an equity perspective Problems with problem lists in Electronic Health Records

Problems with problem lists in Electronic Health Records

an equity perspective

University of Groningen Supervisor Prof. Dr. A. Boonstra Co-assessor: dr. J.F.J. Vos Word count: 12323

2 ABSTRACT

The implementation of Electronic Health Records (EHR) has increased tremendously over the past years, with some EHRs integrating a problem list in order to register the patient's problem(s). To maximize the benefits of such an implementation, proper utilization of the problem list is essential. However, at this moment in time, this remains to be a challenging undertaking in the healthcare setting. Therefore, this study aims to explain how and why healthcare professionals encounter difficulties with the utilization of the problem list and how these can be overcome. With the use of equity theory and the Equity-Implementation Model (EIM) analysis, this study helps provide insight into user acceptance or resistance to the utilization of the problem list. A qualitative analysis was conducted amongst healthcare professionals working in several different departments in a large hospital in the Netherlands. This study shows that system related factors, as well as user related factors impact the utilization of the problem list and create difficulties. From an equity perspective this study explains how users evaluate these factors and subsequently (partly) resist or accept the utilization of the problem list. These insights can provide help in understanding how to develop strategies in order to improve utilization of the problem list by restoring the perceived equity by users. Key words: Electronic Health Record (EHR), Problem list, Equity Theory, Equity Implementation Model (EIM), User Acceptance, Resistance to Change.

3 TABLE OF CONTENTS

INTRODUCTION 5

LITERATURE REVIEW 8

2.1 EHR systems and utilization 8

2.2 EHR systems and difficulties 9

2.3 Problem-oriented medical record 10

2.4 Equity implementation model (EIM) 11

METHODOLOGY 13 3.1 Research approach 14 3.2 Research setting 14 3.3 Data collection 15 3.4 Data analysis 16 RESULTS 17

4.1 EIM: First level analysis 17

4.1.1 General opinion of the EHR 17

4.1.2 Inputs versus outcomes 18

4.1.3 Perceived benefits and drawbacks of the problem list 19

4.1.4 General overview first level analysis 20

4.2 EIM: Second level analysis 20

4.2.1 Perceived benefits between healthcare professional and management 21 4.2.2 Improper utilization of the problem list affecting benefits 22

4.2.3 General overview second level analysis 23

4.3 EIM: Third level analysis 23

4.3.1 User differences 23

4.3.2 Loss of benefits impacted by other users 24

4.3.3 General overview third level analysis 25

4.4 Factors impacting the utilization of the problem list 26

4.4.1 Potential remedies 28

DISCUSSION & CONCLUSION 29

5.1 Discussion 29

5.2 Theoretical implications 30

5.3 Practical implications 31

4 5.5 Conclusion 33 REFERENCES 34 APPENDICES 39 Appendix A 39 Appendix B 43

5 1. INTRODUCTION

Information technology (IT) is a relatively newly founded area in the hospital context, when correctly utilized, research has shown that hospitals fare better in their financial and quality performance (Devaraj & Kohli, 2003). While healthcare based organizations have typically kept paper-based records concerning patients, many are embracing digital means of health record storage, particularly in the form of Electronic Health Records (EHRs). Every action that had previously been tracked by paper, such as visit documentation, medications and test results can now be fully electronically based, which allows for greater ability of that information to be used in a manner that will affect positive change in the areas of care quality, efficiency, and patient safety (Ratwani, 2017).

However, transitioning from one method of storage to another can be costly, in the realm of millions of dollars, when all aspects of this change are considered, from retraining personnel, licensing software, implementation, maintenance, and hardware related costs (Koppel & Lehmann, 2014). EHR adoption is valuable for the field, and ultimately, a seeming inevitability. If properly implemented, the potential for possible improvements in a wide array of areas in hospital settings is vast, including previously mentioned, improved performance and patient care. The digital medium of EHR allows information to be more accessible and transferable than its paper predecessor (Ratwani, 2017). The research shows there are many benefits of implementing an EHR system in a healthcare organization. However, this is only one piece of the puzzle, as to have actualized gains of the benefits from the implementation of the EHR, the process of those using the EHR must happen in the prescribed manner.

As described above, the EHR is a system that should be utilized throughout the whole cycle of patient care. One of the first encounters for healthcare professionals using an EHR is in the early stages of patient care, the diagnosis registration. Research by Quinn et al., (2019) explores EHR related matters and diagnosis registration. Proper diagnosis requires data from the patient, observation and instruments, as well as information from past healthcare providers in some circumstances. Thus, this information comes from a significant amount of sources and it is up to the current healthcare professional to combine this information in a correct manner. In a normal setting, this information is built upon continuously by the various providers a patient visits, with new data affecting the potential or actual diagnosis. This process can be extremely difficult in certain settings, such as in a hospital, where there may be a number of patients that may be more difficult to diagnose, as they are new to the healthcare provider, with an unknown

6 previous history. One of the main challenges outlined is that the EHR has been stereotyped as being non-user friendly, and difficult to operate. This stems from concerns of incomplete records as well as the inverse of there being too much data to work with efficiently (Quinn et al., 2019).

It is evident that to this day EHR related issues are being researched, still providing space for improvement and new insights concerning the adoption and subsequent proper utilization of this system. In other words, many healthcare professionals experience some state of resistance toward full use of the EHR system (Bhattacherjee & Hikmet, 2007). As described above EHRs provide numerous benefits and open the door for new features to incorporate in the daily operations of healthcare professionals. One of these features enabled by an EHR is incorporating the Problem Oriented Medical Record (POMR). POMR was first mentioned by Lawrence Weed in 1968. With the advent of EHRs the incorporation of a POMR seemed to be a worldwide uptake by vendors and users, enabling the healthcare professionals to structure the medical records in an easily understandable way (Weed, 1968). The POMR translates into the problem list integrated as part of an EHR (Sorace et al., 2020). However, problem lists are frequently not utilized to their fullest extent, which translates into issues related to the completeness, accuracy and outdated patient information registered in the problem list. This results into unreliable data, therefore creating an environment where patient care can be compromised in regards to quality and safety concerns (Singer et al., 2016; Wright et al., 2015). Furthermore, recent research is in line with the aforementioned issues showing that the problem list remains to be an underutilized part of numerous EHRs (Li et al., 2018).

This study aims to explain how and why healthcare professionals encounter difficulties with the utilization of the problem list and how these can be overcome. In other words, exploring the reasons hindering proper utilization of the problem list integrated in an EHR. Furthermore, I look at how this relates to user behavior with the utilization of the problem list as part of the EHR system. Therefore, the following research question has been formulated:

How and why do users encounter difficulties with the utilization of the problem list and how can these be overcome?

In order to answer this question a qualitative research was conducted among healthcare professionals working within several medical departments of a large hospital in the Netherlands, where healthcare professionals have been working with an EHR system for a few

7 years. As previously mentioned, this system facilitates the use of a problem list that is a part of the daily tasks a healthcare professional fulfills. Therefore, to address the research question, this study adopts a user perspective. Subsequently, this study adopts an equity perspective, assuming that a perceived threat related to a new technology introduction can result in a change perceived in equity status of the user (Joshi, 1991). As equity theory proposes that in every relationship that engages in exchanges, an ongoing concern exists in individuals regarding their individual inputs, outcomes, and the overall fairness of the exchange (Joshi, 1991). Therefore, the foremost reason to adopt this perspective is to gain a deeper understanding into what actually hinders proper utilization of the problem list in an EHR and how this relates to user behavior, which can provide understanding of users' reaction, resistance or acceptance of the problem list.

Equity theory translates into the Equity-Implementation model (EIM), which adopts a user perspective in which users evaluate a change, such as EHR use, in terms of its impact on their equity status. Since the model adopts a user perspective, different users might evaluate a new technology differently. Consequently, it is not unexpected that users may evaluate the same change in a different way (Laumer & Eckhardt, 2011). The model assumes that resistance to every individual change does not manifest in an absolute manner. The theory purports that change is evaluated, meaning that an individual may not have any resistance to a change that is positive according to their perception. On the contrary, a change that is perceived as negative will be more critically examined. Moreover, the attitude and perception from a user perspective towards a system can play an important role in acceptance or resistance of that system (Joshi, 1991).

The contributions of this study are threefold. Firstly, this study aims to contribute to the literature regarding the difficulties users encounter with the utilization of the problem list integrated in an EHR, more specifically, to contribute to our understanding of EHR-use and non-use by explaining how healthcare professionals use, misuse and ignore problem lists. Secondly, this study contributes to understanding user behavior of the problem list through the lens of equity theory and the EIM. Subsequently, to explain user resistance as a result of gain or loss in equity status (Joshi, 1991). Thirdly, contributions for practice through managerial implications in order to improve problem list utilization are provided.

This research is structured in the following sections. I begin with the literature review where I elaborate on previous research findings and the theory approach. This includes EHR utilization,

8 EHR difficulties and POMR. Additionally, I elaborate on the equity theory and the EIM and describe how the theory will be utilized in this research. Subsequently, I describe the methodology which includes the research approach, research setting, data collection and analysis. Next the results of the research are described, followed by the discussion and conclusion.

2. LITERATURE REVIEW

In this section I provide an overview of previous research conducted on the most important concepts for this study. The focus is on research regarding EHRs and their identified difficulties so far regarding utilization of the system encountered by users, more specifically, healthcare professionals. Furthermore, I elaborate on the Problem Oriented Medical Record (POMR). Lastly, I discuss the equity-implementation model (EIM) and the three levels of analysis used in this study in order to gain insight into explaining user behavior of the problem list in an EHR. 2.1 EHR systems and utilization

A new technology can affect the way individual users react to the new system. Users could partly use the functions, reject it fully, resist it actively, be reluctant to accept or adopt it completely (Laumer & Eckhardt, 2011). It is evident that individual users have a multitude of options how to proceed with the usage of a new technology (Laumer & Eckhardt, 2011). EHRs are a complex technology that offer multiple functions and features, being embedded in and shaped by complex social environments (Ancker et al., 2014). Researchers argue that to actually experience benefits from an EHR system, it should be used as intended through the protocol embedded into the system (Amatayakul, 2005). EHRs rely on accessing information (e.g. problem lists, prior notes, test results) to make safe and appropriate diagnostic and treatment decisions as opposed to older methods of relying on handwritten notation or memory, both of which can be considered outdated and lacking in the modern context. The key point is that EHRs must be properly utilized so that all information is secure yet easily accessible to the right parties, so as to be able to transmit information pertaining to patient safety and other potentially life-saving matters. The proper utilization enhances recordkeeping via clear legibility, a central point for complete information and connectedness in the network. However, this presupposes the behavior of entering documentation and orders in a clear, correct, and complete way (Holden, 2011). Thus, the EHR system is provided but it is up to the healthcare professionals to utilize the system in a proper manner. Users of a technology require confidence

9 in their ability to use technology effectively. Moreover, research shows when users are aware of the potential benefits as well as the actions taken by the organization to reduce possible risks, they are less apprehensive and more receptive toward support and utilization of the system (Sligo et al., 2017).

2.2 EHR systems and difficulties

The way the EHR is intended to be used is one side of the story, in reality healthcare professionals encounter numerous difficulties regarding the usage of this system. Research on EHR adoption and obstacles while making use of the system has been conducted in a multitude of studies. Research by Goetz, Kuzel, Feng, DeShazo and Love (2012) shows difficulties that arise with the utilization of an EHR system. EHR adoption may have some unintended consequences relating to the change between what has been done and what the EHR requires. One such area is time, which can be seen in both reduced time with a patient, increased time entering information, and increased time explaining the parameters of the system to the healthcare professionals. This change in time dedication to different tasks results in some level of frustration with EHR adoption. To build upon time related issues, there is also the process of learning the system and how to facilitate the usage of it, which is difficult in such a busy work setting as that of a healthcare professional. Thus, the process of learning adds to their work time and stress, with some being apprehensive to this change (Goetz et al., 2012; Yu et al., 2013). Furthermore, their research shows that organizations that adopt EHRs do not seek to transform working styles and norms to fit with this new beneficial technology. This, however, is noted to be a difficult undertaking by organizations that have adopted EHRs, as it can interrupt important primary functions such as patient care (Zhou et al., 2009). Additionally, when changes are made, they are resisted due to a twofold problem of being unsure of why changes are being made and being unwilling or unable to incorporate the new knowledge to engage with these changes. Further, another barrier toward EHR adoption is the lack of knowledge as to what the system is capable of providing. This is present in a learning curve for EHR adoption that physicians may find hindersome to engage with (Goetz et al., 2012).

EHR updates, upgrades, and other issues commonplace to computer systems, such as glitches or having system-based issues such as outages or errors can be a massive concern if a healthcare professional does not have a proper IT support system in place. While there may be some difficulties that can be resolved in time without severe consequences, this is not always the case, and thus this can be a dire concern if the system is down at an inconvenient time. Additionally,

10 building upon the aforementioned time issues, research shows that EHRs can take more time than necessary with some processes, and that the system is not always suitable for every situation that a healthcare professional may encounter. Additionally, the EHR can be unwieldy and confusing for those without an intimate knowledge of the system and learned computer skills. The failures of the software’s interface in relation to the users of the EHR is a concern as to how to adopt such a system in an average practice (Goetz et al., 2012; Miller & Sim, 2004).

Research by Van den Hooff and Hafkamp (2017) elaborates further on the misfits between an EHR and medical work practices. Their study shows that there are various misfits between the system and the workflow and practices. The results show that the system presses formalization and inconvenient work practices on the healthcare professionals which has a negative influence on their daily work practices. Moreover, it constrains the flexibility of their daily work practices. To combat this healthcare professionals turn to workarounds in the form of altering their own routines or altering the use of the system within their work routines. Which affects the usability and homogeneity of the system (Blijleven et al., 2017).

2.3 Problem-oriented medical record

As previously described the concept of problem-oriented medical records was first mentioned by Lawrence Weed in 1968. POMR is also known as problem-based charting (PBC) or problem-oriented charting (POC) and is a form of medical documentation that revolves around the organization of patient data by problem or diagnosis (Chowdhry et al., 2017). The traditional way of keeping track of medical records was based on chronology and different medical aspects such as medical specialty, medication and notes written by doctors. POMR was the first medical record that centered around the medical problem(s) of a patient. One of the components included into the POMR was the presence of the problem list. However, Weed predicted that digitization and computerization would be a requirement to acquire its full potential (1968). Nowadays, numerous EHRs include the problem list as part of the system (Chowdhry et al., 2017). Although the problem-oriented approach is the base of modern EHRs, the reality remains that implementing, organizing and user experience concerning POMR differs tremendously. Interestingly, there are only a few studies that researched the computerized problem-oriented record (Chowdhry et al., 2017). Researches have investigated the processes of coding and linking features within the problem-oriented medical record. POMRs are inherently linked to benefits in areas such as billing and auditing (Nilsson et al., 2003; Wright et al., 2012).

11 Furthermore, POMR facilitates linking problems with medications and possible referrals (Carey et al., 2003; De Clercq et al., 2007). This holds potential for studies researching matters related to patient safety and epidemiology. The essential component, the problem list, has numerous advantages. A problem list that is complete increases the outcome of providing proper evidence based care to patients. Furthermore, adding a problem to the problem list allows healthcare professionals to pursue further care if needed in the future, overall providing better patient care, as opposed to the absence of a problem.

The qualitative study by Bossen (2007) researched the usability of a completely problem-oriented medical record in the setting of daily clinical practice. The study found that physicians spend more time documenting their clinical work. Furthermore, fragmented patient care was mentioned due the absence of an overview caused by the entry of separated problems. In addition, the problem-oriented medical records had the best results with patients who experienced a handful of problems as opposed to more complex patients. However, the digital POMR has been noted by medical professionals that utilize the software frequently to be both fragmented in the method of information entry and requiring more effort in terms of time needed to engage with the system (Kushner et al., 2009; Clynch & Kellett, 2015).

2.4 Equity implementation model (EIM)

Equity theory is recognized as an established theoretical basis in studies which relate to social and organizational context (Greenberg, 1982; Miles et al., 1994). As stated before, equity theory proposes that in every relationship that engages in exchanges, an ongoing concern exists in individuals regarding their individual inputs, outcomes, and the overall fairness of the exchange (Adams, 1963; Joshi, 1991). Furthermore, there is an ongoing comparison by individuals to others in their circle to determine the equity of relative fairness in gains made by others versus themselves. In the environment that equity theory looks at, it is noted that a change in the system can and likely will change inputs and outcomes of all involved in these exchanges. If this results in a perceived negative change in terms of gains, but the others do not experience the same result, there is stress about this fact. According to equity theory, the larger the difference between gains, the greater the stress. Thus, those who perceive a loss of equity will possibly resent and resist the change, and experience resistance by minimizing their own inputs and others outcomes moreover seek out to increase the inputs of others. However, those who see that their equity has increased are more receptive to the change (Joshi, 1991).

12 Based on the theoretical analysis, it is apparent that proper utilization of an EHR remains to be a struggle for healthcare professionals. More specifically, in the context of this research, the proper utilization of the problem list in an EHR. In order to explore how and why users encounter difficulties with the utilization of the problem list in an EHR, how these can be overcome and subsequently how these relate to user behavior of the system, I will apply the model of user perspective on change, namely the Equity-Implementation Model (EIM) based on equity theory (Joshi, 1991). EIM provides an alternative theoretical foundation for investigating how users respond to a new technological implementation and users resistance to change (Joshi, 1991). EIM analysis can be utilized as a tool to bring forth understanding of an implementation of a technological system. Moreover, EIM gives greater insight into understanding different aspects that can be used in determining the resistance or acceptance of a new system, work practice or any other change in a work environment (Joshi, 2005; Lauer et al., 2000).

The EIM is built upon three levels of analysis. Firstly, when analyzing change, recipients of change will examine what will be different in the new system compared to the old, in regards to inputs and outcomes. Changes in inputs are related to for example increased efforts, skills or and any changes in outcomes are the perceived benefits or losses that the user experiences with the implementation. Secondly, users will examine the fairness of the change, this entails if the benefits of the new system have been distributed fairly among users and the organization. Thirdly, they address another factor of this fairness, looking at the impacts that others in the organization are experiencing in terms of input and outcomes. This comparison is to ensure that equity is maintained in the burdens and rewards that are given in spite of this change.

These three levels of analysis will ultimately determine if this change is seen in a positive or negative way and could explain users behavior towards a new system (Joshi, 1991; Hess & Hightower, 2002). To summarize, table 1 provides an overview of the EIM analysis, with a brief description per level that pertains to the context in which this research was conducted.

13 Table 1: EIM (Joshi, 1991)

Analysis level

Focus Evaluation Context of this study

1 User (self) Change in users own equity status

Change in healthcare professionals net inputs and outcomes (equity status) when utilizing the problem list

2 User and the employer

User in comparison with the employer

Fair sharing of benefits between the user (healthcare professional) and the employer (management of the hospital)

3 User and other users User in comparison with other users

Impact on equity when

comparing user (self; healthcare professional) and other users (colleagues; other healthcare professionals)

All the aforementioned analyses are an essential part in the determination of the status of equity by the recipient of change. The second strategy of converting the viewpoints of the inputs and outcomes of employees and their co-workers. Training and communication have the highest chance of changing these perceptions, as they can be used to demonstrate what inputs and outcomes actually exist and how benefits are subsequently rewarded, filling in knowledge gaps that may skew the truth from the viewpoint of one party versus another. Thus, this training and communication can paint learning as beneficial to job performance, something that benefits every party of an organization, presenting what upgrades can do for the users. Additionally, the parts of the new system that are particularly beneficial can be highlighted, especially as they pertain to the quality of work. Additionally, explaining benefits versus inputs and outcomes can show the rationale of fairness, as well as emphasize the ability of the organization to thrive and keep a level of job security (Joshi, 1991).

3. METHODOLOGY

In order to answer the research question, a qualitative study was conducted in a large hospital. In this section, the methodological aspects of this study are described. It begins with the description of the research approach and the research setting. It is then followed by the data collection and the analysis.

14 3.1 Research approach

The goal of this research is to identify and understand the different factors that impact the proper utilization of the problem list in an EHR from an equity perspective and to relate these factors to users’ behavior of the system. The research has been conducted using a qualitative approach in the form of semi structured interviews. The qualitative approach allowed for different parts to be taken into account such as healthcare professionals from various departments in order to explore or explain different occurrences and situations. Through the use of qualitative research it enabled me to explore how and why healthcare professionals use an EHR in a certain way (Korstjens & Moser, 2017, p. 278). Furthermore, Edmondson and McManus (2007) also suggest that open-ended research questions are in line with a qualitative data collection method. Additionally, a research based on interviews allowed for open-minded data collection which allowed me to gain deeper insights.

3.2 Research setting

Currently, the hospital faces difficulties regarding EHR utilization, more specifically, the utilization of the problem list. Healthcare professionals in the hospital should use the problem list integrated in the EHR as part of their daily tasks according to the guidelines established for the utilization of the system.

The research began with a phase dedicated to orientation and specifying the research question and the research goal. Several conversations with multiple employees of the hospital led me to the healthcare professional invested in the EHR-implementation, post-implementation and proper utilization of the system in the hospital. After this phase it was decided that the best approach would be to conduct the research with healthcare professionals from different medical departments. Because of the nature of the medical specialty one department is in need of more in-depth patient information than healthcare professionals from other departments (Chan & Ahmad, 2011). Therefore, I have chosen a variety of medical departments to investigate factors that impact the proper utilization of the problem list.

The research was conducted amongst healthcare professionals that work in four different departments within the hospital. Namely, 1) Pediatrics, 2) Internal Medicine, 3) Surgery 4) Obstetrics & Gynecology. The healthcare professionals in the aforementioned departments utilize the EHR and the problem list in their daily work activities.

15 3.3 Data collection

As stated before, I agreed that the interviewees for the research would first be approached by my contact persons involved in the EHR-implementation and utilization of the system. Interviewees were first contacted by the aforementioned healthcare professional through email. After agreeing to participate in the interview, I scheduled the appointments with the healthcare professionals, resulting in the total number of 16 interviews being conducted. Table 2 provides an overview of the interviews.

First, the interviewees were provided an opportunity to sign an informed consent form before or after the interview, in which aspects such as research goal, use of the data, and anonymity were expressed to them in order to assuage any concerns they might have regarding their participation. Additionally, interviewees were asked if the interview could be recorded to ensure an as accurate possible transcribing process. The questions for the interviews were of semi-structured nature to ensure that there was additional room for participants to provide their experiences, information and insights. The questions for the interview were divided in different sections. Starting with general questions regarding the implementation of the EHR, training and opinion of the EHR. Followed by specific questions regarding the interviewees knowledge about POMR and the guidelines for the problem list. Thereafter transitioning into questions related to EIM analysis on the three different levels. The interviews were conducted based on an interview protocol. Both the Dutch and the English version of the interview protocol can be found in Appendix A. All interviews were conducted in the native language of the interviewees, namely, Dutch. Conducting interviews in the interviewees’ native language holds language as a powerful way to form a bond and a sense of connection (Welch & Piekkari, 2006). Additionally, the aim of the research was to conduct the interviews face to face. Unfortunately, because of the COVID-19 pandemic this was not feasible. Only four interviews were conducted face to face, one interview was conducted via the phone and the remaining 11 interviews were conducted through a video-call program such as Google Meet and Microsoft Teams.

16

Table 2: Overview interviewees

Department Code Interviewee Medical specialty Duration

A A1 Medical specialist 53:02 min.

A2 Medical specialist 29:44 min.

A3 Medical specialist 52:55 min.

A4 Medical specialist (in training) 47:30 min.

A5 Medical specialist 41:15 min.

B B1 Medical specialist 39:55 min.

B2 Nurse practitioner 53:05 min.

B3 Medical specialist 39:35 min.

B4 Medical specialist 24:26 min.

B5 Medical specialist 43:08 min.

B6 Medical specialist 34:37 min.

C C1 Medical specialist 29:32 min.

C2 Medical specialist 28:11 min.

C3 Medical specialist 18:20 min.

D D1 Medical specialist 45:54 min.

D2 Medical specialist 38:32 min.

3.4 Data analysis

First, the audio recordings of the interviews were transcribed literally. The transcripts were used as input for the program ATLAS.ti to analyze and code the interviews. Coding in qualitative research enables researchers to identify, organize and build theory to achieve the goal(s) of a

17 study (Williams & Moser, 2019; Gephart, 2004). Therefore, the coding process in this study was inductive.

The coding process involved the following steps: open coding, axial coding and selective coding (Moser & Korstjens, 2017). The coding process started with open coding. This entails labeling relevant (parts of) sentences or sections from the transcripts that hold valuable information known as first order coding. The relevant parts that were labeled were based on differences, opinions, processes, actions. activities etc. In sum, anything that could be relevant for the research, for example when an interviewee stated certain issues multiple times, or the interviewee emphasized the importance of a certain matter. After the first part of the analysis, the open coding, many codes were created. I continued to go through the codes that emerged and combined some codes that were similar to each other. Thereafter, I proceeded to group codes into overarching second order themes. These are the categories that label multiple codes together known as axial coding. Subsequently, the last phase of the analysis consisted of selective coding. This part consisted of combining the aforementioned categories from axial coding into themes. The codebook can be found in Appendix B.

4. RESULTS

Numerous factors mentioned by the healthcare professionals were identified that impact proper utilization of the problem list. I examined the results based on the three levels of analysis of the EIM and the perception of the user regarding the problem list. Furthermore, I looked at the benefits and drawbacks of the problem list, and consequences and effects on various aspects concerning the problem list.

4.1 EIM: First level analysis

The first level of analysis of the EIM model looks at the inputs and outcomes of the user with the implementation of the EHR, pertaining in this study to the proper utilization of the problem list when registering patient problem(s).

4.1.1 General opinion of the EHR

Interviewees were asked about their overall opinion of the EHR, all agreed that it was better than the previous system(s) they have worked with in this hospital. Although some aspects regarding the complexity of the system were mentioned, the final verdict seemed to be more positive than negative. One interviewee stated that working with paper records was still in place

18 before the EHR was introduced: “Well I think the EHR as a whole is a progress because I think that a paper file is really out of date” (A2). In addition to this, interviewee A4 expressed: “I like it, I like the system, but especially that it is one system in which we have everything” (A4). 4.1.2 Inputs versus outcomes

The most important factor mentioned by the interviewees is the input of time. Interviewee B1 states the following concerning the time investment for the proper utilization of the problem list: “Yes time, I think it is a very important thing. And I also think that I don't find it super useful so then yes uhm there is still the question of how much energy you are going to put into it of course” (B1). Furthermore, additional time consuming efforts are also linked to various improper ways of utilization of the problem list by other users: “It takes time. Yes you are also partly filling in the missing registration of colleagues. Or uhm double problems that can be merged in it and I sometimes find it difficult that.. yes.. not everyone works in the same way” (B3). A similar answer was given by another interviewee: “Well a lot of time, it really takes time to make it tidy. This is also because patients we see have often already visited three other specialists who have usually made a mess of it. So it takes a lot of time [...] and that also causes frustration because you are actually doing someone else's administration. Yes, so that's what it costs. Especially a lot of time and also frustration” (B6). All of the interviewees mentioned time consuming matters when it came to problem list inputs. The extra time necessary to utilize the problem list is seen as more administrative work to enter in the data. An additional factor such as skills was mentioned as an input to properly utilize the problem list “Mainly time and skills I think” (B4). This implies an increase of the input regarding effort to learn the new system.

Subsequently. interviewees were asked about their perception of the inputs versus the outcomes with the use of the problem list, specifically, if the inputs and outcomes were in balance or imbalance. A variety of answers were given regarding the question. Some interviewees felt that there was a balance between inputs and outputs: “Uhm yes, and by that I mean, it doesn't take a lot of energy to open or close a problem. And you don't get much in return other than a clear overview of what's going on. I find that in balance” (C2). Others stated that there was an imbalance: “It is not completely symmetrical, you have to put in more than what you get out” (B4). One important factor mentioned by several interviewees is the preliminary work carried out by the Medical Administration (MA). Interviewee C1 stated: “Well I think so, at least with

19 the help we get it is well balanced. And that the medical administration fills it in, in advance, we only have to check it” (C1).

When asked about the balance before the MA did part of the work concerning the problem list interviewee C1 stated: “In the beginning it was not, so the input that you have to do yourself is much larger. The input has now become much lower because someone else does it for you” (C1). However, problems regarding the proper utilization of the problem list still remain in the department of interviewee C1 despite preliminary work carried out by the MA. This is due to the fact that preliminary work carried out by the MA only applies to new patients, thereafter, the healthcare professionals are responsible for the updates and actualization of the problem list of their patients. This becomes clear with the next statement of the interviewee: “And I think the next step is that we do that too, that we keep it up. That you just check it, update it, so maintaining a problem list, I think that could be even better” (C1) and “When you are with a large group, because there are ten of us and one does the work and the rest does not, then the system does not work. I really like how the EHR is set up, but then you have to do it all according to the agreement. If half of them fail to do so, it will take a lot of time afterwards” (C1). Furthermore, interviewees perceive a difference in balance of inputs and outcomes concerning patients that are under their care for a short period of time versus a long period of time. The following quotes indicate this matter: No, I only find that in balance if you have known a patient longer and therefore that investment is worth it. But with a short contact I find that it is not in balance” (B1) and “But it will ultimately save you a lot of time if you see that patient more often [...] If I think I am going to see that patient once or twice then I will not do it [...] And what I said, we are certainly a bit selective in what we do, how extensively we do that per patient. In the end, I think what you put in it outweighs what it brings you” (A2).

4.1.3 Perceived benefits and drawbacks of the problem list

Additionally. interviewees were asked what benefits and drawbacks they experience when utilizing and entering information into the problem list. One of the advantages mentioned by an interviewee is the accessibility to the EHR and the problem list from home and other devices: “You can log in properly from home, so it is very nice to be able to do this from home [...] and you can have it on your phone” (A2). Furthermore, the benefit of having one central point where the problems of the patient are registered, interviewee C2 expressed the following: “Well if you do all that consistently then you can see at a glance what the patient has. And what they are being treated for and what is going on. And if, if used properly, then you have a great

20 overview” (C2). This statement is similar to the quote of interviewee A4: “But if that were the case that not only me but also others keep it very neatly, the advantage would be that you have the correct information very quickly in a very simple way. And that would save so much time that you would have time to keep up with it again” (A4). Referring to utilizing the problem list, updating it and keeping track of patient problems in the system.

Other benefits are mentioned in the following quote: “Yes for logistics, at patient level and scientific research. And I think it would be safer if we all use it the way it is intended. Then you have uniformity in the house and it is also safer if my patient comes into the emergency room. And if I have neatly updated the problem list, it is safer for the patient” (B2). Similar advantages are stated as well by another interviewee: “There are also advantages to this because we can also keep an eye on things and collect data better” (C1).

A drawback of the problem list is that the amount of administrative work has increased: “Yes the registration burden for us has become much higher since the new system” (C1).

4.1.4 General overview first level analysis

In the first level of analysis, users evaluate the impact of the implementation of the new system (i.e. problem list). The changes in outcomes consist of the benefits or losses put forth by the problem list as part of the daily work activities. Altogether, when looking at the inputs of the use and the outcomes of the problem list, the benefits and drawbacks of the problem list in the first level analysis show that the majority of the users feel that they have to invest more (inputs) than they receive back from utilizing the problem list (outcomes), pertaining to an inequity perceived by the users when utilizing the problem list. The perceived benefits do not outweigh the time consuming demand they experience when using the problem list. Furthermore, interviewees who showed motivation to utilize the problem list in the proper manner felt frustrated and experienced decreased motivation to do so because of improper utilization of the problem list and the lack of inputs by other users.

4.2 EIM: Second level analysis

In the second level analysis interviewees were questioned about their perception of fair sharing of the benefits and drawbacks of the problem list for the organization, pertaining to the people leading the hospital such as the board and other executives involved in the decision making process of implementing the EHR and subsequently the problem list. For the sake of

21 clarification I have used the word management as a general umbrella term to indicate the board and the upper management of the hospital.

4.2.1 Perceived benefits between healthcare professional and management

Interviewees indicated different opinions regarding who experiences the benefits and drawbacks of the implementation of the EHR and working with the problem list. Interviewee A1 expressed the following about the fair sharing of the benefits of the implementation of the EHR and the problem list: “Then I would say in management because it is simply very difficult for the healthcare professionals to do it well and to keep it clear” (A1). Other interviewees stated the following, where the perceived fair sharing of benefits also pertains to the healthcare professionals: “Well, I actually think we have just as many benefits from it” (A4) and “I think it is very convenient for the management because they can monitor things much better. Being able to get data from the system much better. So there are advantages to that [...] There are also advantages for us because we can also keep an eye on things and collect data better. Yes, the registration burden for us has become much higher since the new system. That is the disadvantage and I do not think that is an advantage for the management because they only get comments about it” (C1). Interviewee C1 indicated that benefits exist for both the management, as well as the healthcare professionals. However, the interviewee noted that through the increased registration burden other users express negative feelings toward the problem list indicating that the benefits this interviewee (C1) perceives might not be something that other healthcare professionals perceive and experience.

Furthermore, another interviewee indicated that the end users, the healthcare professionals, are the ones who actually have to work with the system and the problem list. Therefore, they carry the weight and the fair sharing of benefits is not evident to them: “Of course, the burden of it, how difficult it is, of course lies with the end users [..] I do think that it has a somewhat negative tone, well we have to work with it and little is done about how that is supposed to be done, that is something that could be facilitated better” (A3). The fair sharing of the benefits of the EHR and the problem list are not perceived, since the healthcare professionals are not supported properly to utilize this in terms of facilitation.

The motivation for the management perceived by the healthcare professionals for the implementation of the EHR and the problem list as a part of daily activities is mostly linked to correctly registering, not only patient problem(s) but the link with DBCs (diagnosis treatment combination, whole set of medical activities and interventions) and other financial aspects such

22 as insurance related matters. Interviewee A1 continues: “Well, what they especially want to see as an advantage is that things are easier to register, so not only diagnoses for which the problem list is intended, but also what you do, so DBCs, so that the hospital receives money for the work you do [...] so they are mainly concerned with [name EHR], I think, that there is much better registration of what is happening and what we as healthcare professionals do” (A1). The perceived benefits for the management by an interviewee is that everything has become measurable in terms of patient care and daily work activities. The following interviewee pointed this out: “For the management everything is measurable I think. They can see exactly how long everything takes, and they can get a lot of data” (C3).

4.2.2 Improper utilization of the problem list affecting benefits

Another interviewee indicated a similar opinion regarding the benefits of the implementation of the system for the management of the hospital but added an important aspect to fully realize these benefits: “What the management wants of course is that the DBC registration is done properly and what they naturally want is to generate reports I can imagine. They can of course also use them to collect information, for example, which diagnoses often occur or things like that, so they can then perform certain registrations. Uhm so that's a very clear advantage for them. Only if those lists are not filled in properly, you wonder what you are currently printing” (B1). Interviewee B1 shows that to fully realize the benefits of the implementation of the EHR and the utilization of the problem list you have to use it in the proper manner. Interviewee B2 indicated the same matter: “If we don't do it right, they don't have the correct numbers of course”(B2) and so did interviewee D1: “Look if you would all register it completely correct, that would benefit the management enormously, but as long as we do not fill it in correctly, then the numbers are also biased” (D1).

However, interviewees also mentioned that the data registered in the problem list is not reflecting the truth because of the improper utilization of the problem list. This concern is expressed in the following quotes: “Even more so, it is not only the trust but I also know it is not used in that way so I know if I only read the problem list it is not up to date” (A4) and “I don't trust it, it is not up to date, especially when you see a last review from 2019 [...] then you will have to go through the problem list because the patient has been seen by a number of healthcare professionals afterwards” (A5).

23 4.2.3 General overview second level analysis

From the second level of analysis, it is clear that the majority of healthcare professionals can see the benefits of the problem list for the management of the hospital. The benefits include better registration of financial aspects, patient data registration and the monitoring of healthcare professional work activities. The healthcare professionals indicate that they also benefit from the EHR and the problem list, however this is overshadowed by the burden they face through using and working with this system. Moreover, improper utilization of the system is an aspect that hinders the potential to maximize and realize the benefits that could be created for the healthcare professionals and the management of the hospital.

4.3 EIM: Third level analysis

At the third level a user compares their relative outcomes with that of other users (this was linked to other users within their department but also colleagues from other departments). Does the new system impact all users similarly, or does the system result in increasing some users' equity and lowering others? Thus, there are changes in the inputs and outcomes for users due to the integration of the problem list in their daily activities compared to that of other users.

4.3.1 User differences

Interviewee A4 indicated an important factor regarding user differences: “I think there is a lot of variation between individuals and ways of working and the advantages and disadvantages that people experience as a result. Because that is partly not organized, how people have agreed to work with it, but partly also dependent on individual skills” (A4). This shows that user differences vary between how people utilize the problem list and the subsequent benefits and drawbacks users experience from it. Furthermore, a clear agreement and a way of working with the problem list is missing which is part of the variation between users. In addition to this, the variation of skills is also seen as a factor impacting user differences.

Besides the above mentioned user variations by interviewees, the attitude other users have toward the EHR and the problem list was also mentioned by interviewees. The following quotes indicate this: “I am sure that other users experience it differently. That means that some people know how to get a lot more out of it than I do and can probably make it work much more for them. But I think a lot of people in particular might use it less well and are less familiar with what can be done, or run into problems that they cannot solve, and therefore have a kind of aversion to the EHR. I know that there are a lot of colleagues out there who actually think it is

24 a necessary evil and do not really want to own or make the program their own. And that those people suffer from it much more than I do” (C2) and “Yes, so you could say that the person may have more problems with it because apparently he/she finds it difficult, or they do not succeed, but yes, it is also a matter of attitude, what do you do with it? (A3).

Interviewees did not mention that they perceive that other users have more benefits of the system since this is tied to the users own investment of time and effort to increase their skills and capabilities to properly utilize the problem list. Several interviewees who perceive their own skills above average in comparison to other colleagues indicated the following: “Everyone deals with it in their own way. I do think that compared to the average colleague I have a little less technical difficulty with this because I have also studied how it could be done [...] my colleagues on average have more problems with it. At least assuming they want to do it the right way. But an average colleague of mine also lets it go more, who thinks it will all be fine, I don't have time for that” (A3). And “I think that my colleagues experience even more disadvantages because they just say this is way too complicated. I will not do this, period. So I think my colleagues are experiencing more difficulties and more disadvantages than I do. Because I have been trained in it a bit more” (B6).

4.3.2 Loss of benefits impacted by other users

It is noted that there is a perception of perceived losses of benefits with improper utilization of the problem list. Interviewees who have invested more time and effort to get familiar with the problem list, the guidelines and are trying to properly utilize it, experience less difficulties with the system overall. Considering that all healthcare professionals are expected to work with the EHR and utilize the problem list, it becomes a group effort to keep everything organized and up to date in the problem list. This is connected and intertwined with other users from different departments. Notably, the users who invested more time in order to expand their knowledge of how to properly utilize the system and have the motivation to do so, encounter difficulties and experience frustration causing them to not experience and achieve the full benefits of the additional effort they have invested to properly utilize the problem list. The following statement by interviewee A4 indicated this: “Yes because then you also benefit from the work of others while now, I see a patient, I put a lot of time into it and six months later my colleague sees that patient and he does not use all the work that I put in and then six months later I see the same patient again and then I have to see if it is all still up to date. So it feels a bit like double work” (A4). Therefore, the healthcare professionals who are motivated to use the system and have

25 invested extra time to learn how to work with it, do not reap the benefits of the system at all, because other users do not use the system as they should be using it. Consequently, in the end, no one has the full benefits from the utilization of the problem list.

4.3.3 General overview third level analysis

From the third level of analysis it is clear that the users do not perceive that the problem list holds more benefits for other users (i.e. colleagues) in comparison to those of themselves. However, a perceived loss of benefits is expressed from users who invested more time and effort to get familiar with the system and the problem list. Therefore, they experience a loss in benefit which translates into a decrease in motivation and increase in frustration when utilizing the problem list. The lack of a clear agreement between users of the EHR system adds to these problems.

To summarize the results of the three levels of EIM analysis, a complete overview of the most significant results is presented in table 3.

Table 3: Complete overview EIM analysis

Level 1 Changes in inputs Changes in outcomes Perception user

Increased time investment entering data

Increased effort in learning to work with the EHR and the problem list

Accessibility of the problem list from home and through additional devices (phone) One central point to register patient problems

Collecting patient data for various purposes

Increased registration burden

There is an imbalance perceived where the users on an individual level feel that the inputs outweigh the outcomes

Selectiveness in utilization of problem list of short-term patients versus long-term patients

Loss in motivation to keep using the problem list

Level 2 Benefits healthcare professional (user)

Benefits management hospital (employer)

Perception fair sharing of benefits between user and

employer

Collecting patient data Patient information access

Increased measurability of data Increased preciseness of financial aspects such as billing and health insurance

declaration

Increased ability into monitoring healthcare professionals activities

Overall there is a mixed perception of the fair sharing of benefits of the EHR and the problem list between the healthcare professionals and the management

Improper utilization hinders the maximized benefits that can be obtained, the

26

realization of this holds value (benefits) for the hospital and the management as well as for the healthcare professionals

Level 3 Outcomes user Outcomes other users Perceived impact on equity user compared to

other users

Decreased motivation to utilize problem list as a result of the improper utilization of other users

Increased frustration caused by improper utilization by others Increased dependence on others No shared responsibility and/or awareness

Ambiguous feeling toward proper utilization of the problem list and the consequential agreement.

Saving time by not using or not properly utilizing the problem list

Users do not perceive that other users have a greater advantage or disadvantage when working with the problem list

Users acknowledge that other users who gain more skills through training benefit probably more from the problem list

4.4 Factors impacting the utilization of the problem list

Moreover, as stated above, specific factors related to utilization of the problem list have been mentioned by interviewees. They can be divided into 1) system related factors, pertaining to the EHR system itself such as the complexity of the system: “It just has to be easier to edit with less clicks, less rigid link with the care activities registration” (A3) and the DBC registration, referring to the whole set of activities and interventions of the medical specialists registration in the problem list: “I also find the DBC registration very complicated to find, where the DBC's are and what they are related to, that is ultimately why someone registers a problem, in order to be able to open a DBC” (B6). Additionally, 2) user related factors such as the lack of uniformity when utilizing the problem list. It is apparent that most of the benefits listed by the interviewees can only truly be actualized with proper utilization of the system by the users. This is also indicated in the following quotes: “Well, it does not necessarily have to be changed in the EHR but I think if everyone just keeps it neatly, it will bring a lot of benefits” (A2). Interviewee C2 captures multiple factors relating to the issues such as a lack of mutual awareness, taking responsibility on an individual user level but also on a department level:

27 “I think we need some kind of general awareness about it, that actually starts with what we all indeed agree on about the problem list. And that it is the same between departments. Uhm and then a kind of awareness of all users, that you just have to put in a little bit every time instead of a lot every now and then. Or a lot on the shoulders of one user. So if people are a little more aware of how you can easily use the problem list, then you can also get more out of it alone without having to be frustrated about it” (C2).

There are several consequences mentioned by the interviewees regarding improper utilization of the problem list related to user behavior. There is a decrease of trust concerning the information registered in the problem list of a patient: “Look at information in different places before you feel completely sure that you actually have all the relevant ones” (B3). Interviewee C2 stated a similar opinion: “Yes, because I do not trust that it is correct, so I will check that again in notes and in dismissal letters. If I have to do something with that patient myself, yes” (C2).

Furthermore, workarounds are being created to bypass the system in order to not utilize the problem list in their daily work activities: “[..] but I must admit that our department is not working with this yet [...] So until now, we do not work with the problem list and the history, but we have a heading of the history in our letter and there it is written out fully what the medical history is” (B2). This can potentially result in compromising patient safety because different departments and users will store their patient data in places unknown to other users. The following statement explains this: “But what I actually think is unsafe, what my criticism is to the team is that other people don't look there anymore. It is very easy to find for us and it is very complete for us and we are meticulous in keeping those plain texts up to date, we always do that very consistently, but that is not in the right place where other people are looking for it” (B2). Additionally, there are no formal consequences from management if healthcare professionals do not utilize the problem list: They actually do something that is against the rules, but that is generally accepted within such a hospital [...] in 2017 you are told how to use the system and then it is up to you whether you do it or not. There is optional training but there is no mandatory update training. But no one says: how is it possible that you don't do it? You don't obey the rules. We are going to make an action plan for this and I want it to be different within three months” (B2). Thus, the absence of formal rules creates a lack of repercussions, related to improper utilization, which creates no motivation or feeling of responsibility to properly utilize the problem list.

28 4.4.1 Potential remedies

As described above, interviewees indicated numerous difficulties regarding the utilization of the problem list in the EHR and problems they encounter with the utilization of it. Since the interviewees are the end users, they were also asked about their suggestion(s) regarding the necessary change(s) to improve the utilization of the problem list. Pertaining to the problem list requiring less inputs and providing an increase in outcomes for the user(s). Table 4 provides an overview with regard to the indicated problems related to potential remedies mentioned by the interviewees.

Table 4: Overview indicated problems and suggested remedies by users

Indicated problem Potential remedy Associated quote(s) 1. Complex system - Increased ICT

support

- Increase flexibility of the system

- Try to make the system conform better with the workflow

“It could be made slightly more user-friendly. That you can still get it filled in with fewer clicks” (A2).

“But that does not alter the fact that the ICT support could be much better”

(A3).

“For example, if that process became easier, maybe a bit more intuitive, that would really help” (C1).

2. Lack of knowledge

- Increase training and updates regarding problem list utilization through physical training and e-learnings

- Increase the amount of superusers in the form of physician builders

“I will just name a time span, having a meeting once every three months with a bunch of people. So and so, this has changed, that's how we're going to do it” (D2).

“If it were to be invested more from the management network in physician builders, because in my opinion those are the people who make the difference [...] but those are the people who work with that system every day and who have more knowledge of the EHR. I think that much more should be invested there” (B2). 3. Lack of uniformity regarding the problem list utilization - Make work agreements regarding problem list utilization within departments and also interdepartmentally

“So I think that is a very good system to get an overview and if everyone would stick to it, it would work even better”

(A2).

29

differences in the use of the system and yes you need a lot of work agreements between each other” (D1).

4. Lack of responsibility and awareness - Make agreements about who is responsible - Increase awareness through noting the importance and possible benefits and usefulness of the problem list

“You must start with a new patient with a good problem list and you must keep it up to date and it must be clear whose responsibility that is” (A5).

“If you all say this is so important to us, it can yield so much [...]” (A5).

“More than just rules are needed to keep to the agreements. This requires that you feel jointly responsible for your patient [...] and that you see its

usefulness” (B5).

5. Lack of formal regulation

- Increase mandatory trainings and check if they are completed

“I think yes that should be done more with mandatory e-learnings [...] but someone has to physically check and ask why didn't you, and that's just childish but I think that's the only way”

(B2).

5. DISCUSSION & CONCLUSION

This section discusses the main findings of the study in relation to prior literature. Additionally, the theoretical and practical implications are described followed by the limitations, suggestions for future research, and the conclusion.

5.1 Discussion

In this study, I have applied equity theory and the EIM analysis in order to answer the following research question:

How and why do users encounter difficulties with the utilization of the problem list and how can these be overcome?

The results from the EIM analysis indicate that they hold significant importance for explaining this (Adams, 1963; Joshi, 1991). First and foremost, the findings show that the increase in time to enter patient data in the problem list is seen as the greatest input the problem list requires

30 from an user. As expected, based on previous literature, this result ties with previous studies wherein the same time demanding input from users was found (Clynch and Kellett, 2015; Goetz et al., 2012; Kushner et al., 2009). EIM analysis uncovered a perceived inequity by most users when comparing the inputs and the outcomes with the utilization of the problem list. This is an important finding in the understanding of user behavior of the problem list. Namely, users who perceive this inequity will seek to reduce this inequity through the alteration of inputs and/or outputs (Joshi, 1991). Based on this perceived (in)equity a user might (partly) resist or accept the problem list in their daily activities with (im)proper utilization of the problem list as a result. One of the unwanted results of improper utilizations is that users therefore could result in the creation of workarounds which is likely to impede on the realization of the benefits (Blijleven et al., 2017; Van den Hooff and Hafkamp, 2017). Time demanding work such as that of a healthcare professional plays an important role in the perception of the inequity since administration of patient data is more often seen as a burden rather than a blessing. Subsequently, the fair sharing of benefits of the problem list between the user and the hospital's management is perceived as mixed from a user’s perspective. However, as expected, almost all users recognize the perceived benefit of the implementation of the EHR and the problem list holds for the management of the hospital to increase the accuracy related to billing procedures. This perceived benefit by users for the hospital's management has indeed been mentioned by previous studies (Nilsson et al., 2003; Wright et al., 2012). The findings indicate that as users perceive minimal benefits from the utilization of the problem list, their motivation to continue using it decreases as well as their effort, which results in a lacking or minimal effort to utilize it. Furthermore, this also ties to how users perceive their own equity in comparison to other users of the problem list. There is an asymmetry perceived in the impact on the equity by several users when compared to other users. The lack of uniformity and homogeneity amongst users has an impact on the overall utilization of the problem list which relates to the aforementioned lack of inputs such as time entering data and effort to learn new skills in order to utilize the problem list properly. This results in increased user stresses and frustration and decrease in motivation.

5.2 Theoretical implications

This study contributes to the current literature on EHR utilization, more specifically, problem list utilization. Furthermore, research through the lens of equity theory and the EIM provides insights to not solely on how and why users encounter difficulties with the utilization of the problem list in an EHR. Moreover, it contributes to the deeper understanding of a user’s