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Resistances that lead to

modification of the

Electronic Patient Record

by

Arie Schenk

Master Thesis

University of Groningen

Faculty of Economics and Business

MSc Business Administration - Business & ICT

July 2011

Written under supervision of:

Prof. dr. H.G. Sol

Nieuwe Ebbingestraat 78a 9712 NN Groningen

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Preface

This master thesis deals with creating an insight in the different resistances towards electronic patient records, better understanding these resistances and future chances for reducing resistance behaviors. Hospital ‘De Tjongerschans’ in Heerenveen gave me the opportunity to research this topic at the policlinic Cardiology and Pulmonology. Recently an EPR has been implemented and caused a lot of resistance towards the system because it did not work out as people expected.

This master thesis is written during the 3rd and 4th semester (April 2011 – July 2011) for the master; Master of Business Administration (MBA): Business & ICT at the University of Groningen.

It is written under supervision of both representatives from the University of Groningen and hospital De Tjongerschans: University of Groningen: • Prof. dr. H.G. Sol • Dr. R.A. Rozier Hospital De Tjongerschans: • Dr. J.S. van Os • Dr. J. Westbroek • R. van Stralen

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Abstract

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Table of contents

Preface………. 2 Abstract……….... 3 Table of contents………. 4 1. Introduction………...… 6 1.1 Initial motive………. 6 1.2 Problem statement………. 6 1.3 Research question……….……. 7 1.4 Sub-questions……….…… 7

1.5 Definitions and abbreviations……… 7

1.5.1 Abbreviations……….……. 7

1.5.2 Definitions………..….7

1.6 Research methods……….…. 8

1.6.1 Literature review on resistance………... 8

1.6.2 Interviews regarding resistance………... 8

1.6.3 Timing and observing PPF and EPR processes……….. 8

1.6.4 Validation and statistical analysis of the sub-questions……….. 9

1.6.5 Survey on changes to the EPR……… 9

1.6.6 Statistical analysis of changes………. 10

2. Literature review: Resistance to EPR………...……….. 11

2.1 General theory on resistance……….. 11

2.1.1 What is resistance?... 11

2.1.2 Resistance to change………...… 11

2.1.3 Resistance to information systems……….. 12

3. Interviews and work processes…..………...…… 13

3.1 Interviews with representatives from work groups on resistance to EPR……. 13

3.1.1 Interview receptionists…...………. 13

3.1.2 Interview secretaries………... 14

3.1.3 Interview specialists……… 15

3.1.4 Interviews summary………..……….. 16

3.2 Work processes in detail……… 17

3.2.1 Process analysis……….. 17

4. Analysis of interviews and work processes...……….…. 18

4.1 Process observation and timing results……….. 18

4.2 Validation………..……… 19

4.3 Statistical analysis……….…………... 19

4.3.1 Time spent by the specialist in the EPR and PPF………...…… 21

4.3.2 Time spent by the specialist EPR compared to mod. EPR…………. 22

4.3.3 Secretarial time needed for the EPR compared to PPF………...24

4.3.4 Secretarial time needed for the PPF comp. to mod. EPR…………... 25

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5. Confrontation and Change………... 28 5.1 Survey setup……….. 28 5.2 Survey results………. 29 5.3 Statistical analysis………. 30 5.3.1 Resistance to typing……… 31 5.3.2 Lack of overview……… 32 5.3.3 Mobile workplace………... 33 6. Conclusions……… 34 6.1 Sub-question 1……….. 34 6.2 Sub-question 2………... 34 6.3 Sub-question 3……….……….. 35 6.4 Sub-question 4……….……….. 35 6.5 Sub-question 5……….………….. 35 6.6 Sub-question 6……….……….. 36 6.7 Research question……….…………. 36

7. Limitations and further research proposals………..……. 38

8. Reference list………...………... 39

Appendices………. 41

Appendix A: Timetable………...… 41

Appendix B: Administrative Process PPF……….. 43

Appendix C: Administrative Process EPR……….…. 52

Appendix D: Administrative Process EPR Modified……….… 54

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1.

Introduction

1.1 Initial motive

De Tjongerschans is a general hospital in The Netherlands located in Heerenveen. It has all medical functions except plastic- and neurosurgery. The focus of the hospital lies with sports medicine, geriatrics and vascular diseases. The hospital has 365 beds and a staff of 1400 employees (including part time workers).

In 2003 the hospital management and the specialists decided to start a process that would result in the introduction of an EPR (Electronic Patient Record). The mission that was set was to become a total paperless hospital. Goals were set to reach major budget cuts on supporting staff like secretaries and receptionists. The reduction in labor force should pay for the costs of the EPR.

In the initial phase all specialists were interviewed about their vision and resistances towards the introduction of an EPR. This resulted in specifications for an EPR that were used in a second phase where companies were asked to give presentations regarding their current EPR’s and their plans for further development of their EPR.

In 2008 the hospital information system and EPR of Chipsoft (EZIS) were chosen. Initially only the hospital information system was implemented and during 2010 a working group fitted the standard Chipsoft EPR into a workable local Tjongerschans version. The medical staff had many different resistances against the EPR and decided only to continue with the introduction of the EPR if the specialist would be allowed not having to change its work process regarding the handling of the file. This resulted in a modified EPR work process that can be chosen by the specialist who has a resistance against typing. Gelderman described a similar fact: “The specialist is the largest obstacle for the implementation of the EPR.” Gelderman also states that the selected EPR solution must have the highest possible fit regarding the daily practice. Verkerke and Spil advice to implement the EPR not by making it perfect before implementation using the Usability Engineering method, as was used by De Tjongerschans. They suggest using the Use It model (Spil et al 2005) where the implementation is constantly monitored and all obstacles are dealt with when they occur. In the pilot phase of the EPR De Tjongerschans is using such a method but they have to deal with all the harm that already has occurred to the project. (Gelderman, 2005)(Verkerke et al, 2006)

In April 2011 pilots were started at the policlinic Cardiology and Pulmonology using both the EPR and the modified EPR. This pilot resulted in a large delay in the administrative processes of patient files.

All the resistances together create a negative image of the EPR while the EPR is intended to lighten the work pressure and support the work processes in a positive way.

1.2 Problem statement

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The effects of the resistances have never been analyzed and there is no information on what quick measures are needed to adapt the system in order to reduce the resistances. No priorities are given to resistance reducing actions.

1.3 Research question

What kind of measures should the policlinic Cardiology and Pulmonology focus on when trying to resolve the major resistances to the EPR in order to be able to meet the (financial) goals set for the implementation of the EPR?

1.4 Sub-questions

1. What are the most important current resistances towards the EPR in the different work groups?

2. Does the modified EPR solution cost more than the EPR solution? 3. Does the EPR cost the specialist more time due to typing?

4. Does the administrative burden diminish due to the EPR?

5. Does the administrative burden change due to the modified EPR?

6. Does the resistance to the EPR decrease and does the use increase by presenting:

• Handwriting and speech recognition?

• Mobile workplaces?

• A better overview of patient data? 1.5 Definitions and abbreviations 1.5.1 Abbreviations

EPR: Electronic Patient Record PPF: Patient Paper File

MIS: Management Information System Poli: Policlinic

1.5.2 Definitions

Chipsoft EZIS: This is a software application for electronic patient records and the hospital information system.

Modified EPR: Electronic Patient Record modified by the specialist to their personal wishes and experiences with the old system.

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1.6 Research methods

To be able to answer the research questions mentioned in chapter 1.3 and 1.4 the following methods were used.

1. Literature review on resistance 2. Interviews regarding resistance

3. Timing and observing PPF and EPR processes 4. Validation and statistical analysis

5. Survey on changes to the EPR 6. Statistical analysis of the changes 1.6.1 Literature review on resistance

The problem statement mentioned in chapter 1.2 deals with the observation of existing resistances that currently hinder the implementation of the EPR at the policlinic Cardiology and Pulmonology. An understanding of resistance behavior and specifically resistance to information systems will be obtained by a literature review on these topics. Applicable theory written in scientific journals will be consulted, interpreted and when relevant, mentioned. The following databases are consulted:

• EBSCO

• Business Source Premier

• Emerald

1.6.2 Interviews regarding resistance

At the policlinic Cardiology and Pulmonology the different user groups are first identified. Each group will be interviewed on their opinion regarding the EPR and on their positive or negative (resistances) feelings after the introduction of the EPR. As this master thesis is exploratory, the interviews will be held in a semi-structured format. The interviews contain several specific questions but there will be possibilities for deepening into the subjects of the questions and turning the interviews in different directions, to come up with new sub-topics brought by the participants. (Blumberg et al, 2008)

The aim of the interview is to learn about the participants point of view regarding the advantages and disadvantages of the EPR and to get an insight into the resistances to the EPR. (Blumberg et al, 2008).

After the interviews the main resistances to the EPR for each user group will be summarized. 1.6.3 Timing and observing PPF and EPR processes

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the work processes will be determined. Final work processes will be described leaving out all steps that are similar for all processes.

During a period of two weeks (10 working days) all consultation hours are observed. During this period the number of patients attending the policlinic are counted. For the purpose of this research every consultation hour is handled as a stack of files and kept together during the whole research to facilitate the time observations. In case of a paper stack, a form with all process steps is attached and in case of an electronic stack, a form was handed over to the users. Of every patient or every consultation hour, the times for every step in the different processes are measured either by direct observation and timing by the researcher or by direct timing of the process steps by the users. The times are noted on the form for every individual consultation hour stack by the researcher or the user. Similar steps in the different processes are timed only one time and used for all processes. The total handling times for every step on the forms of the stacks are divided by the number of patients in the stack. The average and the standard deviation per patient is calculated for every step in the processes for every one of the ten days. The averages of all steps are added for every day and used for statistical analysis to answer sub-questions two, three, four and five.

To be able to answer the question about potential cost reduction the following simulation method is used. The times of every step in the processes are entered into the iGrafx simulation program. This program simulates a consultation hour after all process steps and the average times for every step with its standard deviations are entered. The salaries for every employee are also entered into the simulation. Using this program, simulated costs for every day of the ten research days in all processes are obtained. The exact number of patients visiting the consultation hours on one of the ten research days is entered into the simulation. The simulation produces different kind of results. It takes into account lost idle time in the process and back-ups when too many patients enter the simulation at the same time. The time that is lost to these inefficiencies is part of the simulation results. The results for the same ten research days are obtained after performing simulation for every process type.

1.6.4 Validation and statistical analysis of the sub-questions

The gathered data of the times per process were validated in two ways.

1. The data were presented to the staff to be evaluated whether they are correct or not and the total production of the policlinic was calculated using the observed times. 2. The number of staff members needed was compared to the number actually working

on the processes.

The populations are independent, the results are integers and there is a random selection of research days For the statistical analysis of the hypotheses derived from the results of the process timing and simulations, the difference between two means for independent samples with either equal or unequal variances is used.

1.6.5 Survey on changes to the EPR

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presented to the specialists. After these demonstrations the specialists were asked to repeat the survey.

The survey is setup according to the theory provided by Blumberg, Cooper and Schindler. The survey is done in the sense of self-administered surveys. The participants receive a list with the questions and have only one option to answer it. The advantages are: time saving, high response rate, perceived as more anonymous and rapid data collection. (Blumberg et al, 2008)

1.6.6 Statistical analysis of changes

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2.

Literature review: Resistance to EPR

2.1 General theory on resistance 2.1.1 What is resistance?

“A force which acts to stop the progress of something or make it slower”. (Cambridge dictionary, 2011)

“Resistance is displayed when the target avoids performing the requested action by arguing, delaying, etc” (Enns et al, 2003)

According to the definitions mentioned above, resistance is a broad term and it is used in multiple contexts. This paper focuses on the resistance to change and the resistance to information systems.

2.1.2 Resistance to change

“Resistance to change is a normal psychological reaction when the perceived consequences (e.g., loss of power) are negative” (Ang & Pavri, 1994)

“The tactical approach to implementation sees resistance as a signal from a system in equilibrium that the costs of change are perceived as greater than the likely benefits” (Keen, 1981)

Resistance to change is a phenomenon impossible to eliminate. Basically every organization in the world is struggling with resistance to change. The primary factor of resistance is behavior. This differs from being passively uncooperative to active destruction behavior. (Lapointe et al, 2005)

Coetsee classified resistance behavior into four levels of resistance: (Coetsee, 1999), (Lapointe, 2005)

• Level 1: Apathy (lack of interest, inactive, etc)

• Level 2: Passive resistance (delay tactics, persistence of former behavior, etc)

• Level 3: Active resistance (voicing opposite points of view, forming coalitions, etc)

• Level 4: Aggressive resistance (threats, strikes, boycotts, sabotage, etc)

According to Lapointe et al, resistance arises from perceived threats. People do not naturally resist change, they react to a threat that they perceive caused by the changes. Examples of threats could be loss of power, loss of revenue and loss of status. People who feel threatened will behave differently during the change process. Initial conditions, for example the distribution of power or established routines, can affect the degree of threat. (Lapointe et al, 2005)

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2.1.3 Resistance to information systems

“Resistance to the MIS sometimes occurs when people experience changes in the content of their jobs and their relative power versus others”. (DeSanctis & Courtney, 1983)

“Behaviors intended to prevent the implementation or use of a system or to prevent system designers from achieving their objectives”. (Markus, 1983)

User resistance has always been a major issue regarding the implementation and use of information systems. Currently it is the number one issue for organizations that are facing a change with regard to large-scale information systems. (Kankanhalli et al, 2009)

According to Gibson: “User resistance becomes particularly significant in such large-scale information systems implementations due to the multifarious changes in social as well as technical systems that result” (Gibson, 2003). People react to this degree of change, when change has a huge impact, people are eager to perceive this as a threat and they will cause delays. (Kankanhalli et al, 2009)

To better understand user resistance and to reduce future chances for user resistance to information systems, Lapointe and Rivard made a model that shows the causes for user resistance. They based their model on five dimensions:

• Initial conditions

• Object interaction

• Subject interaction

• Threat

• Behavior

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3.

Analysis

3.1 Interviews with representatives from work groups on resistance to EPR

At the policlinic Cardiology and Pulmonology all the work groups are facing barriers in the implemented EPR. A short interview with representatives from different work groups is performed in order to get an insight in the current resistances towards the EPR and their vision on what to do to reduce these resistances. These interviews are set up according to the theory written by Blumberg, Cooper and Schindler.

3.1.1 Interview Receptionists

Three receptionists are interviewed. One is interviewed for a longer period of time and the others shorter with the focus on confirming and commenting the interview with the first receptionist.

Advantages of the EPR:

• Process of creating patient files

Compared to the classic process of creating patient files, the new system is easier and time reducing. No more paper work to print and to fill in, just hitting the ‘new patient’ button in the system and entering a small amount of data is enough. However, due to the importance and irritations of the disadvantages of the EPR, the advantages are overwhelmed by the disadvantages.

Disadvantages of the EPR:

• Loss of overview

• Being a pilot department

• Making patient files ready for consultation hour

Being the first (pilot) department where the EPR is implemented results in a lot of struggles and various things going wrong. The biggest issue for the receptionists is the loss of overview due to the loss of the polibak. This polibak was, in the classic situation, essential for checking whether all examinations were completed and no patients were waiting for further treatments or results. The new system has a similar system in a digital environment, however this system is not working the way it should work. This results in a constant uncertainty among the receptionists regarding the patient’s progress and they are afraid that a patient is accidentally forgotten or that serious pathology is missed.

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3.1.2 Interview Secretaries

Three secretaries are interviewed. There were more secretaries listening to the interview while working and they sometimes commented or made a remark.

Advantages of the EPR:

• Less searching for files

• Less lagging behind if the system works as intended and the implementation phase is finished

When all patient files, examination results, laboratory results and more patient related files are digital, no more searching for files is necessary. They are available or not. It can not be lost in the internal mail or left behind in a specialist room. The loss of searching is time saving and annoyance reducing.

When the system works the way it is supposed to work and every specialist is working with the EPR as they are supposed to, it will become a time saver. An important condition for this is that the implementation and training phase should be finished. For example, right now some specialists work with the EPR and other specialists work with the modified EPR. This creates two different processes to handle for the secretary instead of the one process it used to be. Together with other issues this resulted in large delays.

Compared to the receptionists, the secretary agrees about the fact that the disadvantages are overwhelming the advantages and as they are currently still in the implementation and training phase, it is hard to think positive about the system.

Disadvantages of the EPR:

• Fear of losing their job

• Loss of overview

• Being a pilot department

• Assigned system rights

• Reduction in administrative tasks

The secretary is afraid that there will be significantly less work for them after the implementation of the EPR. The first experiences during the pilot phase already show them that the handling of the secretarial work for the specialists that fully use the EPR is much less compared to the PPF.

The secretary has the same problem as the receptionists with the loss of overview due to the currently incorrect working digital polibak. They are not able to see what work still has to be done and whether no patient files are left behind. The current digital polibak displays too much information, it is hard to determine whether the given information is important or not. For example, a patient that has to make a return appointment with the specialist in approximately one year is displayed in the polibak and urgent things like changing medication for a patient are displayed as well. Consider the amount of patients coming to the policlinic every day, it is sometimes hard to distinguish the urgent and less urgent messages. In the end there is still a lot of work to be done with regard to the digital polibak.

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also directly affects the patient’s healthcare, patients have to wait longer than they used to wait for their examination results.

While working with the system, the most annoying side-issue is the fact that some scanned documents in the medical viewer (system where scanned patient paper documents are available) are not accessible for the secretary. The distribution of system rights went partly wrong. In order to solve these issues, the proper rights have to be requested through several internal bodies. This takes at least a couple of days.

When eventually the system works as it is supposed to work and the delayed administration is done, people are afraid of a reduction in administrative tasks and again logically losing their jobs.

3.1.3 Interview Specialists

Ten specialists are interviewed on the advantages and disadvantages they experience regarding the new EPR.

Advantages of the EPR:

• Remote access

• Reduction in time for administrative tasks

A big advantage for the specialist is the remote access. While being on call duty, they can enter the system from their home or mobile environment and they can see all the patient history, examination results and electronic files. Currently handheld devices like tablet pc’s are bought to increase the mobility of the system. When using a handheld device for entering the system, no more desktop computer presence is required. Remote access relieves the task while being on call duty.

No more dictation and no more paper order forms for further examination, probably will result in a reduction of administrative tasks. All tasks can be performed using the system around the EPR. This means no more walking around carrying paper files or searching for them. When a specialist has time in between treatments, every accessible computer is enough to do administrative tasks.

Disadvantages of the EPR:

• Typing in the system

• Overview of examination results

• Delay in the implementation phase

• Mobility

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EPR fields, this takes more time as in the PPF situation. Some specialists type their findings and conclusions themselves.

Currently the specialists have to switch between four windows in order to find examination results. This is a cumbersome way of getting access to the right results. Every specialist is annoyed by this approach of finding results.

Due to extra work concerning the implementation and training phase of the new EPR, and afterwards a bad timing of implementing, a huge delay in administrative work has developed. This delay affects every work group in the policlinic and evokes resistance towards the system. Another cause of the delay is the refusal to typing by the specialist. The different ways of working among the several specialists confuses the secretaries and combined with the extra work has resulted in this delay.

Lack of mobility is another mentioned shortage of the EPR. For example when the specialist is examining a patient in the examination room, there is no access point to enter the EPR or when the specialist is making their rounds along the clinical patients, they do not have direct access to the system. This is a difference compared to the old system where they could consult the PPF at all times. Suggestions for improving the access possibilities could be, according to the specialists, implementation of handheld devices.

3.1.4 Interviews summary

The disadvantages mentioned above resulted in stress for the users and the fear of typing became a perceived threat for the specialists. The fear of typing is partly because no specialist really knows what other possibilities are available in order to prevent typing. The expected decrease of administrative work for the secretary and reception turned into a perceived threat of losing their jobs. All these threats resulted in resistance behavior towards the EPR. The implementation of a modified EPR is an example of level 4 resistance according to Coetsee (Coetsee, 1999).

Several resistances can be derived from the interview results. The most urgent five resistances are:

• Resistance to typing by the specialist

• Fear of needing more time during consultation hours for every patient

• Lack of overview for the secretary and the specialist

• Lack of mobility for the specialist

• Fear of losing jobs for the secretary and receptionist

For the first four resistances possible solutions may be applicable, however the fifth one is simply a fact. In the EPR situation, less working personnel will be necessary for the same amount of patient file handlings per day. It was an important driving force for the hospital to implement the EPR.

In chapter 3 the effects on the work process concerning the fear of losing their job and the time the specialist needs for the patient during the consultation are examined. Also the cost reduction is examined. In chapter 5 the effects of offering alternatives to typing, overview and mobility are examined.

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3.2 Work Processes in detail 3.2.1 Process Analysis

At the policlinic Cardiology and Pulmonology specialists work using three different types of files. Some specialists still work with the old paper patient files (PPF) while others fully use the electronic patient record (EPR). There are specialists using an electronic patient record in their perception while we observe that they still use paper forms to make notes and orders regarding the treatment of their patients. They still dictate and the secretaries fill the fields of the electronic patient record for them. This system is called the modified EPR for the purpose of this research.

The following processes are observed:

• Paper patient files (PPF)

• Electronic patient records (EPR)

• Modified electronic patient records (modified EPR or MOD)

The three processes are described after some days of observation. Every process is divided into separate process steps and to every step a unique user group (secretary, receptionist and specialist) is added. Identical steps in all three processes are deleted. In the PPF 28 unique process steps are left, in the EPR 5 unique process steps and in the modified EPR 21 unique process steps.

The processes and the descriptions of the process steps can be found in appendix B, C and D. The number of steps in the EPR process are very limited. At first one would think that items are missing. In reality this was checked at the policlinic and found to be accurate. The specialist can finish the administrative work in the EPR with hardly any administrative support.

In the PPF scenario the specialist can split the moment that he sees the patient in the consultation room from the moment that the administrative work is done. In the EPR scenario all the administrative work has to be done at once. Although the total work may be equal, the perception can be that the EPR takes more time during consultation hours.

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4.

Analysis of interviews and work processes

4.1 Process observation and timing results

At the policlinic Cardiology and Pulmonology all consultation hours over a period of two weeks are observed. There are several consultation hours every day during a morning and an afternoon session. For the purpose of this research all files of the consultation hour sessions are kept together in one stack. Every stack is identified as a PPF, EPR or modified EPR stack. During ten days, the following number of consultation hours (sessions) and patients were observed and timed.

Day Number of sessions (stacks) Number of patients 1 7 86 2 5 64 3 6 71 4 5 66 5 6 78 6 7 85 7 4 50 8 5 65 9 5 65 10 6 73

Table 1: number of sessions (stacks) and patients per day

Using direct observation and timing by the users every step of the three processes are timed. The mean time for every process step obtained during 10 days can be found in appendix A. For the statistical analysis the average times of all the process steps are added for every user group, every process and every one of the ten observation days.

The average time per patient for each group in every scenario can be found in table 2.

Process Specialist Receptionist Secretary Receptionist

plus secretary

In seconds In seconds In seconds In seconds

Per patient Per patient Per patient Per patient

PPF 460,0 137,7 751,0 888,7

EPR 486,5 0 117,3 117,3

Modified EPR 419,6 31,4 847,1 878,5

Table 2: Total amount of seconds per patient for the whole process

The specialist seems to gain some time when the modified EPR is used and the EPR seems to cost more time. The differences are small however, around 5,7 %.

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4.2 Validation

The times for every step of the three scenario’s were added. To validate the total times found two validations were performed, a subjective and an objective. This validation is important because the data form the foundation of the answers to the research questions and its statistical analysis.

The total times found for the receptionist and the secretary regarding the handling of the PPF were checked. Both groups agree with the fact that the total time per patient is a reasonable estimation of the total time spent on the PPF. After the introduction of the modified EPR they experience an increase in their workload that is insufficiently compensated by the significant decrease in workload they also experience from the EPR.

There are three secretaries occupied with the handling of all the PPF’s. This means that there are 600 secretarial working days for the handling of the PPF. This study shows an average handling time by the secretary of 751 seconds for every PPF. Every year 18.000 patients visit the policlinic. The total number of days that the secretary will handle PPF’s using the above data is 470 days (18.000 x 751 sec). Taking into account that a few steps in the process that are the same for all three processes were left out intentionally, the results from the observations in this study are likely to be a representation of reality.

4.3 Statistical Analysis

The resistances against the EPR were derived from the interviews with specialists, secretaries and receptionists as outlined in chapter 3. In this chapter some resistances are tested whether they are realistic (true) or not. Also the financial goals and effects related to the introduction of the EPR and the modified EPR are tested whether they are met or not.

The following resistances that can be measured are tested:

1. Resistance of the specialist that the EPR will cost much more time compared to the PPR.

2. Resistance of the specialist that the EPR will cost much more time compared to the modified EPR.

3. Resistance of the secretaries and receptionists that the time needed for the EPR compared to the PPF is so much lower that some may lose their job.

4. Resistance of the secretaries and receptionists that the time needed for the EPR compared to the modified EPR is so much lower that some may lose their job.

The increase in costs resulting from the decision of the medical staff to not having to change the way the specialist is working at the policlinic after the introduction of the EPR resulting in a modified EPR is calculated and tested.

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The inference about the difference of the two means of 10 days of observations in two of the three scenarios is tested using the two means for independent samples statistic (Keller 2005, 8E: page 439 - 443). In this experiment design the parameter of interest is the mean of the population of 10 observation days and its variance in two scenario’s.

Before testing the hypothesis, the F-test to determine the equality of both variances is performed. The test formula and degrees of freedom are different for equal and unequal variances.

F-test : H0 = σ12/σ22 = 1 H1 = σ12/σ22 ≠ 1

For ν1 = n1 - 1 and ν2 = n2 - 1 degrees of freedom. n1 = n2 = 10 (the number of observed days).

α = 0,0025

rejection region (table 6d : Keller 2005, 8E: page B-18) = F < 0,15 and F > 6,54

test statistic: F = σ12/σ22

T-test for the difference between two means:

Test statistic for equal variances, the following formulae are used :

Figure 1: t-statistic for equal variances (Keller 2005, 8E page 441)

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Figure 2: t-statistic for unequal variances (Keller 2005, 8E page 442)

4.3.1 Time spent on the file by the specialist in the EPR and PPF

The first hypothesis that is tested is the assumption by the specialists that the use of the EPR will cost them significantly more time compared to the PPF. The specialists are afraid that it will cost so much time that they will be unable to treat all patients in the time that is available during the consultation hour. To test this assumption the mean time needed for the specialist per patient on day 1 to 10 in the EPR scenario is tested against the mean time per patient on day 1 to 10 in the PPF scenario using the t-test. The mean specialist file or record handling times per patient for every observation day were obtained from the total times of the steps in the EPR and PPF processes.

H0 : There is no difference between the time spent on the patient record for the specialist between the PPF or EPR scenario.

H1 : The specialist has to spend more time on the patient record in the EPR scenario, compared to the PPF scenario.

Day Mean time per patient Mean time per patient EPR (in seconds) PPF (in seconds) (specialist time) (specialist time)

1 546,4 470,7 2 500,0 447,6 3 441,2 477,8 4 508,3 441,0 5 482,1 508,6 6 500,0 457,0 7 507,7 463,2 8 487,5 435,1 9 444,4 424,5 10 446,5 476,0 N=10 Mean 486,41 460,15 Variance 1146,89 607,04

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Equal sigma F - test

Rejection region, α = 0,0025 F < 0,15 and F > 6,54

test statistic F = 1,89

NOT REJECTED

conclusion equal sigma

F- test for equal sigma

Degrees of Freedom = 18

Rejection region , 18 DF , α = 0,005 t > 2,88

test statistic t = 1,98

NOT REJECTED

Table 4: Sigma and t-test Hypothesis handling times of the EPR and PPF by specialists

The sigma’s of the EPR and PPF data are tested using the F test and found to be statistically equal, the t- test for equal sigma’s was used to test the hypothesis.

The value of the test statistic is t = 1,98 and outside the rejection region of t > 2,88, this means that H0 is not rejected.

The test result shows that there is no evidence to infer that the specialist will spend more time writing in the EPR compared to the PPF. The fear that there will be not enough time to treat all patients due to the transition from the PPF to EPR cannot be confirmed with the results of this test.

4.3.2 Time spent by the specialist on the EPR compared to the modified EPR

The second hypothesis that is tested is the assumption by the specialists that the use of the EPR will cost them significantly more time compared to the proposed modified EPR. The specialists are afraid that it will cost so much time when they use the EPR that they will be unable to treat all patients in the time that is available during the consultation session.

To test this assumption the mean time needed for the specialist per patient on day 1 to 10 in the EPR scenario is tested against the mean time per patient on day 1 to 10 in the modified EPR scenario using the t-test. The mean times per patient for every observation day were obtained from the total times of the steps in the EPR and modified EPR processes.

H0 : There is no difference between the time spent on the patient record for the specialist between the EPR or MOD scenario.

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Day Mean time per patient Mean time per patient EPR (in seconds) MOD (in seconds) (specialist time) (specialist time)

1 546,4 410,8 2 500,0 400,6 3 441,2 441,6 4 508,3 421,0 5 482,1 454,1 6 500,0 395,3 7 507,7 420,2 8 487,5 417,1 9 444,4 400,4 10 446,5 435,7 N=10 Mean 486,41 419,68 Variance 1146,89 371,06

Table 5: Mean specialist handling times of the EPR and MOD per observation day

Equal sigma F - test

Rejection region, α = 0,0025 F < 0,15 and F > 6,54

test statistic F = 3,09

NOT REJECTED

conclusion equal sigma

F- test for equal sigma

Degrees of Freedom = 18

Rejection region , 18 DF , α = 0,005 t > 2,88

test statistic t = 5,41

REJECTED

Table 6: Sigma and t-test Hypothesis handling times of the EPR and MOD by specialists

The sigma’s of the EPR and modified EPR data are tested using the F test and found to be statistically equal, the t- test for equal sigma’s was used to test the hypothesis.

The value of the test statistic is t = 5,41 and inside the rejection region of t > 2,88, this means that H0 is rejected.

There is enough evidence to infer that the specialist will spend more time writing in the EPR compared to the modified EPR.

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4.3.3 Secretarial time needed for the EPR compared to the PPF

The third hypothesis that is tested is the assumption by the secretaries and receptionists that the use of the EPR will cost them significantly less time compared to the PPF. The secretaries and receptionists are afraid that using the EPR will cost so much less time that they will lose their jobs.

To test this assumption the mean time needed for the secretary and receptionist per patient on day 1 to 10 in the EPR scenario is tested against the mean time per patient on day 1 to 10 in the PPF scenario using the t-test. The mean times per patient for every observation day were obtained from the total times of the steps in the EPR and PPF processes.

H0 : There is no difference between the time spent on the patient record for the secretaries and receptionists between the EPR or PPF scenario. H1 : The secretaries and receptionists will spend less time on the patient

record in the EPR scenario, compared to the PPF scenario.

Day Mean time per patient Mean time per patient EPR (in seconds) PPF (in seconds) (secretary/receptionist) (secretary/receptionist) 1 113,6 862,2 2 114,0 893,0 3 124,7 839,4 4 113,9 963,9 5 125,0 905,1 6 115,8 902,4 7 120,0 883,9 8 116,7 867,7 9 114,8 880,5 10 114,4 887,6 Mean 117,29 888,57 Variance 19,42 1088,36

Table 7: Mean secretary/receptionist handling times of the EPR and PPF per observation day

Equal sigma F - test

Rejection region, α = 0,0025 F < 0,15 and F > 6,54

test statistic F = 0,02

REJECTED

conclusion not equal sigma

t- test for not equal sigma

Degrees of Freedom = 9

Rejection region , 9 DF , α = 0,005 t > 3,25

test statistic t = 73,3

REJECTED

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The sigma’s of the EPR and PPF data are tested using the F test and not found to be statistically equal, the t test for unequal sigma’s was used to test the hypothesis.

The value of the test statistic is t = 73,3 and inside the rejection region of t > 3,25 , this means that H0 is rejected.

There is overwhelming evidence to infer that the secretaries and receptionists will spend less time in handling the EPR compared to the handling of the PPF.

There is a risk that the need for secretaries and receptionists will be much lower according to the findings from this test and that jobs are lost.

4.3.4 Secretarial time needed for the PPF compared to the modified EPR

The fourth hypothesis that is tested is the assumption by the secretaries and receptionists that the use of the modified EPR will cost them significantly less time compared to the PPF. The secretaries and receptionists are afraid that it will cost so much less time when they use the modified EPR that they will lose their jobs.

To test this assumption the mean time needed for the secretary and receptionist per patient on day 1 to 10 in the PPF scenario is tested against the mean time per patient on day 1 to 10 in the modified EPR scenario using the t-test. The mean times per patient for every observation day were obtained from the total times of the steps in the PPF and modified EPR processes.

H0 : There is no difference between the time spent on the patient record for the secretaries and receptionists between the modified EPR or PPF scenario.

H1 : The secretaries and receptionists will spend less time on the patient record in the modified EPR scenario, compared to the PPF scenario.

Day Mean time per patient Mean time per patient PPF (in seconds) MOD (in seconds) (secretary/receptionist) (secretary/receptionist) 1 862,2 854,2 2 893,0 871,3 3 839,4 872,5 4 963,9 866,0 5 905,1 879,4 6 902,4 897,2 7 883,9 906,9 8 867,7 891,2 9 880,5 867,1 10 887,6 878,3 Mean 888,57 878,41 Variance 1088,36 253,65

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Equal sigma F - test

Rejection region, α = 0,0025 F < 0,15 and F > 6,54

test statistic F = 4,29

NOT REJECTED

conclusion equal sigma

t- test for equal sigma

Degrees of Freedom = 18

Rejection region , 18 DF , α = 0,005 t > 2,88

test statistic t = 0,88

NOT REJECTED

Table 10: Sigma and t-test Hypothesis handling times of the PPF and MOD by secretaries/receptionists

The sigma’s of the PPF and modified EPR data are tested using the F test and found to be statistically equal, the t- test for equal sigma’s was used to test the hypothesis. The value of the test statistic is t = 0,88 and outside the rejection region of t > 2,88, this means that H0 is not rejected. There is no evidence to infer that the secretaries and receptionists will spend less time in handling the EPR in the modified scenario compared to the handling of the PPF. There is no risk that the need for secretaries and receptionists will be much lower according to the findings from this test if the modified scenario is chosen after introduction of the EPR.

4.3.5 Cost reduction EPR compared to the modified EPR

The fifth hypothesis that is tested is the assumption that financial goals are not met using the modified EPR compared to the EPR.

To test this assumption the mean secretarial costs per day on day 1 to 10 in the PPF scenario is tested against the mean costs per day per patient on day 1 to 10 in the EPR scenario using the t-test. The total costs per day were obtained using the iGrafx simulation program after entering all the times with the standard deviation for all steps of the three scenario’s and after entering the salaries for the receptionists and secretaries.

H0 : There is no difference between the total costs for secretaries and receptionists between the EPR or MOD scenario.

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Day Mean costs per day Mean costs per day EPR (in euro's) PPF (in euro's) (secretary/receptionist) (secretary/receptionist) 1 445,73 59,33 2 331,49 44,15 3 367,58 49,06 4 341,53 45,52 5 403,99 54,00 6 440,33 58,85 7 259,33 34,63 8 336,63 44,86 9 338,59 44,50 10 377,96 50,49 Mean 364,32 48,54 Variance 3136,04 56,48

Table 11: Mean secretarial/receptionist costs in the EPR and PPF scenario per day

Equal sigma F - test

Rejection region, α = 0,0025 F < 0,15 and F > 6,54

test statistic F = 55,5

REJECTED

conclusion not equal sigma

t- test for unequal sigma

Degrees of Freedom = 9

Rejection region , 9 DF , α = 0,005 t > 3,25

test statistic t = 17,7

REJECTED

Table 12: Sigma and t-test Hypothesis costs in the PPF and MOD for secretaries/receptionists

The sigma’s of the EPR and PPF data are tested using the F test and not found to be statistically equal, the t- test for unequal sigma’s was used to test the hypothesis.

The value of the test statistic is t = 17,7 and inside the rejection region of t > 3,25, this means that H0 is rejected.

There is overwhelming evidence to infer that the cost reduction using the EPR compared to the PPF is significant.

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5.

C

onfrontation and Change

In order to check whether the specialist still shows resistance behavior towards the EPR after some other available possibilities are demonstrated, simulated and explained, a small survey is setup. This survey consists of a few statements and questions about their resistances. The specialist has to answer the questions about the statements by grading on a scale of 1 to 10. 1 is minimal resistance and 10 is maximum resistance.

5.1 Survey setup

From the interview results in chapter 3, three statements about resistances are derived: 1. Resistance to typing

This resistance is questioned before and after a demonstration of speech recognition (currently available for the radiologists in the hospital). The following grading questions were asked :

a. Grade from 1 to 10 your resistance towards typing in the EPR situation?

b. If voice recognition and handwriting recognition applications are added to the EPR, would your previous answered number change? Grade again please. 2. Lack of overview

This resistance is questioned before and after a simulation showing a screen where all examination data of a patient are shown with one mouse click in one screen. The following questions were asked:

a. Grade from 1 to 10 your resistance towards handling up examination results in the current situation?

b. If a new function was added, providing an overview in one screen of all examination results (in other words: combining the four screens to one screen and dividing this into four sections) would your previous answered number change? Grade again please.

3. Mobile work place

This resistance is questioned after the installation of EZIS using Cytrix software on an handheld device. The specialists could use the handheld device during a consultation hour. The following questions were asked:

a. Grade from 1 to 10 your resistance towards the system with the current mobility possibilities?

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5.2 Survey results

The survey and simulation is presented to ten specialists, all specialists have answered the survey by grading the statements in the old and in the proposed new situation. Additional information requested by some of the specialists was given. These are the results:

Statement 1: Resistance to typing Statement 2: Lack of overview (a) Grade for the

Old situation

(b) Grade for the Proposed situation 1 3 2 2 4 2 3 8 4 4 9 6 5 6 5 6 8 4 7 9 8 8 2 1 9 7 5 10 4 2

Table 13: Resistance to typing Table 14: Lack of overview

Statement 3: Lack of mobility (a) Grade for the

Old situation

(b) Grade for the Proposed situation 1 3 1 2 4 2 3 6 7 4 5 5 5 6 3 6 4 4 7 4 6 8 3 1 9 5 8 10 4 2

Table 15: Lack of mobility

(a) Grade for the Old situation

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5.3 Statistical analysis

In order to prove whether the resistance has changed significantly after presenting the proposed changes to the EPR, a statistical test is applied to the given results in the tables shown above.

The change in resistance to the various subjects before and after the simulation is tested using the Wilcoxon Signed Rank Sum Test (Keller 2005, E8: page 774). In this test the differences between the paired results are ranked, 0 values are left out of the test. The ranked sum of all positive and negative differences is calculated. The test hypothesis is that there is no difference between the two observations. The alternate hypothesis is either an increase in resistance or a decrease in resistance.

H0 = There is no difference

H1 = There is a positive/negative difference The test statistic is T, the sum of all positive differences. The z value with α =0,025 in a one-tail test is : Z = ± 1,96

For a small number of pairs (< 30) a table with upper and lower critical values is used to establish significance (Keller 2005, E8: page 775 table 19.4)), it can also be calculated.

The z-statistic is calculated using the equation: z = T – E(T)

σT

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5.3.1 Resistance to typing

The change of the intensity of resistance with the specialists to the EPR is calculated by combining the interview results before and after the speech recognition simulation. From 10 specialists data were obtained. The resistance to the EPR was asked to be given on a scale of 10 (0 for no resistance and 10 for maximum resistance).

The hypothesis to be tested using the Wilcoxon Signed Rank Sum Test is :

H0 = The resistance to the EPR does not change after the introduction of speech recognition.

H1 = The resistance to the EPR is lowered by using speech recognition.

Resistance before Resistance after Difference Rank + Rank -

1 3 2 1 2,5 2 4 2 2 6 3 8 4 4 9,5 4 9 6 3 8 5 6 5 1 2,5 6 8 4 4 9,5 7 9 8 1 2,5 8 2 1 1 2,5 9 7 5 2 6 10 4 2 2 6 + - T Sum 0 55

Table 16: Resistance to EPR before and after speech recognition

Z-statistic Wilcoxon SRST T 0 N 10 E(T) 27,5 σT 9,81 Z -2,80 Z (α=0,025, 1 tail) z < -1,96 H0 Rejected

Table 17: Test results

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5.3.2 Lack of overview

The lack of overview regarding different kind of patient data is another source for resistance against the EPR. The resistance is asked on a scale of 0 to 10 before and after a simulation showing a different kind of presentation of patient data. From 10 specialists data were obtained. The resistance to the EPR was asked to be given on a scale of 10 (0 for no resistance and 10 for maximum resistance).

The hypothesis to be tested using the Wilcoxon Signed Rank Sum Test is :

H0 = The resistance to the EPR does not change after offering an alternate way of presenting patient data with more overview.

H1 = The resistance to the EPR is lowered by providing more overview.

Res before Res after Diff Rank + Rank -

1 7 3 4 9 2 7 5 2 6 3 8 6 2 6 4 9 4 5 10 5 6 7 1 2 6 5 4 1 2 7 5 3 2 6 8 3 2 1 2 9 7 5 2 6 10 4 2 2 6 + - T Sum 2 53

Table 18: Resistance to EPR before and after speech recognition

Z-statistic Wilcoxon SRST T 2 N 10 E(T) 27,5 σT 9,81 Z -2,6 Z (α=0,025, 1 tail) z < -1,96 H0 Rejected

Table 19: Test results

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5.3.3 Mobile work place

The lack of a more mobile working environment is another source for resistance against the EPR. The resistance is asked on a scale of 0 to 10 before and after a simulation showing a different kind of presentation of patient data using a handheld device. From 10 specialists data were obtained. The resistance to the EPR was asked to be given on a scale of 10 (0 for no resistance and 10 for maximum resistance).

The hypothesis to be tested using the Wilcoxon Signed Rank Sum Test is:

H0 = The resistance to the EPR does not change after offering a mobile way of presenting patient data using a handheld device.

H1 = The resistance to the EPR is lowered by offering a mobile way of presenting patient data using an a handheld device.

Res before Res after Diff Rank + Rank -

1 3 1 2 4 2 4 2 2 4 3 6 7 1 1 4 5 5 0 5 6 3 3 7,5 6 4 4 0 7 4 6 2 4 8 3 1 2 4 9 5 8 3 7,5 10 4 2 2 4 + - T Sum 12,5 23,5

Table 20: Resistance to EPR before and after speech recognition

Z-statistic Wilcoxon SRST T 12,5 N 8 E(T) 10,5 σT 7,14 Z 0,28 Z (α=0,025, 1 tail) z < -1,96 H0 Not rejected

Table 21: Test results

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6.

Conclusion

The objective of this research is to find the most important resistances to the EPR in the user groups and to simulate a condition or demonstration after which a change in resistance might be measured. The most important and largest effects can help the management of the hospital in setting new goals and priorities regarding the EPR.

The following sub-questions were set :

1. What are the most important current resistances towards the EPR in the different work groups?

2. Does the modified EPR solution cost more than the EPR solution? 3. Does the EPR cost the specialist more time due to typing?

4. Does the administrative burden diminish due to the EPR?

5. Does the administrative burden change due to the modified EPR?

6. Does the resistance to the EPR decrease and does the use increase by presenting: a. Handwriting and speech recognition?

b. Mobile workplaces?

c. A better overview by combining several screens of results? 6.1 Sub-question 1.

What are the most important current resistances towards the EPR in the different work groups?

This sub-question is answered in chapter 3.1.4. There are various resistances to be found in the three working groups. Some of the resistances are against the EPR but during the interviews many resistances seemed to be fueled by the mistakes and insufficient communication the hospital made during and after the implementation of the EPR. The delay creates a chaos at the policlinic that obscures the possible advantages of the EPR. The reduction of small flaws in the EPR software is hindered by the administrative chaos.

The five most important resistances are:

• Resistance to typing by the specialist

• The specialist needs more time during his consultation for every patient

• Lack of overview for the secretary and the specialist

• Lack of mobility for the specialist

• The fear of losing jobs for the secretary and receptionist 6.2 Sub-question 2.

Is the modified EPR solution costing more than the EPR solution?

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The cost reduction for every working day is € 315,80. This is about € 80.000,- for only the policlinic Cardiology per year. With 14 policlinics in the hospital the potential cost reduction can mount well over 1 million euro. It is clear from the results that the hospital organization should avoid allowing specialists to use the modified EPR . The staff should be asked to revoke their decision to allow specialists to work with a modified EPR.

6.3 Sub-question 3.

Does the EPR cost the specialist more time due to typing

The total handling time of the specialist was tested in chapter 4.3.1 for the PPF and the EPR working process. The specialists spends 460,2 seconds per patient in the PPF situation and 486,4 seconds in the EPR situation. This difference was found not o be significant.

There seems to be a small, not significant, increase in handling time for the specialist regarding the use of the EPR. This finding is not consistent with the major resistance found against typing in the EPR. This finding suggests that not the extra time is the problem but the refusal to type. This may either be that the specialist refuses to type or that the specialist never learned to type.

The resistance against typing is the leading motive for the implementation of the modified EPR. The specialist couples this resistance to the fear that using the EPR will cost more time. This is not true. De Tjongerschans should focus on resolving this resistance against typing to be able to eliminate the modified EPR.

6.4 Sub-question 4.

Does the administrative burden diminish due to the EPR

The resistance due to the fear of the administrative workers to lose their job is researched by comparing all the times needed for every step in the old (PPF) and new (EPR) working process. In chapter 4.3.3 the secretarial time needed for the PPF and EPR was compared and tested. For the PPF the secretaries need an average 888,6 seconds of handling time, for the EPR an average handling time of 117,3 seconds. The difference is highly significant. This also answers sub-question 4. The administrative burden is indeed lowered by 83 % after the introduction of a fully implemented EPR.

This justifies the fear and resistance towards the EPR with the secretarial and receptionist groups. Unfortunately this resistance cannot be reduced. One of the main objectives of the introduction of the EPR was to reduce administrative costs. The research shows that this goal can be met. To reduce the resistance with the administrative workers a good social plan could help. If all would know that there would be no forced lay-offs than the resistance would be much lower on this front.

6.5 Sub-question 5

Does the administrative burden change due to the modified EPR?

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will work eventually and that cost reduction targets set by the hospital are met. In chapter 4.3.4 the average secretarial time needed was tested, for the PPF the administrative time is 878,4 seconds and the average time for the modified EPR is 888,6 seconds. The difference is statistically not significant.

This result implies that the cost reduction goals will not be met when all specialists turn to using the modified EPR. It is important for De Tjongerschans to try to turn the specialists from using the modified EPR into using the EPR. Large cost reductions can be achieved as was found with sub-question 2. Although not significant, there is a chance that the costs for using the modified EPR are even higher as the old costs for handling the PPF.

6.6 Sub-question 6

Does the resistance to the EPR decrease and does the use increase by presenting:

• In chapter 5.3.1 the effects on resistance against the EPR was tested when instead of typing the specialist could use speech recognition. The resistance against the EPR was reduced significantly by this action.

• In chapter 5.3.2 the effects on resistance against the EPR was tested when instead of multiple screen switching the patient data were shown in one screen. The resistance against the EPR was reduced significantly by this action

• In chapter 5.3.3 the effects on resistance against the EPR was tested when a mobile workplace was offered using an handheld device. The resistance against the EPR did not significantly change by this action.

Some interventions have the potential to reduce the resistance against the EPR. For an alternative to typing and for a more and faster overview significant improvement can be achieved. It was not tested but is likely that when these conditions are met that the specialist is inclined to use the EPR instead of the modified EPR with all the organizational advantages. This study shows that simple interventions are capable of changing negative attitudes towards the EPR in the direction of a more positive attitude.

6.7 Research question

The main research question can now be answered.

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Suggestions for improvement:

1. Improve the communication and training program surrounding the implementation of the EPR.

2. Create an environment and encourage the staff to revoke their decision to use a modified EPR.

3. Focus on short term gains. The most urgent is the improvement of the resistance against typing, this can be achieved by offering a typing course or by offering speech recognition solutions.

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7.

Limitations and further research proposals

The study was performed while the introduction of the EPR was still in a pilot phase. All the times of the old (PPF) working processes could be measured with a high degree of accuracy. The administrative workers at the policlinic have been working with this old system for more than 10 years and they are very efficient with handling the paper files.

The new EPR environment was just recently introduced. Everyone at the policlinic was still getting used to the new processes. The large delay in the administration processes didn’t help in getting familiar with the new EPR. The fact that some specialists chose to use a modified version of the EPR was an additional hindering factor. The measurements of the process steps for handling the EPR and the modified EPR may change when all the workers are used to working with the EPR, it is anticipated that all process steps will cost less time in the future. De Tjongerschans is recommended to repeat the timing of the steps of the EPR in the future to examine whether there are even more reductions in time realized in the work process.

The specialists are not used to typing and working with a computer system while treating their patients. The resistance against typing is present with many specialists. It is interesting to examine this resistance in the future after the specialists are used to the system and after their typing skills have improved. Some may even be willing to follow a typing course and the effect of that could be a reduction of the resistance. The fact that the specialist has no more work after the consultation hour is finished may even turn the negative feeling regarding the EPR into a positive feeling. This phenomenon was already observed with one of the specialists that tries to adapt to the EPR.

A further limitation to this study is that the psychological effects of resistance and the group processes were not investigated. The simulations however showed that there was a changing perception to the EPR after small interventions. It was not investigated that the psychological factor or the change in work process was the factor that initiated this change in attitude. It is possible that just the fact that something could be done to ease the resistance to the EPR was enough, this subject could be investigated more thoroughly.

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8.

Reference list

Ang, J., and Pavri, F. “A Survey and Critique of the Impacts of Information Technology,” International Journal of Information Management (14:2), 1994, pp. 122-133.

Blumberg, B., Cooper, D.R. & Schindler, P.S. 2008. “Business Research Methods, second European edition”. Maidenhead: McGraw-Hill Education.

Cambridge Dictionary: Resistance

http://dictionary.cambridge.org/dictionary/british/resistance?q=resistance Access date: 15-06-2011

Coetsee, L. D. “A Practical Model for the Management of Resistance to Change: An Analysis of Political Resistance in South Africa,” International Journal of Public Administration, (16:11), 1993, pp. 1815-1858.

Coetsee, L. D. “From Resistance to Commitment,” Public Administration Quarterly (23:2), 1999, pp. 204-222.

DeSanctis, G., and Courtney, J. F. “Toward Friendly User MIS Implementation,” Communications of the ACM (26:10), October 1983, pp. 732-738.

Enns, H. G., Huff, S. L., and Higgins, C. A. “CIO Lateral Influence Behaviors: Gaining Peers' Commitment to Strategic Information Systems,” MIS Quarterly (27:1), March 2003, pp. 155-175.

Gelderman, P., “Hoe wordt de arts zelf beter van een elektronisch patiënten-dossier.” Nederlands Tijdschrift voor Medische Administratie, 2005. 30(april): p. 27.

Gibson, C. F. 2003. “IT-Enabled Business Change: An Approach to Understanding and Managing Risk,” MIS Quarterly Executive (2:2), pp. 104-115.

Kankanhalli, A. and Kim, H.W. “Investigating user resistance to information systems implementation: A status quo bias perspective”. MIS Quarterly (33:3), September 2009, pp. 567 – 582.

Keen, P. G. W. “Information Systems and Organizational Change,” Communications of the ACM (24:1), January 1981, pp. 24-33.

Keller, G. 2005. “Managerial Statistics” Eight Edition, International Student Edition, South-Western Cengage Learning.

Lapointe, L. and Rivard, S. “A multilevel model of resistance to information technology implementation” MIS Quarterly, Sep2005, Vol. 29 Issue 3, pp. 461-491

Markus, M. L. “Power, Politics, and MIS Implementation,” Communications of the ACM (26:6), June 1983, pp. 430-444.

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Appendix A: Timetable

Time for every step in the PPF scenario PPF

process step Mean Standard

deviation RE SE SP In seconds In seconds 1 print schedule 4,6 0,44 X 2 sort schedules 3,6 0,62 X 3 search PPF 72,8 22,47 X

4 present file to spec 29,9 2,69 X

5 write in file 199,9 16,27 X

6 write order 85,4 14,64 X

7 attach order to PPF 16,1 3,42 X

8 attach note 26,8 1,08 X

9 pick up PPF 12,1 0,65 X

10 prepare for polibak 61,0 2,61 X

11 enter polibak 10,2 0,50 X

12 put results in polibak 17,5 1,33 X

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Time for every step in the EPR scenario EPR

process step Mean Standard

deviation RE SE SP In seconds In seconds 5 write in file 288,2 19,22 X 6 write order 61,0 11,09 X 16 dictate letter 137,3 28,39 X 26 type corrections 92,8 4,18 X 27 send letters 24,5 1,61 X

Time for every step in the modified EPR scenario Modified EPR

process step Mean Standard

deviation RE SE SP in seconds in seconds 1 print schedule 4,6 0,44 X 5 write in file 199,9 16,27 X 6 write order 61,0 11,09 X 8 attach note 26,8 1,08 X

10 prepare for polibak 61,0 2,61 X

11 enter polibak 10,2 0,50 X

12 put results in polibak 17,5 1,33 X

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