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Factors that Influence Electronic Health Record

Adoption and Use in Primary Care Practices: A

Three-Country Comparison

Shen Minzhu

Student number: 1660535

University of Groningen

Faculty of Economics and Business

MSc Business Administration Business & ICT

Duindoornstraat 675

06-34123958

lareinesh@hotmail.com

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Abstract

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Table of contents

Abstract ... 2 Table of contents ... 3 Chapter 1: Introduction ... 5 1.1 Introduction ... 5 1.2 Research Method... 6

Chapter 2: Concept of EHR ... 7

2.1 Electronic Health Record ... 7

2.2 EHR system...11

2.3 Potential benefits of EHR use ... 14

2.4 Problems and challenges of EHR... 16

Chapter 3: Literature Review ... 18

3.1 Theoretical background ... 18

3.2 Factors that influence IT adoption and use ... 22

3.3 Factors that influence EHRs adoption and use ... 26

3.4 Theoretical Model ... 28

Chapter 4: Comparison of EHRs Adoption and use in primary care practices in US, UK and Australia ... 29

4.1 EHR Development in the United States ... 29

4.2 EHR Development in the United Kingdom ... 33

4.3 EHR Development in Australia ... 37

4.4 Conclusion ... 40

Chapter 5: Possible Reasons for the Differences ... 42

5.1 System Characteristics ... 42 5.2 Financial issues ... 43 5.3 Government support ... 45 5.4 External facilitates ... 46 5.5 Vendors‘ efforts ... 47 5.6 System-individual Fit ... 47 5.7 System-practices Fit ... 48 5.8 System-task Fit ... 49

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5.10 Stakeholders‘ interests ... 50

5.11 Interpersonal networks ... 50

5.12 Network effect ... 51

5.13 Conclusion ... 51

Chapter 6: Implications and Conclusions ... 54

6.1 Implications concerning barriers facing US ... 54

6.2 Implications concerning barriers facing UK ... 57

6.3 Implications concerning barriers facing Australia ... 58

6.4 Instructive experience ... 59

6.5 Limitations and implications for further research ... 59

6.6 Conclusion remarks... 60

References ... 63

Appendix A ... 71

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CHAPTER 1

INTRODUCTION

1.1 Introduction

It is argued that the use of Electronic Medical Records has the potential to greatly improve quality as well as lower costs of providing ambulatory care by introduce new efficiencies to health care delivery. However, the use and its outcomes didn‘t come up to expectations especially in solo or small group practices. Emergent evidences indicated that not only the adoption rate of EHR was low (Steven et al., 2007) but also many uses of EHR failed to deliver the benefits expected (Jeffrey et al., 2007).

Primary care practices play an essential role in healthcare industry since practitioners of these smaller practices account for a large percent of all outpatient visits (Woodwell et al., 2004) (Thomson, 2002) (Sarah et al., 2002). The use of EHR in these practices would not deliver expected benefits to a large portion of the population until they could remove the barriers concerning financial issues, technical support, privacy issues etc. (Bates, 2005) (Steven, 2007) (Jason et al., 2005) compared with their larger counterparts like hospitals. Moreover if EHR adoption among smaller providers lags behind, the continuity of care will be impaired as patients move from highly computerized inpatient settings to paper-based outpatient settings The objective of this paper is to describe EHR adoption and use within these smaller primary care practices in US, UK and Australia as well as explain reasons for the differences in terms of country comparison. The country comparison is used to take a look at EHR adoption and use in different environment for a more comprehensive understanding of what makes each one unique in its own right while showing the inherent similarities. The three countries: US, UK and Australia are selected for the comparison since 1) they are leading countries in different parts of the world such as America, Europe and Oceania in respect of encouraging health information technology diffusion in health systems; 2) however, the similar great efforts lead to different results in each country; 3) they are different in many other respects including the health system, EHR definition and policy etc.

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theoretical model of this paper is applied for explaining possible reasons, which consist of both barriers and promoting factors, of the differences among the three countries. Finally,

implications are suggested aiming at removing the prohibitive factors and enhancing the promoting ones for both regulators and healthcare providers.

1.2 Research Method

This literature-based paper select research aims to help understand the adoption and use of EHR in smaller practices in the three countries, the literature research approach serves the purpose of description and explanation. In the first place, the phenomenon is described and secondly, the forces causing the phenomenon in question are explained.

The data is acquired through the sources include: 1) Health related organizations and National health institutes (e.g. ICMCC, HIMSS, HHS, department of health of UK, Australian

department of health and ageing); 2) Databases (e.g. PubMed Central, PQDD, Scopus) and search tools (e.g. Scirus, Google Scholar, OPAC, PiCarta); 3) Journals: International Journal for Quality in Health Care, The Journal of the American Medical Association, Health Affairs, International journal of medical informatics etc.

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CHAPTER 2

CONCEPT OF EHR

2.1 Electronic Health Record

It is commonly accepted that EHR refers to electronic health record, an individual patient‘s health record in digital format, which can be supported by EHR system. EHR system enables the storage and access of individual records on a computer, often over a network. Figure 2.1 shows a sample Electronic Health record with image and document links. It includes basic demographic and medication information, as well as history health record and details of previous healthcare providers.

Figure 2.1 Sample Electronic Health Record (Source: Canada Health Infoway)

However, it is still difficult to make EHR definition at international level and few formal ones even at national level. The report ISO/TS 18308 lists seven separate definitions for EHR from different countries and organizations. Many use a wide range of more or less variant terms such as EMR (Electronic Medical Record), EPR (Electronic Patient Record), CPR

(Computerized Patient Record), and EHCR (Electronic Health Care Record) (ISO, 2004). According to the Healthcare Information and Management System Society, the definition of EHR in the US is a ―longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.‖ In addition to store information, it also ―supports other care-related activities directly or indirectly, including evidence-based decision support, quality management and outcomes reporting‖ (HIMSS, 2006).

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of information associated with the outcomes of periodic care held in the EPRs, which are the records about the periodic care provided mainly by one institution. The electronic health record of Britain includes elements shown in Figure 2.2 (Protti, 2002).

Figure 1.2 EHR in Britain (Source: Protti, 2002)

Since it‘s difficult to encapsulate all of the many and varied facets of the EHR in a single comprehensive definition, an effective definitional approach is provided by ISO to make a clear distinction between the content of the EHR and its form or structure (ISO-TR 20514, 2005). The structure of the EHR is defined first as a container, which is called basic-generic EHR. It is then supplemented by a more detailed and specialized definition to cover two of the most essential characteristics of the EHR: ability to share patient health information between authorized users and primary role of EHR in supporting continuing, efficient and quality integrated health care. This approach will only keep an essential minimum number of formal definitions of the EHR types while other important characteristics that depend on scope and context of care will not be explicitly expressed in a single supplementary definition. Figure 2.3 illustrates the specialization of the basic-generic EHR.

Figure 2.3 Specialization of the Basic-Generic EHR (Source: ISO-TR 20514) UML (Unified Modeling Language) diagrams are used here to show

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The basic-generic definition is a repository of information regarding the health status of a subject of care, in computer processable form. Besides, the difference between the

non-shareable EHR and a shareable EHR is similar to the difference between a stand-alone PC and a networked PC. The three levels of shareable EHR are:

1) Level 1 - between different clinical disciplines or other users, all of whom may be using the same application, requiring different or ad hoc organization of EHRs,

2) Level 2 - between different applications at a single EHR node (i.e. at a particular location where the EHR is stored and maintained), and

3) Level 3 - across different EHR nodes (i.e. across different EHR locations and/or different EHR systems).

When level 3 sharing is achieved and the object of the EHR is to support the integrated care of patients across and between health enterprises, it is called an integrated care EHR (ICEHR), which is defined as a repository of information regarding the health status of a subject of care (patient and client) in computer processable form, stored and transmitted securely, and accessible by multiple authorized users. It has a standardized or commonly agreed logical information model which is independent of EHR systems. Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent, and prospective.

This definition is used for defining EHR in Australia according to the notes on ISO-TR 20514 for Australian Public Comment (Schloeffel, 2005). Besides, both definitions of EHR in the US and UK emphasis the term ―longitudinal record‖ and focus on the point that the information is generated and accessed by one or more multiple authorized encounters. Therefore, Integrated Care EHR is being pursued mostly, which is mainly because of the trend towards integrated health delivery through multi-specialty and multi-disciplinary teams to provide health care services regardless time and location. In addition, the integrated shared care can support

treatment of chronic diseases as well as some episodic or periodic conditions, since this kind of treatment needs to be planned and delivered over an extended period of time with the

requirement of the longitudinal record and multi-users included.

Instead of EHR, many other related concepts are being used, some of which could be confusing. The common types of health records are:

a) Electronic medical record (EMR)

The EMR is an element of the EHR, restricted in the scope of the medical domain. b) Electronic patient record (EPR)

It can be considered as part of the EHR, since it focuses on periodic record provided by one institution.

c) Computerized patient record (CPR)

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The term was commonly used in Europe (ENV 13606-1:2000), but is now rapidly being replaced by the term EHR.

e) Electronic client record (ECR)

It is a special case of EHR with the scope defined by the non-medical health professional group.

f) Virtual EHR

It usually refers to an EHR which is assembled ‗on the fly‘ through a process of federation of two or more EHR nodes.

g) Personal health record (PHR)

The difference between PHR and EHR is that PHR can be maintained and controlled by the patient/consumer. It is argued that PHR can have the same record architecture as EHR and still meet all of the patient/consumer requirements.

h) Digital medical record (DMR)

It is web-based record maintained by healthcare providers or health plan and it has the functionality of EHR (Waegemann:2002).

i) Clinical data repository (CDR)

It is recognized as a service-centric ather than patient-centric source system for the EHR (Infoway:2003).

j) Computerized medical record (CMR)

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2.2 EHR system

The use of EHR has to be supported by certain systems. An EHR system is a set of components that form the mechanism by which electronic health records are recorded, stored and retrieved. It includes people, data, rules and procedures, processing and storage devices and

communication and support facilities (ISO/TC 215, 2003). There are three types of EHR systems: Local-EHR system, Shared-EHR system and EHR directory service. The types of EHR they can support are shown in Table 2.1 (ISO-TR 20514, 2005).

Table 2.1 Types of EHR

(Source: ISO-TR 20514)

EHR is encouraged in many countries because of its potential abilities of enabling higher level of efficiency, decreasing costs and improving health care quality etc. These potential abilities are based on the main functions of successfully implemented EHR system. HL7 (Health Level Seven, Inc.) released the EHR System Functional Model draft Standard in 2007 (HL7, 2007), which is from a user perspective with the intent to enable consistent expression of system functionality. In this model, there defined more than 160 functions which are broken into three main sections: Direct care, Supportive, and Information infrastructure. These sections are then divided in a hierarchical manner with ―parent‖ functions and ―children‖ functions, which are shown in Appendix A.1 - Appendix A.7 together with brief summaries:

 Direct care: it addresses functionality related to the care delivery process under three components: DC.1 care management, DC.2 clinical decision support, and DC.3 operations management &communication.

 Supportive: it addresses functionality related to administrative and financial requirements associated with care delivery. It includes support for medical research, public health, and quality improvement. There are three main components: S.1 Clinical Support, S.2

Measurement, Analysis, Research, and S.3 Administrative and Financial.

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These functionalities are defined with the intention to support following function and workflow of primary care practices (HL7, 2007):

1) Tracking

Part of Care Management, Administration & Financial, and Clinical Support can track patient physical location through all phases of visit, from pre-arrival through disposition by means of manually data entry or radio-frequency ID (RFID) or other technologies. This information is useful for patients‘ arrangements making in the practices. Besides, the time the patient entered treatment area can also be automatically captured for further analysis. The tracking of status of care is covered in Clinical Workflow Tracking and Task Management.

2) Registration

Patient arrival and registration are relatively complex and time-sensitive tasks involving data capture of both clinical and administrative data. Part of Care Management and Clinical Support can assist in managing patient before formal registration has occurred by automatically merging administrative data with the unique patient record through quick identification of a single patient ID to timely generate account or billing number to facilitate interoperability with other systems. Besides, system also enables quick registration with only minimal amount of data entered, so that some clinicians can order some procedures on the patient before formal registration, which is necessary under emergency.

3) Clinical Workflow and Task Management

Operations Management and Communication is used for management and display of various tasks to be accomplished, which include orders, consultations, clinical tasks such as

transportation to radiology, and flags for patient follow-up, etc. The systems should be extensible enough to accommodate the complexity of clinical task routing according to local needs by linking every clinical task to a particular patient and resource. They then display those tasks which have been ordered or initiated, but have not been completed, as well as display and notify providers about tasks which have returned results that are awaiting review.

4) Orders

Clinical Decision Support and Care Management provide means to order laboratory, radiology, medications, nursing tasks, and materials management. Orders are a unique subset of clinical tasks that possess certain qualities. The system can ensure orders being highly specific and customizable by personnel role, physical location, and patient-specific factors. The system should also be sufficiently extensible to support institutional variations and preferences. 5) Clinical Documentation

Measurement, Analysis, Research and Report, and Operations Management and

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observations and medical decision making. This information re-use also enables the management of inter-practitioner discrepancies, which can be of severe medical and medical-legal consequence, allowing providers to agree, comment, update, or annotate information gleaned at different points during the encounter.

6) Public health

Clinical Decision Support functionality can find health risks within the population by

monitoring aggregate data of health. Therefore, it offered the possibility to provide preventive care services to public before wide spread of certain diseases.

7) Managing Record Completion

Record completion is essential and time-consuming. Measurement, Analysis, Research and Report supports the process of authorship (one or more providers may need to document at the same time), signature, authentication, completion and addendum of records. The system can display patient records needing attention or completion as well as enable creation of

addendums to documents that have already been signed and hence cannot be changed. It also allows for completion of the encounter record in a discontinuous sequence, but to retain particular formatting. This point is important since documentation is often accomplished in fragments and outside of sequencing.

8) Post-Disposition Management

Numerous tasks may exist after the completion of patient care and disposition. Clinical Decision Support and Clinical Support, and Care Management help to to track all flavors of outstanding patient issues after the visit is completed, so that providers can arrange follow-up care. In addition, the system can track patients requiring administrative action after discharge. Furthermore, the system also provides a means to reconcile preliminary diagnostic test results with the final interpretations of the services requested. Therefore, the quality of healthcare is further improved.

All of the functions are supported by Administration and Financial as well as Information Infrastructure.

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2.3 Potential benefits of EHR use

The believed potential benefits of EHR usage can be related to Potential productivity and Financial Improvement, and Quality of care improvement.

2.3.1 Potential productivity and Financial Improvement 1) Improved billing accuracy

Billing is an essential and also tedious task if the electronic format of the records is not compatible with the billing program, or when the records are in paper format. Therefore, the integration of electronic medical record and billing system is needed to expedite and makes billing more accurate.

2) Improved operational efficiency

Efficiency of handling telephone messages and medication refills can be improved by reducing errors in handwriting (PÉ REZ-PEÑ A, 2004), improving coding and charge capture, eliminating lost orders, and reducing the time to fill orders (Babbitt,2003); Promote nurses‘ work efficiency through accurate documentation (Sublett, 2002); Patients‘ information can be accessed more easily compared with using paper record, which can results in more efficient health care. 3) Efficiency-related savings or revenue gains

The use of EHR is expected to reduce or eliminate transcription and paper supply costs (McColm et al., 2005), to reduce office visits with telecommunication between physician and patients (Liederman et al, 2003), to inform providers about cost-saving options (Tierney et al, 1990), revenue enhancement from higher payment for increased levels of coding and increased visits due to reduced provider time per visit (Robert, 2005),

2.3.2 Quality of care improvement

It is asserted that the use of EHR may lead to higher level of health care quality (Bates, 2005), increase use of immunizations and other appropriate preventive services (Shea et al., 1996), and improve chronic disease management and coordination of care (Burton et al., 2004). Other potential benefits could be:

1) Reduction in duplication of services

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2) Provides secure, reliable, real-time access to patient health record information where and when it is needed to support care

With many tools including access audit trails, the patient health information confidentiality and security can be better guaranteed compared with the use of a paper record. Besides, EHR is expected to be accessible 24/7 wherever needed (inpatient and ambulatory care sites, remote access) to provide integrated health care.

3) Facilitation of clinical trials

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2.4 Problems and challenges of EHR

The following problems need to be addressed before EHR can be further deployed with gains of potential benefits: financial risks, privacy and security issues, lack of interoperability, legal barriers, difficulty of transforming from paper-record to electronic ones, as well as human and organizational issues.

First of all, before adoption decisions can be made, the high costs of EHRs and lack of

interoperability could be problems for practices. The steep price of EHR systems and the high maintenance costs, together with the uncertainty of return on investment are obstacles for EHR deployment (Blumenthal et al.. 2006). Blumenthal et al. also found that productivity was

decreased and staff was increased due to EHR use, which can offset gains in efficiency. In other words, physicians have to take the heavy financial burdens including excessive costs of

purchase and maintenance of the systems, as well as fees of training for staff without definite financial incentives in return. In this case, many are resistant to invest in a system whose returns they are not confident with (HIMSS, 2005). Lack of interoperability of EHR systems remains a problem in US, according to Njuki (2005) and Blumenthal et al. (2006). Many small vendors together with their diverse systems cause the lack of product interoperability. This could leads to users‘ problem as lack of compatibility of the EHR product with existing systems and infrastructure. In this case, physicians can hardly make choice from vast vendors or even make adoption decisions.

Privacy and security concerns of EHR use is a big challenge. The information of records exchanged over the Internet is under much risk than paper ones because of much easier access from more stakeholders including all the health providers involved in the care, patients

themselves, insurance companies, and other unauthorized visitors. These electronic versions would be much convenient to store, copy and exchange, which increases the risks of privacy violation and data disclosure. Therefore, regulations and advanced technologies are required to protect patients‘ privacy record from abusing by authorized parties as well as from

unauthorized access (Dick et al., 1997).

In addition, although there are several methods such as scan the documents and optical

character recognition aiming at incorporating older paper medical records into electronic ones, physicians are less satisfied with the accuracy of results (Læ rum et al., 2003). After conversion of paper records or creation of electronic records, there will be concerns about preservation and storage or these records. The challenges are to ensure longitudinal and integrated use across sites of care as well as to ensure the future accessibility and compatibility of archived data with future systems. Possible solutions to the challenges could be standardizing information in a time-invariant way like with XML (Olhede and Peterson, 2000).

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CHAPTER 3

LITERATURE REVIEW

3.1 Theoretical background

Prior research covers most aspects of EHR development through the phases of adoption, implementation, and evaluation. Many of them are related to human, organizational and political issues except the ones on EHR technical design and development.

Literature on EHR adoption mainly conducts surveys on adoption rates, explores determinants of adoption and gives out recommendations accordingly. The majority of this kind of research focuses on practices in US, since EHR development is still in the phase of adoption there. The common finding is that adoption rates among smaller practices are much lower than those of larger ones (Simon et al., 2007) (Jha et al., 2006) (Gans et al., 2005) (Miller et al., 2005). According to the study of Jha et al. (2006), the overall adoption rates in US is low (24%) with those of smaller practices much lower than those of hospitals.

Various reasons and recommendations are provided from practice characteristics to policy issues. Simon et al. (2007) examine the survey data and find that adoption rates are lower in smaller practices, especially those not affiliated with hospitals, or those that do not teach medical students or residents. The explanation could be that these smaller practices not only lack of financial support but also require additional assistance to remove cultural and

technological barriers to adoption. This explanation is consistent with the findings of Lee et al. (2005), Gans et al. (2005) and Miller et al.(2005). According to Gans et al., the adoption of EHRs was progressing slowly, at least in smaller practices because of the complex and varied process of choosing and implementing an EHR, while Lee et al. (2005) emphasized the importance of workflow redesign and resources reallocation in successful EHR adoption in small practices.

Similarly, Miller et al. (2005) suggested that adoption rate for smaller practices are lower because they found difficulty in obtaining adequate training and changing practice processes to adapt to EHR capabilities. Moreover, they also found limited use of EHR quality-improving capabilities and measurement of physicians‘ performance. These points lead to the

recommendation of providing better technical and practice redesign support services, and the need for pay-for-performance incentives for quality improvement. Bates (2005) concludes external and internal reasons from prior studies including technical barriers, reimbursement, lack of interoperability, capital and risk tolerance, resistance and fears from physicians, system maintenance, and barriers related to vendors, among which the current reimbursement system is considered to be the biggest barrier. Likely, Kaushal et al. (2005) also put emphasis on financial issues. They argue that financial, personnel, and technical constraints can cause smaller

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In addition, Middleton et al. (2004) explores the reasons from another perspective. They argued that low EHR adoption rate was due to a fundamental failure of the healthcare IT marketplace, which was because of a misalignment of incentives, limited purchasing power among providers, variability in the viability of EHR products and companies, and limited demonstrated value of EHRs in practice. Possible recommendations include financial incentives, promotion of EHR standards, enabling policy, and educational, marketing, and supporting activities for both the provider community and healthcare consumers.

Besides literature on EHR adoption in primary care practices, there are also studies on other small practices. For example, Kemper et al. (2006) study the EHR adoption in pediatric practices and found that smaller and independent practices could hardly get access to the electronic records although they were the most common types of practice. This was mainly because of the huge expenses of systems, lack of standards for interoperability, and lack of decision support. Bates et al. (2004)concludes various reasons for the low adoption and diffusion rates for both inpatient and outpatient EHRs including resistance to workflow

redesign, financial and safety concerns, technical issues, and organizational culture. Therefore, they recommend that it is important to provide communications, education, and incentives for both physicians and patients.

When adoption decision was made, the following concerns would be on implementation. Literature on EHR implementation mainly draws lessons from implementation process they observed and makes recommendations on how to achieve success. Cooper (2003) studied the process of EHR implementation in a small practice and concluded its ingredients for success as the workflow was minimally reengineered; the EHR was incorporated into the business

processes; staff‘s commitment; the benefits were quickly recognized; EHR was utilized in new ways; and vendor‘s support. In addition to workflow redesign and change management, Baron et al. (2005) elaborated Cooper‘s recommendations with more issues that may promote

successful implementation such as financing; interoperability, standardization, and connectivity of clinical IS; technical support and training.

Moreover, Adler (2007) draws conclusion from previous findings that EHR implementation would have a better chance for success if it was organized into three categories: Team; Tactics; and Technology. Kenneth recommends that everyone should be involved in the implementation team with an identified champion as the critical role. The team needs to be open-minded about the change management and be given realistic goals. When it comes to tactics, spend as much time as possible on planning. It is also essential to redesign workflow; make balanced and consistent strategy for scanning paper charts and data entry; identify essential EHR interfaces and functions; and provide continued training. Besides the people issues, technological ones could also cripple an implementation. Therefore, it‘s important to ensure excellent

infrastructure and network; get IT support and maintenance ready.

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The perceived benefits of EHR use are reported in terms of financial benefits and practice activities‘ improvements etc. Robert et al. (2005) evaluate EHR system‘s financial influence on primary care practices and found it‘s plausible that quite many practices can gain financial benefit such as quickly cost cover and handsome profit after that. However, some practices could not cover costs quickly and even suffered from financial risks. Besides, Gans et al. (2005) evaluates EHRs use in several practices, which believed to have made some contributions to the practices such as improved access to medical record information; improved workflow; and other features in the direct care of the patient. In addition, Moody et al. (2004) make evaluation of EHRs use from nurses‘ perspective. According to them, more than one third of the nurses perceived that EHRs had resulted in a decreased workload, while the majority of nurses thought EHRs had improved the quality of documentation; improved safety and patient care.

Despite the benefits, other research also suggests concerns regarding quality of EHR use and even unexpected results from its use. When evaluate EHRs use among primary care practices, Menachemi et al. (2007) indicate their concerns about the quality of EHR use since they found EHRs used by recent adopters appear to be missing key patient safety and cost control

functions compared with early adopters, which shows the possible lower quality of EHR use and diffusion rate than published. In addition to lower quality of EHR use, many authors report the unsatisfactory results from EHR use. Ventres et al. (2006) explore the effect of EHRs use on physician-patient encounters. They found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter with both intended and unintended consequences, and moreover, the effects of EHRs may not be automatically and universally positive. Baron et al.(2007) report the unexpected influences of their use of EHRs. According to them, there was no clearly positive financial impact; their existing workflows were substantially disrupted; and staff, physicians, as well as patients were disturbed initially. However, they found this technology enabled them to better meet patient expectations; simplified tedious work processes; and created new ways of improving healthcare quality.

Even worse, some studies found no effects or negative results from EHR use. According to assessment of Linder et al. (2007) on the association between EHR use and the quality of ambulatory care in a nationally representative survey, only to find that EHRs has little association with better quality ambulatory care. The possible reasons for this finding include lacking clinical decision support function in EHRs, and lacking focus on quality improvement; or insufficient use of decision support function; and the gaps between studies‘ outcomes and real-world results. Moreover, Sidorov (2006) concludes some negative evaluations of EHRs use such as even higher billings, decreased office productivity, inconsistent quality

improvement like error reduction, and lack of linkage between performance and premiums. It is then argued that EHR should be viewed more as an inconsistent means of transformation , which needs the support of initiatives such as patient-centeredness, shared decision making, teaming, open access, chronic care model and outcome responsibility.

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Architecture is essential in EHR development, which is also discussed by many authors. Blobel (2006) suggested that the underlying EHR architecture must be based on the component

paradigm and model driven, component-oriented to ensure the future-proof EHR architecture could be open, user-centric, user-friendly, flexible, scalable and portable. Katehakis et al. (2001) presented the architecture of distributed EHR segments maintained by IS in a regional

health-telematics network that enable autonomous facilities to operate in a cooperative working environment.

Besides the architecture, other elements of EHR are also addressed in order to enable sharing and exchanging information with EHR. The paper of Watzlaf et al. (2004) addresses the

development and use of standard data elements and data content recommended in the American Society for Testing and Materials in the EHR to achieve information sharing and exchanging. On the basis of converging format standards for electronic health data, Humphreys (2000) presented technical issues that enable EHR to be linked to the digital library to achieve the long-standing informatics goal of seamless integration of automated clinical data and relevant knowledge-based information to support informed decisions.

Other research on EHR technology mainly focuses on hardware and software design. For example, Muñoz et al. (2006) present an EHR server designed and developed as a

proof-of-concept of the revised European standard concerning EHR communications. It could perform as a middleware service in a platform for the out-of-hospital follow-up and monitoring of patients with chronic heart disease.In addition, Schramm and Weber (2001) provide a software framework concerning standardized data management, fast integration in the current clinical situation as well as data sources by utilizing subsystems.

Finally, there are country-comparison studies giving out general lessons by comparing

differences across countries. Detmer et al. (2006) identify EHR experiences in several countries and conclude that the underlying cultural differences could explain the slower EHR

development in US. Besides, common focuses are also identified such as the need to improve quality and safety of systems; the need for robust information infrastructures; and the

importance of patient-centric systems. In another research, Schade et al. (2006) identify features of EHRs perceived as having high value to practices in UK that might also broaden adoption in US. These features include the use of electronic prescribing; improved quality and consistency of care; improved efficiencies and revenue; and potential shielding from

malpractice claims. They suggest that if physicians in US can focus on these features, there‘re chances to motivate broad adoption there.

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3.2 The likely factors that influence IT adoption and use

The relative literature on influencing factors can be categorized into IT adoption focus; IT continued use emphasis and comprehensive studies.

As the precondition of IT use, it is argued that determinants of IT adoption may be different from those of IT use since the use of a certain product can change user‘s perceptions, attitudes, and needs of that product (Tornatzky et al. 1983) (Cummings and Venkatesan, 1976). Therefore, some research was developed to explain the difference between factors influencing IT adoption and factors affecting IT continued use. According to Cooper and Zmud, the factors that affect adoption is more ―rational‖ such as task-technology fit and determinants that influence later implementation stages like infusion are more socio-political and ―learning‖ such as self-interest (Cooper and Zmud, 1990). Thus, literature on factors that affect adoption mostly is reviewed followed by the review of studies on IT use only. These determinants are also categorized into external and internal ones. Other comprehensive studies indicate factors considered to be influential in both phases of adoption and use.

3.2.1 Literature concerning IT adoption

The Diffusion of Innovation Theory (DOI) focuses on the innovation characteristics that can affect adoption of innovations: relative advantage, compatibility, trialability, observability and complexity (Rogers, 1995). Moore and Benbasat expanded upon the five factors, in an IS context, generating eight factors: voluntariness, relative advantage, compatibility, image, ease of use, result demonstrability, visibility and trialability that impact the adoption of IT (Moore and Benbasat 1991). The descriptions of these characteristics are listed in Table 3.1 and Table 3.2.

Table 3.2 System characteristics

(Source: Moore and Benbassat, 1991)

Table 3.1 System characteristics

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Later research consistently applies and adapts DOI in numerous ways finding that technical compatibility, technical complexity, and relative advantage are important antecedents to the adoption of the information technology (Tornatzky and Klein, 1982) (Bradford and Florin, 2003) (Agarval and prasad, 1998) (Cooper and Zmud, 1990) (Crum et al., 1996), which is called IS diffusion variance model shown in Figure 3.1. This model shares the same point with TAM model in terms of ease of use and perceived usefulness.

Figure 3.1 IS diffusion variance model

In addition to system attributes, IT adoption is also influenced by social effect. Elena et al. study found that potential adopter intention to adopt is solely determined by normative pressures, whereas user intention is solely determined by attitude (Elena et al. 1999). They argue that interaction with social network may influence IT adoption decision via informational influence and normative influence, which can reduce the risk and uncertainty with effective source of evaluative information and strong evidence indicating the legitimacy and

appropriateness of the adoption decision (Elena et al,1999). It is also suggested that for

potential adopters, the top management support and interpersonal networks such as friends are important for adoption decisions. In addition, the study found trialability also an important promoting factor for adoption decision with reduced uncertainty and risks.

Besides, others found that external stakeholders play an important role in decision making in adopting innovation or IT as well. Dos Santos and Peffers found that the success of innovation diffusion will depend upon the introduction of similar applications by competitors and the efforts of technology vendors. Vendors‘ influence was important to speed adoption in the first few years after introduction, and after that, competitor influence appears to be more important to firms still considering adoption (Dos Santos and Peffers, 1998).

3.2.2 Literature concerning IT use

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predictor of adoption or continued use behavior. Some literatures study these intentions at individual level with most of them focusing on end users‘ beliefs and attitudes (Davis, 1989) (Mathieson, 1991) (Taylor and Todd, 1995) (Moore and Benbasat, 1996). These papers have enhanced the understanding of determinants of initial usage and continued usage by examining the influence of two innovation attributes, perceived usefulness and perceived ease of use on technology acceptance outcomes. Among them, the most famous one is the Technology

Acceptance Model (TAM) developed by Davis (Davis, 1989), which examines the relationship between user‘s attitude to the system and the use of the system. The attitude includes the perceptions about the usefulness and ease of use of the system. According to Davis, although both of perceived usefulness and ease of use can influence usage, the usefulness-usage relationship is stronger. Besides, the perceived usefulness is also prominent for adoption driving. The study also emphasizes the importance of system design features as external stimulus that can influence the actual system use.

Moreover, according to Theory of Reasoned Action (TRA), the behavioral intention is

determined by two basic factors: not only personal interests but also social influence (Fishbein and Ajzen, 1975, 1980). Therefore, other literature put emphasis on the effects of social as well as work related factors on continued usage of IT. Elena et al. included social influence into the study of IT diffusion in addition to personal influence (Elena et al., 1999). They argued that as for users, the opinion or behavior of peers from work net and formal change agents like computer experts may influence their decisions of continued usage.

As further complement to previous theories, Ammenwerth et al. (2006) present the framework of fit between the attributes of the users (e.g. computer anxiety, motivation), of the attributes of the technology (e.g. usability, functionality, performance), and of the attributes of the tasks and processes (e.g. organization, task complexity), which is called FITT framework, as shown in Figure 3.2 (Ammenwerth et al., 2006). According to them, the fit between the attributes is more important than the attributes themselves, especially the fit between user and task, since the problems may come from a more fundamental ill-acceptance of the new task to be done.

Figure 3.2 FITT framework

Research in the third category considers the IT adoption and use as one process and examines various determinants of this process comprehensively. Some research is conducted at various levels instead of user‘s level alone. In a comprehensive paper, an integrated model is presented by Frambach and Schillewaert, which addresses both direct and indirect effects of the

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factors influencing organizational adoption decision while Figure 3.4 shows the factors that affect individual acceptance and continued use after the adoption. Similarly, Liette Lapointe et al. also listed in their study the adoption and resistance factors at three levels in terms of participation, perceived benefits at individual level and divergent interests at group level, specific characteristics, external support, competition, and availability of resources, at organizational and environmental level (Liette Lapointe et al., 2002)

Figure 3.3 Conceptual framework of organizational innovation adoption

Figure 3.4 Conceptual framework of individual innovation acceptance in organizations

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3.3 Literature concerning EHRs adoption and use

Other studies focus on EHRs adoption and use particularly in terms of external and internal factors.

3.3.1 Literature concerning EHRs adoption

In addition to the general factors stated previously, some internal and external determinants are considered to be especially important for EHR adoption and use. In the research conducted by Bates, it is shown that financial issues could be the single most important issue influencing EHR adoption (Bates, 2005). Similarly, Miller et al. suggested that the Physicians‘ EHR

adoption is slowed by a reimbursement system that rewards the volume of services more than it does their quality and the financial incentives for potential adopters are required (Miller et al., 2005). Besides the financial issues, other internal determinants that influence the adoption rates could be the specific characteristics of a practice (Simon et al., 2007).

Despite these internal factors, external determinants are also found could influence EHR adoption. However, after apply technology diffusion theory to estimate future EHR adoption trends and time lines in small practices, Ford et al. suggested that the external influence factors appear to be less powerful for accelerating diffusion than the internal ones including adoption risk associated with vendor volatility, monetary costs, negative effect on workflows, and physicians‘ internal social networks (Ford et al., 2006).

3.3.2 Literature concerning EHRs use

The determinants of EHR use are different from that of EHR adoption, which are more related to system performance in work support and the capability of using the system. Office workflow requires close attention before the practice settings especially smaller ones can achieve

successful adoption of HIT products and services (Lee et al., 2005). If physicians felt the system cannot support their daily workflow effectively (i.e. reduce their face to face

communication with patients), they would hardly willing to use EHRs. Menachemi et al. also found that the less tolerance of uncertainty and less technical knowledge regarding the innovation are the reasons for not using EHRs or only using certain critical functionalities of EHRs (Menachemi et al., 2007). Therefore, the possible influences of user training on the quality of EHR use is stressed by Evelyn Hovenga‘s study (Hovenga et al.,2005). These

determinants reflect the requirements for ease of use and perceived usefulness during the use of EHR for physicians to make decisions of continued use.

Some studies categorized various factors throughout the process of EHR adoption and use comprehensively (Ash and Bates, 2005) (Boonstra, 2003). According to Ash and Bates, the adoption and use rates for both inpatient and outpatient EHRs are affected by a myriad of factors, which tended to be environmental, organizational, personal, and technical (Ash and Bates, 2005). Environmental trends concern mainly financial and safety issues while

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Likely, Boonstra in his study about the acceptance of Electronic Prescription System

(functionality of EHRs) makes categories of system extrinsic factors, which include process factors, cultural factors, financial factors and environmental factors (Boonstra, 2003). Process factors concern how well the system can support the process where it is aimed to be used. Cultural factors relate to the influence of system adoption on job satisfaction, social status and reputation of the user and fit with values and norms of the user. Environmental factors are related with users‘ opinions about the wider objectives of the system.

3.4 Theoretical Model

The theoretical model used in this paper shown in Figure 3.5 is based on previous literature. Various factors and their influences on adoption and use are presented in this model. They have different influences on adopters and users. Users are intended to be affected by social factors while adopters are more likely to be encouraged or prevented by rational factors.

Stakeholders’ interest

Work flow Privacy and security issues

Rational adopters Social-political users System-practice Fit++ Practices’ characteristics: Size+/- Culture+/-External facilitates: Training+ Availability of resources+/-Network effects System-task fit++ Interpersonal network: Peers+/- Patients+/-Government support: Legitimate support+ Deployment strategy++ Vendors’ efforts: Targeting+ Risk reduction+ Individual characteristics: IT experience + Norms and

value+/- System-individual Fit Job satisfaction+/-Social status+/- Reputation+/-Ease of use+/-Perceived usefulness+/-System characteristics: Voluntariness+/-Compatibility+ Relative advantage+ Observability+ TrIalability+ Complexity-Financial issues: Startup capital--Expected

ROI++/--Figure 3.5 Theoretical Model

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with the number of users. In return, potential adopters are then more likely to be attracted by these increasing benefits, which could lead to a virtuous circle.

System-practice fit, vendors‘ efforts, financial issues, and stakeholders‘ interest are factors that have affect on potential adopters only, while privacy and secure, external facilitates, workflow, and system-individual fit have influence on users only. Similar to system-task fit, the fit of system-practice, and system-individual focus on their interaction instead of the attributes alone. Stakeholders refer to patients, healthcare providers, and vendors, whose interests are different and sometimes even contrary to each other, which could cause failure in EHR adoption and implementation. External facilitates consist of Training and Availability of resources, both of which can reduce the risks and improve the quality of EHR use.

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CHAPTER 4

COMPARISON OF EHRs ADOPTION AND USE IN PRIMARY

CARE PRACTICES IN US, UK AND AUSTRALIA

4.1 EHR Development in the United States

4.1.1 National initiatives of EHR in US

A survey conducted by Schoen et al. (2004) showed that only 13 percent of solo practitioners and 57 percent of physicians who practiced in groups of fifty or more ―used occasionally‖ the EHRs in 2003. In 2004, President Bush outlined a 10-year plan to establish a national

electronic health record system and doubled funding in 2005 to$100 million for demonstration projects on healthcare information technology. The Office of the National Coordinator for Health Information Technology (ONCHIT) was established to promote this plan. This office relied on miscellaneous funds directed from the Agency for Healthcare Research and Quality to operate in 2004 and 2005. At the beginning to 2006, a bill of$125 million was authorized in 2006,$155 million in 2007 and ―such sums as necessary‖ for 2008 through 2010.

Until now, the emphasis has been put on providing a better environment for EHR adoption in the United States. After the announcement of Health IT Adoption Initiative, the US department of health & human services (HHS) announced the contracts to develop prototypes for the Nationwide Health Information Network (NHIN) architecture. In 2006, it also announced that 22 states and territories entered subcontracts with RIT International Inc. to address privacy and security policy questions affecting interoperable health information exchange (HIE). To

accelerate the adoption, the US health department also provided a new opportunity for various state-level decision makers to collaborate in their efforts to address challenges in state-level interoperable health information exchange also in 2006. Besides, the American Health Information Community (AHIC) developed Emergency Responder Electronic Health Record Final Detailed Use Case with respect to emergency response activities, network information systems, and use of health data by non-care provider entities (HHS, 2006). Also, standards acceleration and identification and endorsement of a select set of standards for use in federal programs are underway (Health & Human Services, 2006).

Later, in 2007, the Health & Human Services planned to develop an efficient, credible

certification process with the program called CCHIT, as well as another project to enhance data quality in EHRs including the development of model anti-fraud requirements for EHRs in 2007. At the same time, it announced a five-year demonstration project to encourage small to

medium-sized physician practices to adopt EHRs. After that, a EHR implementation initiative was proposed which will take place in the context of Health Resources & Services

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Recently, a new federal health IT strategic plan is released for 2008-2012 (ONCHIT, 2008). The plan has two main goals: 1) Patient-focused Health Care; and 2) population health. Under each of the two goals, there are four objectives addressing privacy and security, interoperability, adoption, and collaborative governance respectively. It focuses on using health IT to aid direct care to patients, as well as population health, which addresses efforts to improve public health, planning for large-scale emergency health events, and biomedical research.

4.1.2 Main EHR system functionality being used in US

Two kinds of adoption of EHR systems are defined, which are fully adoption which is defined based on the Institute of Medicine framework and minimal adoption which is based on a set of functionalities used in 2005-2006 to encompass a minimum set of functionalities. The minimal adoption defines essential EHR systems and their functionalities using in US. The main

systems are Health information and data, Order Entry Management, and Results management with main functionalities including Clinical notes, Computerized orders for prescription, Computerized orders for labs, Computerized orders for Radiology, Viewing lab results, and Viewing lab results. Other systems and functionalities of fully adoption are shown in Table 4.1.

Table 4.1 Functionalities of EHR systems defined in the United States

Functional EHR Min Functional EHR Min Functional EHR Min

Health information and data Order Entry Management Results management

Patient demographic information Computerized orders for prescription Viewing lab results

Patient problem lists Computerized orders for labs ○ Viewing imaging results ○ Patient medication lists Computerized orders for Radiology ○ Electronic images are returned Clinical notes ○ Orders sent electronically for prescriptions Decision Support

Notes include medical history and follow up notes

Orders sent electronically for labs

Warnings of drug interactions or contraindications are returned

Electronic communication and connectivity

Orders sent electronically for radiology

Out of range lab levels are highlighted

Patient support Administrative processes

Reminders for guideline-based interventions and screenings

Reporting and population ahealth management

(Source: Institute of Medicine framework 2005-2006)

4.1.3 EHR adoption and use rate in US

Despite the efforts made by US government, survey showed slow progress toward Bush‘s 2014 goal in the following years. According to a survey (Gans et al., 2005) conducted by the Medical Group Management Association (MGMA) Center for Research and the University Of

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and at all practice locations. Only 12.5 percent of medical group practices with five or fewer physicians (defined as small practice) have adopted an EHR and the adoption rate increased with the size of practice. Moreover, 47.8 percent of practices with 5 or fewer physicians have no immediate plans for EHR adoption.

Although there was an increase of EHR infusion rate in 2006 the rate of full adoption was decreased. The adoption rate for all medical group practices was 24.9 percent, much higher than that of the previous year, but the adoption rate of full EHR was only 8.9%. Besides, the number of small practices that use EHR ranges from 16 percent to 24 percent of total number, which was much lower than the 39% of large practices (Blumenthal et al., 2006).

According to Department of Health & Human Services, in 2007, the EHR adoption rate among physicians increased to 41%, among which about 20% said that their practices still work with part paper and part electronic. Only 4 percent claim that they are using fully functional EHR, and only 14 percent are using minimally functional EHR. There is an increase of adoption rate for small practices with the figure of 27 percent. But most of them only use certain functions like prescription orders, lab orders and viewing, radiology tests and results viewing, and clinical notes.

4.1.4 Benefits perceived from EHR usage in US

Although adoption rate is low, the practices which overcame difficulties and successfully adopted EHR are reaping various benefits reportedly in US.

Miller et al. (Miller et al., 2005) found in their case study that a typical primary care physician in a solo or small group practice could generate the average gains, approximately $33,000 each year, in each financial benefit category by increasing coding levels for approximately 15 percent of visits, eliminating 0.25 of an FTE medical records staffer, eliminating transcription, and having 1 percent more patient visits.

In another study focusing on EHR use impact on practice operation, it is suggested that there are practice-perceived benefits in improving documentation completeness, access to patient records, office productivity, more confidential and secure. It also reported improved quality of care, reduced risk of medical errors and result in long-term savings (Kemper et al., 2006). 4.1.5 Main problems facing US

However, there is a long journey ahead before US could achieve the goal of nationwide healthcare information technology use.

First of all, the lower adoption rate in the United States compared with that of other

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Besides the lagging behind in EHR adoption, there are also concerns of incomplete adoption. It is suggested that some key EHR systems attributes which have been linked to improved patient safety and averted costs were not widely adopted among the physicians claimed to be using EHR in their practices. This incompletion of EHR adoption may suggest that published estimates of EHR adoptions may be overestimating the true level of meaningful system availability. The adoption requires considerable changes to existing processes and work flow, which then increases the level of uncertainty and the possibility of implementation failure (Menachemi et al., 2007).

Even among EHR users, other research also found evidences of disappointing outcomes of EHR use. An investigation conducted by Jeffrey et al. showed that EHRs were not associated with better quality ambulatory care (Jeffrey et al., 2007); the study from Maria Staroselsky et al. confirmed earlier reports that it is common for medication list information in an EHR to have inaccuracies (Staroselsky et al., 2007).

Since it is argued that the financial incentive is the most significant barrier of EHR adoption in US, physicians are reluctant to purchase EHR systems because of the absence of solid evidence on the economic benefits of EHR. The fundamental alignment of incentives between providers purchasing HIT and those who fund health care (Berner et al., 2005), such as public and private payers and employers is required.

There are also barriers concerning vendors and their products. The EHR marketplace is replete with hundreds of vendors trying to fulfill niche requirements instead of focusing on

functionality, data representation, or interoperability standards for EHR due to the lack of barrier to entry and clarity around basic product definition, relevant standards, as well as market segments. Moreover, the progress of standards acceleration is slow in the private sector among EHR vendor companies. There‘s little support for information exchange between disparate systems due to the absence of a solid business case for interoperability among vendors‘ products that results in a variety of standards.

Besides, although US has been working on removing legal barriers, there‘s still concern over the legal burden of compliance, i.e. stemming from laws such as HIPAA (Health Insurance Portability and Accountability Act) would add to the burden and cost of practice. What‘s more, the electronic personal health information is lack of protection from extensive federal, state, and common law concepts of privacy and confidentiality.

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4.2 EHR Development in the United Kingdom

4.2.1 National initiatives of EHR in UK

The NHS (National Health Service) of UK is the world‘s largest publicly funded health service charged by the Department of Health. It released IT strategy in 1998, including making

standards for systems, connecting users to the NHS networking infrastructure, improving data quality, gradually adopting EHR and EPR among all trusts and practices, as well as the transfer of records between practices, and patient access to records by 2005 (Burns, 1998). Then the strategy was updated in 2001, which gave more prominence to providing information directly for patients than the original one did. Besides, it also revised targets to be more specific and realistic. At the same time, Tony Blair promised to provide financial support for NHS plan. As a result, the funding for health ICT increased to£1.3 billion in 2004 and the government planned to raise total (public and private) healthcare spending to match the EU average as a proportion of GDP by 2006 (Protti, 2002).

In addition, the Health Records Infrastructure (HRI) and 12CIT program started in 2002, and the national specification for Integrated Care Records (ICR) Service was released in 2003 to further delivery IT support for the NHS by taking greater central control. Moreover, the three-year Electronic Record Development and Implementation Program (ERDIP) came to an end in 2003. It was a national co-ordination trial program supporting the NHS by building integrated care record (ICR) (NHS, 2003). It demonstrated implementation issues through selected communities, evaluated outputs and defined emerging concepts.

Based on the strategy, the National Program for IT (NPfIT) was established and the NHS Connecting for Health (CfH) was formed to deliver the program in 2005. NpfIT covers 330 acute hospitals and mental health trusts, and primary and community care organizations across England (Scotland, Wales and Northern Ireland have opted not to participate). This Program is expected to end in 2014-15 and some£12.7 billion had been spent on it until now according to the National Audit Office.The key deliverables consist of NHS Care Records Service , the N3 network (national network for NHS), the Spine (the national data spine) together with its applications, Choose and Book, HealthSpace (Online personal health

organizer), Electronic Prescription Service, NHSmail, GP to GP transfer, Quality Management and Analysis System, Picture Archiving and Communications Systems, and Health Service Desk. The whole systems and services are indicated in Appendix B.1.

The N3 network and the Spine, with various applications, are the infrastructure of the program, which have been deployed on or ahead of schedule now with plans for further development ready. The picture is similarly favorable on Quality Management and Analysis System and NHS Connecting for Health Service Desk, though there is further progress needed on NHSmail and GP to GP transfer. The main challenges remain with Choose and Book, Electronic

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4.2.2 Main EHR system functionality being used in UK

The EHR used in UK now is called the Summary Care Record is an important component of the service, which in the first instance will contain a patient‘s demographic details and information on current medication, allergies, and adverse reactions.

The main EHR systems functions include Choose and Book, Electronic Prescription Service, NHSmail, GP to GP transfer, Care Records Service, Quality Management and Analysis System, and NHS Connecting for Health Service Desk. Other functions are Electronic clinical orders, results reporting, electronic prescribing, integrated multi-professional care pathways, NHSnet, and e-mail system. Table 4.2 lists the descriptions of the main functions:

Table 4.2 Main EHR system functionality being used in UK

Functions Descriptions

NHS Connecting for Health Service Desk

Provides support to users of the IT systems, covering most parts of England now

Quality Management and Analysis System

Gives out evidence and feedback on the quality of care delivered, which was fully deployed in 2005

Electronic Prescription Service

Allows prescribers to generate and transmit electronic prescriptions. It is introduced in two releases with different systems for GP and pharmacy. By the end March 2008, 79 percent GPs and 75 percent pharmacies were able to make

electronic prescription

GP to GP transfer

Enables patient records to be transferred electronically and securely between GP practices, with 3,500 GP practices to be live by the end March 2008 and a plan of full national rollout in 2009

NHSmail An e-mail and national directory service for NHS staff in England and Scotland, which is used by 341,332 NHS staff Choose and Book Provides patients with a choice of time and place for their appointments for NHS services and private healthcare

providers by linking Acute Trusts to hospital systems. At 31 March 2008, 84 percent of Acute Trusts had access to a compatible hospital system

NHS Care Records Service

Includes The Summary Care Record and supportive care records system, being delivered through the Program‘s national systems. The early adopter program is underway consisting of two waves covering five areas

(Source: NHS 2001)

4.2.3 EHR adoption and use rate in UK

These efforts lead to the success in national and local supportive strategy, as well as the development of infrastructure. A 2001 survey by Harris Interactive (2001) found that only 52 percent of GPs and 22 percent of specialists used EHRs. However, by Sep 2001, all GPs and hospital consultants were connected to NHS network by 2002. As one of the leaders in the EHR journey, a 2004 report on GP computer systems in England reported that ―more than 95% of GP practices in England are automated‖ (Protti, 2004). It was then reported that 89 percent of primary care doctors were using Electronic Patient Medical Records in 2006 (The

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4.2.4 Benefits perceived from EHR usage in UK

In contrast with the US reimbursement system, by using mixed reimbursement models like pay-for-performance programs, EHR in UK contributes to achieving performance or quality benchmarks that warrant increased reimbursement or increased return of withhold payments. Most physicians benefited financially from the new system due to the substantial increase in funds provided to the NHS for payments to physicians (Epstein, 2006).

In addition to increasing incomes, there were also evidences of benefits delivered by EHR use such as health care system performance improvement from (Delpierre et al., 2004), reduction of medical errors (Gans et al., 2005). Moreover, certain case study (Schade et al., 2006) reported following main practice-perceived benefits of EHR in terms of practice development, practice operation, practice care.

1) Practice Development: Developing and motivating practice staff, increasing job satisfaction

There was reported satisfaction–perception of doing the best job for the patient, and control–perception that necessary information is actually available at the time of patient encounter.

2) Practice operation: Improving practice operation and management capability

Although statistical reports can be discussed at staff meetings, GPs can be overwhelmed with data. However, financial rewards mentioned very frequently because of capturing billable items and pay for performance. Legibility of records and ability to locate records were emphasized many times as well as protection of the documentation against

negligence claims. There were also cited benefits from prescription management. Besides, some physicians suggest that they feel more competitive than others not using EHR.

3) Patient Care: Improving patient care, particularly chronic disease care

The reported benefits of this kind include more timely and concise information resources; better chronic disease care and more health promotion; reduced risk of errors and variation in chronic disease care; and easier identification of individuals needing intervention. 4.2.5 Main problems facing UK

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national program, as well as the controversial decision to lock the NHS into contracts with suppliers without such capacities to deliver in time. Furthermore, the contracts bound suppliers to a vague specification that has cost the NHS around£30 million in legal fees to sort out. Despite benefits as stated previously, there is significant disquiet among some clinicians and priorities of program not fully matching those of the clinical community (Hendy et al., 2005). Many trusts, who have already implemented the Care Records System, haven‘t received the key software yet. Besides, it is the systems delivered in some instances offer less functionality than the ones they replaced. According to criticism in the National Audit Office report, this is because that NHS fell into the trap of leading with technology rather than clinical need. In addition to the problems of low suppliers‘ capacities and little clinical engagement, the patient consent model is also under debate. UK is using ―opt out‖ model in which patients by default are included within the system, and make an informed choice to leave it. However, many critics, such as the British Medical Association, counter that an informed choice to ―opt in‖ would be a fairer model, as there is no room for doubt about a patient‘s intentions. Finally, some functions of the EHR systems being used now are underperformance. For

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