT definition or the GRT scale with the EC definition, we examined whether the definition displayed to respondents significantly influences their answers on the scale. The results of the analyses show that there is no evidence for a significant effect of definition wording on GRT levels. This means that, although there is a substantial difference in wording between the definitions, hospital staff reflects on the same underlying red tape concept when evaluating red tape levels in the hospital.