The effect of EHR-use on work processes of
medical professionals
University of Groningen Faculty of Economics and Business Nettelbosje 2, 9700 AV Groningen.
MSc BA - Change Management Date: 04-02-2019
Thesis supervisor: dr. J. F. J. Vos Second assessor: dr. B. C. Mitzinneck
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ACKNOWLEDGEMENTS
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TABLE OF CONTENTS
ABSTRACT ... 4
INTRODUCTION ... 5
THEORETICAL FRAMEWORK ... 8
Theory of Effective Use ... 8
Representation Theory ... 8
Theory of Affordances ... 9
Linking both theories... 10
Electronic Health Records & Effective Use ... 11
System misfits ... 12 METHODS ... 13 Research approach ... 13 Research site ... 13 Data gathering ... 14 Data analysis ... 16 RESULTS ... 17 Outpatient clinic A ... 18 Outpatient clinic B ... 20 Outpatient clinic C ... 22 Outpatient clinic D ... 25 Outpatient clinic E ... 27 Cross-case analysis ... 30 DISCUSSION ... 34 Standardization ... 34 Administrative burden ... 36
Workarounds & Reliability issues ... 36
Distractions ... 37
Theoretical implications ... 38
Managerial implications ... 39
Limitations and further research ... 39
REFERENCE LIST ... 41
APPENDICES ... 45
Appendix A: Interview protocol medical professionals ... 45
Appendix B: Interview protocol business managers and HMAs ... 48
Appendix C: Codebook ... 51
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ABSTRACT
The use of EHRs in hospitals has significantly increased over the past decades and is expected to increase even more in the years to come. However, the expected benefits: time-efficient, effective, and lower cost care, appear to be poorly achieved. Furthermore, recent studies showed evidence that the effect of EHR-use on work processes of medical professionals is still controversial. Therefore, this study aimed to create a deeper understanding of how work processes of medical professionals are influenced by EHR-use. Mixed data research on departmental level was performed on five outpatient clinics in an academic teaching hospital. Across these clinics there was a clear returning pattern of delay in the work processes of medical professionals, indicating that effective system use has not been achieved in any of the outpatient clinics. This study identifies three main impeding factors on work processes of medical professionals according to system misfit categories, namely: standardization of processes and roles, the administrative burden, and distractions caused by the EHR. Furthermore, workarounds and reliability issues emerged in outpatient clinics where, according to medical professionals, EHR-use resulted in a reduced quality of care.
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INTRODUCTION
Multiple demographic trends in the Netherlands require healthcare providers to find more efficient and effective ways of treating patients (Kemperman, Geelhoed & Hoog, 2014; Van Rossum et al., 2016). Due to an aging population, it is expected that one in four people needs to work in the healthcare sector by 2030 in order to facilitate the group of elderly. Also, multimorbidity will increasingly raise the complexity of clinical pictures. If not adequately responded, these trends will cause healthcare costs to rise significantly (Van Rossum et al., 2016), especially for complex care providers such as large academic teaching hospitals. Hence, focus is increasingly placed on value-adding activities and chain care organization (Kemperman et al., 2014, Drupsteen, van der Vaart, & van Donk, 2016) in order to increase timeliness and quality healthcare processes. One frequently used tool that can contribute to this focus is an Electronic Health Record (EHR). EHR-systems store data associated with each patient encounter, including demographic information, diagnoses, laboratory tests and results, prescriptions, radiological images, clinical notes, and more (Birkhead, Klompas, & Shah, 2015). Even though implementing a single EHR can cost over 20 million dollars, the use of EHRs in hospitals has significantly increased over the past decades and is expected to increase even more in the years to come (Hsiao & Hing, 2012).
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improved process adherence (which can lead to improved chain care), no effect on required time per patient and slightly decreased quality of care when adopting advanced EHRs. However, a recent national survey in the United States, in which 3,400 physicians participated, resulted in a more definite outcome: 61 percent of the respondents reported the feeling that EHR systems disrupt clinical workflows, increase time required per patient, and lessen clinical productivity (Monica, 2018). Next to this, a recent study revealed significant increase in time spent on documentation by physicians: for every hour of patient treatment, two hours of administration is required by physicians (Sinsky et al., 2016). Due to this administrative burden, physicians experience increased stress and dissatisfaction and often display resistance towards EHR-adoption. Furthermore, EHR-use has even been linked to physician burnout (Collier, 2018; Babbott et al, 2013; Martin & Sinsky, 2016; Read-Brown et al., 2017).
This implies that system affordances are not always experienced by medical professionals and that a consistent picture of the effects of EHR-use on work processes of medical professionals is missing. Therefore, from both a theoretical and managerial perspective, there is need for clarification and further explanation regarding the effects of EHR-use on work processes of medical professionals (Nguyen, Bellucci, & Nguyen 2014; Adler-Milstein et al., 2015; Read-Brown et al., 2017). Taking the recent healthcare trends into account, especially large academic teaching hospitals require new insights on how to increase the timeliness and quality of their processes and what impedes them. This study contributes to this gap by combining qualitative and quantitative data, also known as mixed data (Creswell & Plano Clark, 2017), on the effect of EHR-use on the work processes of medical professionals. Whereas previous studies often based their research on national surveys, this study is based on both in-depth interviews with medical professionals and hospital data analysis, and thus allows for creating a deeper understanding of how work processes are influenced by EHR-use. Therefore, the following research question will be answered in this study: “How does EHR-use influence the work processes of medical professionals in academic teaching hospitals?”
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al. (2014, p. 69) describe an affordance as “the potential for behaviours associated with achieving an immediate concrete outcome and arising from the relation between an artefact and a goal-oriented actor or actors”. In this study, the artefact is an EHR system, and the “goal-oriented actors” are individuals engaging purposefully in professional tasks in the healthcare organization. Because affordances are simply potentials for action, effective use of the system entails actualizing affordances. Thus, effective use can be conceptualized as the effective actualization of affordances arising from the relation between the system and its users (Burton-Jones & Volkoff, 2017). In addition, the representation theory claims that information systems exist in order to help people understand the states of some real-world systems that are relevant to them. In order to do so, representations should be faithful, or in other words, consistent with reality (Burton-Jones & Grange, 2013).
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THEORETICAL FRAMEWORK
In this section we will first dive deeper into the theoretical background of effective system use and its theoretical lenses: the representational theory and the theory of affordances. Secondly, a detailed background regarding EHRs, potential advantages and disadvantages will be presented. Finally, a detailed description of potential information system (IS) misfits will be presented, which will be used to make an in-depth analysis of potential problems influencing the work processes and affordance actualization of medical professionals. We will now dive deeper into the theory of effective use.
Theory of Effective Use
At the base of the theory of effective use lies a technological artefact, which exists in multiple forms (hardware, software, techniques or systems). Orliwkowski (2000, p. 425) stated: “Technology per se cannot increase or decrease the productivity of workers’ performance, only use of it can”. Thus, in order to generate an actual outcome with a technological artefact, it should be used (Burton-Jones & Grange, 2013). However, just using a system will not yield benefits: to generate benefits, the use of the artefact must be effective (Burton-Jones & Grange, 2013). According to these authors, regular use of a system is a goal-directed activity, while effective use of a system helps attain the relevant goal. An important note to this is that different stakeholders (medical specialists, outpatient clinic managers, nurse) may have different views on the goals for using a system and its affordances (Burton-Jones & Volkoff, 2017). Where a hospital on organizational level might require effective system use in order to increase standardization and lower costs, a physician might only want to effectively use the system in order to make better notes and do this quicker in order to spend more time and attention to the patient. However, the condition for gaining benefits and achieving effective use is that the system is representative (Burton-Jones & Grange, 2013), which leads us to one of the theoretical foundations of effective use: the representation theory.
Representation Theory
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representations do. By relying on faithful representations, also known as representational fidelity, people are able to make better, informed actions (Burton-Jones & Grange, 2013). If a representation is unfaithful, e.g. data in an EHR is incomplete or incorrect, system users would not be able to make proper informed actions, which consequently can lead to time delays or a reduced quality of care. Data-inconsistency and errors require the medical professional to perform extra checks and tests, which can hinder effective use of the system (Burton-Jones & Grange, 2013).
According to Strong and Volkoff (2012), an IS or a technological artefact exists of multiple structures: a physical structure, a surface structure, a deep structure, and a latent structure. The physical structure is that what you can touch (e.g. a computer or laptop). The surface structure allows the user to access the artefacts’ facilities and interact with the system (e.g. an interface or menu). The deep structure exists of scripts (e.g. embedded data) that provide a representation of a real-world system (e.g. a hospital setting). Finally, the latent structure represents the implicit assumptions of people about roles, control structures, and cultures of organizations. It emerges from the way that the other IS-structures are designed and influences the way the artefact is used (Strong & Volkoff, 2012). Leonardi (2012) refers to the latent structures as the “social subsystem”, which influences a person’s intentionality on how to use a system and which influences the materiality of an artefact: “As people approach a technological artefact, they form particular goals (human agency) and they use certain of the artefacts’ materiality to accomplish them (material agency)” (Leonardi, 2012, p. 22). These collective agencies are imbricated and produce a certain use that, in turn, is influenced by constructed affordances and constraints that arise from the material and human agencies (Leonardi, 2012). Thus, people make choices on how they imbricate both agencies depending on whether the technology affords or constraints their goals, which leads us to the theory of affordances.
Theory of Affordances
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data, coordinate and monitor operations, substitute medical professionals, facilitate informed action making, and shift work across different roles. In particular the standardization affordances can contribute to the success of the later, more-advanced affordances (Strong et al., 2014).
How affordances are perceived and actualised is also contextually influenced by cultural, social, and technical factors. Furthermore, the variability of the context can reveal different sets of affordances in a specific environment because affordances are always relative to an actor's goal (Volkoff & Strong, 2018; Thapa & Sein, 2018). Hence, an affordance, easily achievable by one actor, may take more time or effort for another. Furthermore, the perception and actualization of affordances are dependent on the relationship between system and user in the context in which IS are used: “Affordances are not properties of either the organization or the IT artefact alone, but rather relations and dynamic interactions between the two” (Pozzi, Pigni, & Vitari, 2014, p. 6). In these terms, affordances are technology and actor specific (Strong et al., 2014). For example, where a nurse might experience the system affordance standardizing processes as beneficial for routine tasks, medical specialists dealing with unique and complex clinical problems of patients can experience the same affordance as a hindrance.
Linking both theories
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faithful, affordance actualisation and effective use of the system will be hindered or may even lead to serious problems.
Electronic Health Records & Effective Use
Häyrinen, Saranto and Nykänen (2008, p. 293) defined an EHR as “a repository of patient data in a digital form, stored and exchanged securely, and accessible by multiple authorized users”. Theoretically an EHR has the potential to increase timeliness of processes and performance of medical professionals, leading to improved quality of care and lower healthcare costs (e.g. Adler-Milstein et al., 2015; Thurston, 2014; Agarwal, Gao, Desroches & Jha, 2010). Effective system use can be facilitated by an EHR on multiple facets. Firstly, an EHR facilitates standardization, as it is an integrated system. For example, a standardized EHR can prevent multiple departments in hospitals from using their own selected programs, which reduces the chance on potential data and communication problems. By standardizing an EHR, the system can ensure that medical professionals have access to all existing and up-to-date information, which prevents searching and therefore saves time, and facilitates effective use (Burton-Jones & Grange, 2013). Secondly, an EHR has the potential to facilitate effective use by enabling digital communication and improved coordination (Strong et al., 2014; Adler-Milstein et al., 2015). Examples are facilitating process completion via task lists and showing pop-ups when one or more measures have not been met for a patient. Next to this, by enabling digital communication, medical professionals can easily share and discuss patient data. Therefore, in theory one would say that by effectively using an EHR, less time would be required to perform work processes.
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organization and system (Strong & Volkoff, 2010), which may hinder users in achieving effective use.
System misfits
By implementing a generic EHR that is based on best practices, which lacks customization for different specialities, insufficiencies and misalignments between the system and medical professionals, departments or even the organization can arise, which is referred to as an imposition misfit (Strong and Volkoff, 2010). Next to this, Strong and Volkoff (2010) also specify deficiency misfits, which arise from system features that are missing but needed. Consequently, users cannot undertake a specific action due to missing functionalities, data or controls. Whereas deficiency misfits can be solved by adding the missing functionalities, “imposition misfits are generally more serious as these misfits arise from characteristics that are necessarily present in the system and cannot be eliminated” (Strong & Volkoff, 2010, p. 737). In order to further specify misfits, these authors defined six categories of misfits, which are explained in table 1. Within this study, these misfit categories are used to make an in-depth analysis of the reasons how EHR-use influences work processes and how these misfits influence the ability of medical professionals to actualize affordances and achieve effective use. How this will be done, will be discussed in the next section of this study.
Category Description (Strong & Volkoff, 2010)
Functionality misfit When processes executed with the new ES lead to reduced efficiency or effectiveness as compared to history.
Data misfit When data or data-characteristics stored in or needed by the IS leads to data quality issues such as inaccuracy, inconsistent representation & inaccessibility.
Usability misfit
When interactions with the ES required for task execution are confusing or cumbersome, i.e. requiring extra steps that add no extra value, or add difficulty in
extracting or entering information.
Role misfit
When roles in the IS are inconsistent with the skills available, create imbalances in the workload, leading to bottlenecks and idle time or generate mismatches between
responsibility and authority.
Control misfit
When the controls embedded in the ES provide too much control, inhibiting productivity, or too little control, leading to the inability to assess or monitor
performance appropriately.
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METHODS
Research approachGiven that the actual effects of EHR-use on thework processes of medical professionals and the patient’s trajectory are sparsely researched, a qualitative inductive research method is appropriate for this research. However, to strengthen the results of this study, a mixed data approach was used: quantitative data was used to substantiate or invalidate qualitative data (Creswell & Plano Clark, 2017). Next to this, where previous effective system use studies mostly addressed affordance actualization from an individual or organizational level of analysis, this study addresses affordance actualization from a departmental level of analysis, contributing to this literature gap (Burton-Jones & Grange, 2013; Volkoff & Strong, 2018). Therefore, a multi-case study approach was used. By performing single- and cross-case analyses, a well-spread picture of the effects of EHR-use on work processes and development of new insights about contextual variables can be made. In order to collect both qualitative and quantitative data, interviews were held, and archival data was analyzed. By combining data, interviews and literature, triangulation was achieved (Yin, 2003). This enables the sources to validate and confirm each other, increasing the reliability of research results (Bruns, 2016). Furthermore, by incorporating quantitative data into this research, this study extends on research into effective use (Volkoff & Strong, 2018).
Research site
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trajectory and cooperation between different sub specialisms. Therefore, especially these outpatient clinics are of interest for this research. Also, the other outpatient clinics in the hospital are about to start or are currently busy with a large rebuilding process which might conceivably reduce the benevolence to cooperate in this research. Therefore, it is a good choice to perform research on the new, merged outpatient clinics as they were in a more stable phase. Finally, as the selected outpatient clinics all contain different specialties (varying between two and six specialties per outpatient clinic) and work cultures, they ensure a valid sample.
Data gathering
Quantitative data: archival data of outpatient contacts
A quantitative analysis was executed in order to visualize the impact of EHR-use on the work processes of medical professionals. The quantitative analysis was performed on composed Excel dumps of historical data of the EHR since the go-live in December 2017 and data of the old system from one year before up until go-live of the EHR. All data had been stripped from patient details in order to secure information safety. The archival data exists of multiple variables that required filtering before the data could be analyzed. The two archival data files from before and after the EHR-implementation were compared based on throughput time of patients, in order to visualize whether medical professionals are able to effectively use the system, and therefore can treat patients faster. This was done by looking at unique patient codes and outpatient clinic contact dates. By subtracting the first treatment date from the last treatment date and increase this number with one so that patients that visit the hospital for just one treatment are also taken into account, the difference in days can be measured. This is the throughput time of a patient, or in other words, the duration of the patient’s trajectory in the hospital. In order to compare the durations of patients’ trajectories before and after the EHR-implementation, cumulative percentages of patients’ throughput time of both situations were plotted as a scatter diagram.
Qualitative data: interviews
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with the system. By selecting multiple functions per outpatient clinic, different perspectives can be considered, ensuring internal and construct validity (Yin, 2008). This resulted in a selection of the following functions: Medical Specialist (MS), Nursing Specialist (NS), Medical Intern (MI), Medical Manager (MM), Head of Medical Administration (HMA), and Business Manager (BM). A short description of all functions can be found in table 2.
Function title Function description System use
Medical Specialist (MS) Responsible for performing medical care within a particular field of
expertise. Continuously
Nursing Specialist (NS)
Responsible for performing nursing specialist care and documented
medical care within a particular field of expertise. Continuously
Medical Intern (MI) Doctor-in-training, performing specialist care while under
supervision of the Medical Manager (MM). Continuously Medical Manager
(MM) Doctor responsible for the quality of care in the outpatient clinic Daily Head of Medical
Administration (HMA)
Responsible for the administration of the outpatient clinic and the
reception and guiding of patients Daily Business Manager (BM) Manager responsible for the daily ins and outs of the outpatient clinic Weekly
Table 2: short description of all interviewee functions
The MSs, MMs, NSs and MIs were of particular interest as they use the EHR every day, both during patient contact and for administrative tasks. In particular these people are of interest as they can properly sketch where the system facilitates or hinders timeliness of the patient’s trajectory and why effective use is achieved or not. Also, since the system’s go-live, many administrative tasks have now become the responsibility of MSs and NSs. Therefore, it is of interest to conduct research on how this potentially affects timeliness of work processes. The other functions were selected as they could provide a general overview of EHR-use in their outpatient clinic. The time scheduled for interviews were based on the position of the interviewee, varying from approximately 25 to 45 minutes.
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written and performed in Dutch, as all the interviewees were Dutch. This way, language barriers could be prevented. In order to be able to properly transcribe the interviews, all interviews were recorded. All interviewees were asked for their approval prior to start of the interview and all but one signed informed consent forms. In addition, an overview of all interviewees per outpatient clinic can be found in table 3. As you can see, the outpatient clinics are named A-E to preserve anonymity. Additionally, two interviews were arranged with medical professionals of another academic teaching hospital in the Netherlands that implemented the same EHR five years ago. This was done to gain insights of problems they experienced post go-live, which benefits and disadvantages they experience, and whether there can be spoken of time-related effects. All interviewees from that hospital were NSs.
Data analysis
The data analysis was executed in multiple stadia. Firstly, the quantitative data was analyzed and the effect of EHR-use on work processes of medical specialists was visualized. This was done in order to sketch an overview of how the time required for work processes of medical professionals is influenced by EHR-use. Secondly, the in-depth interviews were transcribed and inserted into Atlas.ti, in which they were be organized based on their outpatient clinic in order to separate the different cases. Thereafter, text fragments that seemed relevant for the research were labeled, also known as “open coding” (Egan, 2013). Thirdly, both inductive and deductive coding was applied. Deductive codes were assigned to the EHR-affordances previously discussed within the theoretical framework. Inductive codes were created by analyzing emerging concepts from the interviews, which are called first-order codes. Thereafter, second-order codes were created by classifying first-second-order and deductive codes into groups, which were later aggregated into different themes, such as: “Standardization” or “EHR Functions”. Fourthly, after completing the within-case analysis, a cross-case analysis was applied, comparing the different within-case results in order to (Egan, 2013). A codebook, providing an overview of the different level of codes and quotes, can be seen in Appendix C.
Outpatient clinic # of specialties Participants
A 4 MS, MM, BM (is also HMA)
B 2 MS (2), MM, NS, BM, HMA, EHR-superuser C 3 MS, MM, BM, Outpatient clinic-planner
D 4 MS (3), NS, BM, HMA
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RESULTS
Within this section, the results of the quantitative and qualitative analysis are discussed. First the quantitative result serves as a global sketch of how the EHR influences work processes of medical professionals. Thereafter, the qualitative results will provide an in-depth description of the phenomena that influence the ability of medical professionals to achieve effective use and actualize EHR-affordances, and why the effects are stronger in certain departments compared to others. In order to examine whether the new EHR facilitates or hinders work processes of medical professionals, a comparison has been made between outpatient clinic data prior and after the implementation of EHR. The result can be seen in figure 1.
Figure 1 illustrates a clear difference between the trajectory duration before (blue) and after (orange) the EHR implementation of the new EHR. The graph shows that in both situations, approximately 50% of all outpatient clinic contacts had a throughput time of one day. However, from 80% and onwards, it becomes clear that there can be spoken of a significant deterioration. Whereas the line of the old situation rises steeper, the line of the current situation rises gradually. This means that since medical professionals work with the new EHR, more time is required for approximately the same amount of patients. When comparing the average required time (in days) per patient from both situations, data analysis shows that the duration of the patient’s trajectory has increased by 14 days per patient on average. As can be seen in Appendix D, this pattern is similar for every outpatient clinic. This means that work processes of medical professionals are impeded and effective use is not achieved, which indicates the presence of system misfits. Within the qualitative analysis, these impeding factors (e.g. misfits) on effective
Figure 1: Scatterplot of the effect of EHR-use on the duration of the patients’ trajectory
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 50 100 150 200 250 300 350 400 Cumu lat iv e p erce n ta ge
Patient trajectory duration in days
Effect EHR-use on patients' trajectory duration
Trajectory duration before EHR-implementation
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use will be discussed on a departmental level, in order to find out if there are contextual variables that influence EHR-use.
Outpatient clinic A
Within outpatient clinic A, many disciplines work together that previously had different work methods. Their recently renewed outpatient clinic layout facilitates chain care and cooperation. Therefore, chain care and cooperation are increasingly realized according to multiple interviewees, which in turn can result in time-benefits and better quality of care for the patients. However, as can be seen in Appendix D.1, time-benefits are not realized. According to the interviewees of outpatient clinic A, this has to do with: standardization, an administrative burden and distractions caused by the system.
Standardization
According to the interviewees of outpatient clinic A, integrating all systems into one is the main advantage of the new EHR. It ensures standardization of processes (EHR affordance) and prevents the need to swap between several systems in order to get a complete picture of the patient’s available information, which was common in the previous system. This way, using the EHR can save time and increase standardization of processes. However, according to all interviewees, standardization also leads to significant disadvantages. According to the MM and MS, one of these disadvantages is that the system’s functionalities are highly structured and based on hospital facilities in the United States. The system is clearly split between outpatient clinic and the clinic (US healthcare), while hospitals in the Netherlands integrate both domains. As a result, medical professionals must switch frequently between different domains. Furthermore, information in the different domains is displayed differently, which, according to a MS, causes confusion and may result in mistakes:
“You also need to pay attention to what environment you are. Am I clinical, pre-clinical, in an outpatient clinic, and so on. This sometimes leads to errors and confusion.” – [A-MS1] Next to this, a MS states that the system is not optimally arranged. A logical, chronological sequence of steps is missing in the program, as the priority is experienced as placed with ordering Diagnosis Treatment Combinations (DTCs), which implies the presence of culture and usability misfits:
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Next to this, the EHR facilitates standardization of roles (EHR affordance), by facilitating functions and accessibility based on functions. However, since the implementation of the EHR, the hospital organization decided to cut out on administrative personnel and place the responsibility of carrying out administrative tasks into the hands of medical professionals. Consequently, medical professionals now must deal with a significant administrative burden next to their normal occupations. According to all interviewees, MSs are responsible for filling in the complete medical history of patients, and every process step needs to be ordered. This results in loss of time, which implies the presence of role and functionality misfits:
“You now need a bit more time for each patient. (…) If you want to properly insert all patient data into the EHR, it will cost you a lot of time. More as compared to the situation before the
EHR-implementation. – [A-MS1]
A specific example of the increasing administrative burden given by the MM is that colleagues spend up to 20 minutes per patient on filling in all the required data for the patient’s medical history. Several interviewees state that they are still in a learning curve, thus they expect the required time for administrative tasks to be reduced in the years to come. The medical manager implies:
“Until now we are still in some sort of a learning curve. (…) It still costs more time as compared to before.” – [A-MM1]
Distractions
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“The disadvantages are: the many clicks and the administrative burden that has been passed over from the administrative personnel to the doctors. They now have to do so much more administration than before, which costs them a lot of time and which, according to me, is at
the expense of patient care." – [A-BM1]
Outpatient clinic B
Outpatient clinic B exists of two departments that differ greatly from one another in terms of specialties. Therefore, cooperation is not sought. However, according to several interviewees, this also is not necessary to provide good care. This outpatient clinic in particular has many collaborations with external parties, such as other hospitals, research institutions and so on. Therefore, an EHR is of interest for this department, when it can facilitate activities such as information sharing. However, according to the interviewees, this is not the case, and a loss of time is caused by EHR-use (Appendix D.2), due to: standardization, the administrative burden and distractions caused by the system.
Standardization
Firstly, all interviewees of outpatient clinic B indicate that the new EHR facilitates standardization. According to all interviewees, the integrated EHR-system compared to the previous situation, where one had to use several applications in order to complete a process, is an improvement. The MM states that by integrating everything in one EHR, offering functions as “smartphrases” and quick reports, work process can be accelerated. As soon as medical specialists iplace an order, it can immediately be seen by the administrative personnel. An MS stated that this yields time-benefits:
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“When someone has done an anamnesis on the clinic and we open it here at the department, we still have to edit and save the file, because otherwise the system does not record that an
anamnesis has been carried out. (...)It really results in overtime.” – [B-NS1] Administrative burden
According to all interviewees, the most impactful disadvantage of the EHR-use is the administrative burden and the time that the administration requires. Especially the medical specialists place emphasis on the time required for the increasing administrative burden, existing of filling in the medical history of patients and placing orders. According to an MS, this results in reduced efficiency and a reduced amount of patients that can be treated per day:
“Before the EHR implementation, I spent a lot less time on preparation of consults: approximately 20 minutes. Now it varies between 1,5-2,5 hours. (...) If a patient has already
visited another doctor, it is fine, then I am lucky. But if I first have to update the medical history, and partly have to fill in medication-details... I do not have time for that.” – [B-MS1] In order to be able to continue to treat approximately the same amount of patients, it is therefore necessary to take time elsewhere to compensate. The MM and MSs of the outpatient clinic states that they are often finishing their administrative tasks at home after work, or they skip filling in queries until after the consultation or treatment or fill in minimal information in order to spend enough time to the patients. This can be classified as workarounds and it implies the presence of role and functionality misfits. As a result, the quality of data is decreasing:
“And do you know when most people are working in THE EHR? At 20:00 pm. Only then people have time to complete their administration, that is not how it is supposed to be.” –
[B-MM1]
“I have been busy for an hour to fill in the file as it should be filled in, including the medication, medical history, putting everything in the right place, etc. There was another colleague in the room, which I asked: "Do you ever do this too?" to which he said: "No never actually, because I do not have the time to do that". (...) The consistency of data in the EHR is
therefore still very moderate, since everyone enters things differently.” – [B-MS2] Reliability
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organization. Therefore, data-consistency is lacking, which implies a data-misfit. Furthermore, the NS states that she and others does not trust the system yet as it provides "false safety":
“I had to check with a colleague as a second nurse. (...) The system stated that a patient must have 2000mg. My colleague accidentally scanned 4000mg, and the EHR accepted it as "correct." Then I thought: "wait a minute, this is not right". (...) That creates a feeling of false
security for me.” – [B-NS1] Distractions
Furthermore, interviewees frequently talked about the distractions caused by the system. According to all interviewees, warnings pop up frequently, and each of them requires reading-time and a mouse click. They do acknowledge the positive side of the warnings, since you are being alerted to unfilled questions, allergies of patients and the effects and combinations of different medicaments. However, according to the interviewees, the warnings come up so often that it leads to frustration and the careless and quick clicking away of warnings:
“Because you have to click so many times, you will start making routine clicks after a while. At a given moment you get so many pop-ups that you will just blindly click them away. When
that happens, those pop-ups do not serve their purpose any longer.” – [B-MM1] Another delaying factor on efficiency of work processes is the amount of InBasket messages that medical professionals receive. The MM states that, as he supervises multiple departments, he receives so many messages in his InBasket that he does not even check it anymore, which implies the presence of a usability misfit:
"Even if an assistant has not signed his letter, I will get a note of it. As a result, I receive an abundance of nonsense in my InBasket. (...) After a while you think: "this is no longer useful, I
will not look at that anymore". It is such an overkill of signals, after a while you think: "f * ck off".”– [B-MM1]
Outpatient clinic C
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“We have ensured that the system is properly filled with data. Only then will you be able to benefit from the system.” – [C-BM1]
However, even though the medical history of the existing patient group is entered in the EHR, there still can be spoken of time loss (Appendix D.3). According to the interviewees this is caused by standardization, the administrative burden and distractions caused by the system.
Standardization
As with the previous outpatient clinics, the multiple interviewees see the "integrated system" as the biggest advantage. Next to that, the BM states that the system leads to standardization as it provides protocols based on certain DTCs. Both the MM and MS agree on this and state that the various functionalities of the system are adding to standardization and can increase speed of work processes. Furthermore, when there are results available from tests, operations or consults, they are placed into the InBaskets of appointed MSs. Therefore, MSs do not require time to search for specific results:
“You now have access to fantastic functions, e.g. smartphrases and templates that you can create. This also results in time savings. The assurance of the system has really improved enormously compared to what it was. (…) What is very good about the EHR is that the results
appear in your InBasket, and that you can access them there. I think that is a huge quality improvement.” – [C-MM1]
However, according to multiple interviewees, standardization of the EHR resulted in the fact that the system is designed according to US healthcare standards: the system splits the outpatient clinic and the clinic, and a lot of emphasis is placed on ordering and checks. The BM states that this often hinders work processes. This implies the presence of culture and functionality misfits, as the smallest activities have to be ordered, which costs extra time:
“It is very much based on US healthcare. That means: check, check, double check, to be accountable afterwards. As we are in the Netherlands, this does not function. Invoicing now
has a higher priority than working more efficiently in the EHR.” – [C-BM1] Administrative burden
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misfits, as doctors are not trained to perform administrative tasks and therefore require more time to fulfil them compared to administrative personnel:
“I spend way more time on administration. Consequently, I can spend less time per day on things for the patient. (...) Therefore, I require more time for treating the patient.” –
[C-MM1]
In order to circumvent administrative struggles as completing the medical history of patients or ordering a new bandage, the MS and MM both state that workarounds are used. According to them, this is caused, among other things, by the fact that there is too little guidance or pressure at organizational level for filling in the administration, which allows medical professionals to fill in random things in order to prevent delays. This however has consequences for quality and reliability of data and implies the presence of a data misfit.
“There are blockages in the system. You sometimes cannot go any further because of the design of the system. (...) You have to fill in something, but that is not always possible. So, then something random is filled in. That is partly because we are setting it up incorrectly, so
it has to be better arranged in that respect. But there also is a feeling of saturation in that matter: how much time do you want to spend on it?” – [C-MM1]
“Yes, in my opinion the organization has not really made a uniform policy yet. Everyone just does whatever they want, because things are not arranged well enough yet by the
organization to be able to demand uniformity.” – [C-MS1] Distractions
Another time-consuming factor are the multiple distractions the system causes. The BM and an MS state that the notifications regarding allergies or medicines have a good purpose, however, they come in abundance. According to the MS, this results in the fact that you are constantly clicking while trying to fill in DTC protocols, which hinders the workflow and is not beneficial for patient safety as notifications are often quickly clicked away:
“You also get a lot of things that you have already seen and that you have to click away again. This ensures, for example, that you click things away too quickly, and look less
accurately at them.” – [C-MS1]
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important messages from test results of patients they do not treat anymore. The distractions imply the presence of usability and functionality misfit.
Outpatient clinic D
Outpatient clinic D is rather small and localized within another outpatient clinic. Outpatient clinic D is focussed on one specialty, centred around a group of chronic patients with a rich medical history in the hospital. To guide the patient as well as possible after their treatment, the outpatient clinic spends a lot of attention on lifestyle and rehabilitation. Therefore, in addition to having access to a complete medical history of patients, the possibility to efficiently cooperate with other specialisms or care providers via the EHR is very important for this outpatient clinic. However, according the interviewees the system currently does not support this, which leads to work process delays (Appendix D.4), caused by three main factors: standardization, the administrative burden, and distractions.
Standardization
As with the other outpatient clinics, all interviewees of outpatient clinic D acknowledged that the new EHR both improves and declines time required for work processes by standardizing processes. The new system improves efficiency of work processes as it facilitates the availability of information from all specialisms in one database. Multiple interviewees mention that having access to all available data about a patient's medical history in one system instead of having to search in different subsystems increases the speed of work processes. Furthermore, MSs state that the EHR provides a good overview of which actions have already been carried out by colleagues and contains useful tools, such as smartphrases and the InBasket function, which enables them to work faster:
"If I finish a note now, I am able to send a letter out within 10 seconds. The system standardly includes all information, e.g. from the lab. This is far more efficient." – [D-MS2] However, multiple interviewees state that the system currently allows many ways of filling in information and achieving certain outcomes. According to these interviewees, this freedom in filling in information ensures that different outpatient clinics develop their own work processes and ways of information processing, which results in varying degrees of information consistency. According to an MS, this is a hindrance to the preparation of a consultation and the completeness of the medical history of patients, and thus reducing representational fidelity:
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the input is simply not tailored to the specialism you work for, then you will suffer more from it than that you benefit from it.” – [D-MS3]
Another disadvantage that all interviewees addressed is the fact that the system is a standard version, designed based on the US healthcare. Therefore, there is a strong difference between outpatient and clinical settings, which creates confusion. Interviewees indicate that problems have arisen with orders from the clinical setting that could not be performed in the outpatient clinic. In addition, it is sometimes difficult to view data from the other domain, so that medical professionals often do not have a good overview of all available information. Also, dashboards of the different medical professionals and the MA differ in layout. Therefore, communication between people who experience a problem with the EHR has become quite difficult.
Furthermore, two MSs also address that standardization of data leads to problems. Currently, system data is currently displayed based on priorities. However, the MSs state that every specialism has different priorities, which creates a strange sequence in chronology of data. Due to this, the MSs state that the EHR is not offering a clear summary of data, which increases the time required for searching the right information and implies the presence of a data misfit:
“We specifically want to see chronology. Even if something from 2007 is very important, it should not stand above certain events from 2017. That is something that makes working with multiple specialisms difficult. Everyone has their own ideas about what is important, and you
cannot arrange that in the system.” – [D-MS1]
“Currently I do not see the sequence of events, while that is extremely important. (...) We analyse patients according to their story. A patient record can be compared to a journal, but
that journal is in this case poorly organized.” – [D-MS3] Administrative burden
According to all the interviewees, another important impeding factor caused by the EHR is the administrative burden that particularly the MSs experience. Because MSs suddenly had to perform administrative tasks since the go-live, the care process within the outpatient clinic was initially considerably delayed. The BM states that where consultations lasted for ten minutes before the EHR-implementation, it now takes fifteen minutes per consultation, which is an increase of 50%:
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happy. So, I do not think we have made an efficiency improvement with implementing the new EHR.” – [D-BM1]
This implies the presence of role and functionality misfits. Another disadvantage of the increasing administrative burden that multiple interviewees experience is that the system requires the medical professionals to order everything themselves. According to a MS this applies even to the smallest activities, which leads to a reduced efficiency of work processes:
“Where previously was said: "get rid of the catheter", they are now waiting until 15:00 pm to get the order via the system. Of course, that’s not effective.” – [
Distractions
The EHR allows for distractions to pop up, such as notifications concerning danger of certain combinations of medicaments, unfinished tasks or specific allergies to consider. The interviewees were enthusiastic about the potential of these notifications. However, currently, notifications are popping up in abundance. Also, the InBaskets of medical professionals are often flooded with notifications and new messages. A MS stated that he receives around 250 new messages a day, which causes serious delay and imprudence in discarding certain messages. Other MSs made similar comments about the amount of InBasket messages and stated that, next to inefficiency, the current abundance of messages leads to a reduced patient safety.
“I've been doing this for 25 years, and I still get warnings from the system. That irritates me, so I click them away quickly. So, safety and irritation are closely related.” – [D-MS3]
Outpatient clinic E
Outpatient clinic E is a rather small clinic, however, with a varied range of patients with complex syndromes. The department works together with multiple different specialities and departments, and often switches between clinical and outpatient clinic settings. However, according to interviewees, working with the EHR causes delays (Appendix D.5), caused by multiple impeding factors. Especially rigidity of the system is one of the bottlenecks according to the interviewees of this department.
Standardization
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they ought to be fitting to the patient’s syndrome. Furthermore, a MI stated that the system allows for making certain personal smartphrases and adjustments to your dashboard, which enhances the efficiency of work processes:
“It is also useful that you can automate certain preferences for yourself, that you can generate certain standard texts and place standard orders that should actually make your
work more efficient.” - [E-MI1]
However, at the same time, all interviewees address that standardization of the EHR results in the fact that the system is designed according to US healthcare settings. According to interviewees, the focus is heavily placed on ordering. Furthermore, interviewees state that the complexity of the patients’ care demand results in a misfit between the standardized functionalities and the type of treatment or care that the MS want to provide:
“I think the academy is less suitable for all the automation options offered by the EHR compared to the periphery, which perform certain operations 700 times a year. At that kind of
hospital, you can make a standard letter, which you can use hundreds of times a year. But it does not work like that here.” – [E-MI1]
Finally, an MS, the BM and a MA-superuser state that the system’s rigidity is an impeding factor for the efficiency of work processes. As described earlier with other outpatient clinics, the multiple professionals see different screens, based on location (clinic or outpatient clinic) or function (MA or MS). Furthermore, MSs state that for certain complex syndromes, there are no fitting DTCs. However, the system does require you to fill in a certain DTC. Consequently, MSs fill in a DTC that was previously used or something else that is not right:
“The system is as good or bad based as what is put into it: garbage-in, garbage-out. An intervention that we first did fifteen times a year, we only perform five times a year since the implementation. I can assure you that someone could not find the DTC when he entered this procedure and would therefore introduce and think of something else: "this will suffice", and
then write in the text below that it is concerning another intervention. I sometimes also do that myself.” – [E-MS2]
Administrative burden
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patients is experienced as extremely time-consuming by all MSs and MIs, which implies the presence of role and functionality misfits:
“A patient you do know and whose things are already registered, that goes much faster: one click and you copy your note from the previous day, you can automatically enter the vital
parameters, lab results, etc. (...) But for a new person, specifically in a hospital like this, where patients do not have a standard problem, it is not efficient.” – [E-MI1] “I have to put a lot of time into the EHR, especially with a new patient. Of the 30 minutes I am only able to spend 10 minutes on the patient. (...) There are patients with endless lists of
medical history. To enter all that into the system takes so much time.” – [E-MS1] According to the MSs, a large proportion of time is also spent processing the right order. Several MSs once again indicate that the system places a strong focus on ordering and that the US-based system design is very noticeable, which according to them, slows down work processes as even the smallest activities need to be ordered. This implies the presence of culture and functionality misfit. A MI mentioned that, due to this, work processes become viscous:
“You now have to reach a conclusion, a problem, a DBC, a consultation process... You have to register so many things, for example even when you need to make a bandage around a bruised finger. (...) That makes the system fail, because it does not make processes faster and
better, but rather slower and more viscous, which leads to more frustration.” – [E-MI2] Reliability
Furthermore, MSs and MIs state that since it is so much work to completely fill in the administration, people often only take the time to briefly write down things and sometimes even write down nothing at all. According to several interviewees, the consequence of this is that the medical history of patients is not reliable:
“It is completely unreliable as entering such a history is a hell of a job, so it does not happen. Some doctors do it, others do not, and some do it half.” – [E-MS3]
“The medical history in the EHR is totally inaccurate and perhaps incomplete. Therefore, I do not use it in my letters anymore.” – [E-MI1]
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they cannot achieve representational fidelity and therefore cannot perform informed actions. Furthermore, this can be harmful for patient safety as well.
Distractions
Next to standardization and administration, interviewees often stated that the system causes a lot of distractions. According to an MS and a MA-superuser this is partially due to that the system requires you to click often and shows an abundance of notifications during patient contact, which implies the presence of usability and functionality misfits:
“Before you really reach the important tasks: the documentation for your patient or arranging something for your patient, you have to go through all other steps, such as ticking
off allergies. It distracts a lot from the tasks that you actually have to do.” – [E-MI1] Furthermore, multiple MSs state that the amount of InBasket messages is so much that this causes an information overload. Two MSs state that do not read their InBasket messages anymore, willingly accepting the risk of missing out on important notifications:
“You get notifications about everything. I do not even look at my InBasket anymore. If people from the outpatient clinic want something from me, they have to call or mail me.” – [E-MS1] “The problem is that you can read 200 mails a day, or you can think "180 are irrelevant, I am
not going to read them". The consequence is that you miss out on important mails.” – [E-MS3]
Cross-case analysis
Within the different cases, multiple similarities emerge. Firstly, according to every outpatient clinic, the EHR contains useful functions and therefore can facilitate and enhance work processes of medical professionals. However, what also emerges in all within-case analyses, is that there currently are three main factors that cause a significant delay, namely: standardization of processes and roles, the administrative burden, and distractions caused by the EHR. Furthermore, in three of the five cases these three factors also lead to other problems, such as data reliability issues and workarounds, which reinforce each other again. Next to this, in every case, misfits between the EHR and work processes of medical professionals emerged. An overview of the qualitative analysis can be seen in table 4.
Factors Cases Key message from the different cases Misfits
EHR functions (+)
A, B, C, D, E
31 Standardization (-) A, B, C, D, E
Standardized EHR functions are not as effective in academic teaching hospitals due to the focus on highly complex care. Therefore, standardization is limiting possibilities. Furthermore, the implementation of an US healthcare-based system hinders medical professionals due to system rigidity (differences between outpatient clinic/clinic and blockages in protocols) and the focus on/required amount of orders.
Culture imposition, Usability imposition, Functionality imposition. Administrative burden (-) A, B, C, D, E
Medical professionals experience too much time delay caused by the administrative tasks they have to fulfil, in particular with new patients that have no medical history yet within the EHR. Furthermore, interviewees address that even the smallest actions need to be ordered, which slows down work processes significantly. Role imposition, Functionality imposition. Workarounds (-) B, C, E
Medical professionals try to postpone completing the administration until after the consultation, fill in a minimal amount of information and sometimes even select another DTC when the right order cannot be found (case E). Medical professionals of cases B, C and E state that this is done to be able to help the same amount of patients per day and keep the quality of patient care on a desired level.
Reliability issues (-)
B, C, E
Data reliability is questionable due to the workarounds of medical professionals: one cannot know for sure whether a colleague has filled in the right information or not. This in turn results in workarounds or delays, as medical professionals need to find other ways to find correct information (e.g. old letters).
Data imposition, Functionality imposition. Distractions (-) A, B, C, D, E
Medical professionals of all outpatient clinics state that the EHR causes too much distractions: notifications regarding medicine combinations or unfilled questions, mouse clicks and the abundancy of InBasket messages.
Usability deficiency, Functionality deficiency. Table 4: overview results of the qualitative analysis
EHR functions
Across all cases it was addressed that the EHR can facilitate work processes as it is an integrated system. The EHR contains effective functions such as smartphrases, quick reports and others, that can enhance the speed of work processes. In particular the younger medical professionals within case D and E state that the system contains useful functions that speed up the process of administration. However, even they mention that this is only the case when patients already have a properly registered medical history within the EHR. Furthermore, due to integration, the system also facilitates access to all medical data regarding a patient, which prevents searching around in separate files and therefore can enable medical professionals to work faster. However, in all cases these advantages currently do not exceed the disadvantages that the EHR entails.
Standardization
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on ordering and the amount of orders that the system requires, the strict division of roles, and the system-differences between the outpatient clinic setting and clinic setting. Interviewees from all outpatient clinics state that as the hospitals in the Netherlands are more integrated and less distributed, this cultural imposition misfit often leads to frustration and confusion. Secondly, the system offers standardization in work processes. Specific orders are coupled with protocols that medical professionals have to execute. Multiple interviewees from the different outpatient clinics stated that the EHR can enhance simpler operations/consults. However, the researched academic teaching hospital is currently in the process of divesting non-complex care. As a result, clinical pictures of patients will become increasingly complex and less generalizable. Consequently, interviewees state that the standardized functions of the EHR are less applicable. Therefore, in all five cases, standardization causes culture-, usability- and functionality imposition misfits.
Administrative burden
As was mentioned in every case, the administrative burden and the required time to process it properly are the most harmful factors for time required for work processes. Since the EHR-implementation, the hospital management decided to make medical professionals responsible for administrative processes. Consequently, medical professionals from all cases spend a lot of time on administrative process, which causes significant delays. Interviewees claimed that the duration of the patients’ trajectories has reduced since the implementation of the EHR, as medical professionals need to spend a significant amount of time on filling in questions and selecting the right orders. As a MI of outpatient clinic E stated:
“Now an order even has to be placed for a new bandage for a bruised finger.” – [E-MI2] Furthermore, in case B the MM stated that in his outpatient clinic, the most frequent time of logging into the system is 20:00 pm. This strongly implies that medical professionals do not have enough time to finish their administrative tasks during working hours, and therefore need to finish this at home after their shift. In all five cases, the administrative burden leads to role- and functionality imposition misfits.
Workarounds & data reliability issues
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these three cases, medical professionals stated that the system-data is most likely not correct or, at least not trustworthy, meaning that medical professionals cannot rely on the system. Therefore, interviewees from case B, C and E stated that they avoid using EHR-data while working on a patient’s file, and instead try to fill in the patient’s medical history by using old medical letters. Therefore, in case B, C and E, the workarounds and reliability issues lead to data- and functionality imposition misfits.
Distractions
Furthermore, in every case, interviewees stated that the amount of distractions caused by the system have an impeding effect on work processes. According to interviewees the system shows too many warnings and notifications. In particular MSs indicate that the system is not intuitive and that the warnings are most of the time unnecessary, leading to frustration and carelessly clicking them away. Furthermore, in every case it emerged that the amount of InBasket messages also are in abundance, leading to frustration, losing overview, carelessly clicking away and even workarounds in case E. In all cases, MSs, and in particular MMs, because of their supervising role, indicated that they receive up to 200 messages per day. Consequently, two MSs explicitly stated that they will not use the InBasket anymore as it causes too much extra work, for which they do not have time. Therefore, in all five cases, the distractions lead to usability- and functionality deficiency misfits.
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DISCUSSION
The result of the quantitative analysis shows that since the implementation of the EHR, the duration of the patients’ trajectory has increased significantly, namely with 14 days on average per patient. As can be seen in Appendix D, the same pattern of delay of the patients’ trajectory is experienced in every outpatient clinic. This strongly implies that EHR-use has a negative influence on the time required for work processes of medical professionals. The qualitative analysis shows that across the multiple cases, three main factors emerged that explain this phenomenon, namely: standardization, the administrative burden and distractions. These factors have led to workarounds and data reliability issues in three of the five outpatient clinics. Furthermore, both imposition and deficiency misfits (Strong & Volkoff, 2010) between the system and the work processes of medical professionals were identified based on these impeding factors. Due to these misfits, the EHR-affordances: role-, process-, and data standardisation, coordination, digital communication, information processing and informed decision making (Strong et al., 2014) are not actualized by medical professionals, and effective use cannot be achieved (Burton-Jones & Grange, 2013). Figure 2 represents a visualization of these results.
Standardization
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organizational norms of the academic teaching hospital in the Netherlands (Strong & Volkoff, 2010). Medical professionals state that, next to the amount of ordering, the focus is heavily placed on ordering and justifying actions, instead of efficiently processing information. Consequently, MSs mention that the standard protocols that the system entails are not optimally arranged.
Administrative burden
Standardization of the system also leads to an increased administration. Due to the cultural misfit, created by the difference between the US healthcare-based EHR system characteristics and the Dutch healthcare, the system requires an increased amount of logging information compared to the previous situation. Even though the system contains various functions that can speed up the process of administration, such as smartphrases and quick reports, the amount of administration is significantly increasing the time required for completing work processes in the EHR. Furthermore, this factor is also strongly related to choices of the hospital management. As the system got implemented in December 2017, it was also decided to start cutting out on the administrative personnel. Consequently, medical professionals, of which MSs in particular, suddenly gained the responsibility to perform administrative tasks next to their normal jobs. Older medical professionals in particular struggle with the administrative burden and have to use workarounds to keep treating approximately the same amount of patients as before. Therefore, the administrative burden has led to a role imposition misfit as the new roles of the medical professionals are creating clear imbalances in workload (Strong & Volkoff, 2010), resulting in the fact that medical professionals now often finish their administrative tasks at home, next to their normal shifts. The role and functionality imposition misfit caused by the administrative burden hinders EHR-users in achieving effective use, as transparent interaction with the system is impeded.
Workarounds & Reliability issues
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strongly decrease the reliability of EHR-data. Not only for their own outpatient clinic, but also for the other departments that use their data. The other way around, data reliability problems in turn reinforce workarounds, as medical specialists are trying to avoid the use of EHR-data. As medical professionals are aware of colleagues not filling in correct or complete data, they are not able to rely on the system. This leads to representational fidelity problems, which subsequently disables them to use the EHR to make informed actions or achieve effective use. The reliability issue has led to a data misfit, as the data stored in the EHR is not faithful and therefore leads to data quality issues, such as inaccuracy, inconsistent representation and inaccessibility of complete information (Strong & Volkoff, 2010). Also, as medical professionals often chose to search for information of previous treatments, more time is needed, which has led to a functionality misfit (Strong & Volkoff, 2010). As is discussed in the theoretical framework, effective use cannot be achieved without faithful representations of the system, as EHR-users will not be able to make informed actions as they cannot rely on the EHR-data (Burton-Jones & Grange, 2013).
Distractions
Usability and functionality deficiency misfits arise because the system inhibits productivity by showing an abundance of notifications. In every case, the amount of notifications regarding allergies, medicines, unfilled queries and so on is addressed. Whereas on the one hand, warnings regarding medication combinations or allergies can increase the quality of care, it is stated that notifications are showing up for the simplest things. Therefore, the notifications are distracting medical professionals from their work. as every notification needs to be clicked away, which often leads to a loss of focus causes frustration. As a result, a user’s transparent interaction with the system is hindered which can impede the user’s goal attainment (Burton-Jones & Grange, 2013).
