Responses to Electronic Health Record workarounds

(1)

Master Thesis

Rosan Gortworst (S3534286) r.l.gortworst@student.rug.nl

University of Groningen

MSc Business Administration – track Change Management 6 march 2020, Groningen

Supervisor: Prof. Dr. A. Boonstra Co-assessor: Dr. J. F. J. Vos

Word count: 16506

(2)

2

Abstract

Healthcare providers are struggling to fully benefit from the implementation of the EHR, because health professionals are developing alternative ways of working than prescribed by the EHR, known as workarounds. The literature mentions various perspectives of

workarounds. This research aims to improve the understanding of the various perspectives expressed by health professionals by taking into account the context in which workarounds are performed. Therefore, we identify and analyse responses to workarounds. These responses reveal the perspectives that health professionals hold regarding workarounds. A qualitative analysis at a Dutch hospital is conducted in which 17 interviews and 10 observations are held with health professionals and members of the EHR project team. This resulted in fifteen responses to workarounds shown by nurses, physicians, administrators, managers and the EHR project team. The scale of the responses are categorised as ‘engaged’, ‘compliance, ‘non- compliance’ and ‘reluctant’. The results indicate that various stakeholders give contradicting responses to workarounds. Therefore, this research shows the complexity of dealing with workarounds based on the divergent responses and mutual relationship between stakeholders. This makes it difficult for a manager to respond adequately to workarounds.

(3)

3

1. Introduction

Organisations are facing a digital transformation. However, this transformation does not always goes smoothly (Consultancy UK, 2015). The failure rate of digitised projects is between 66% and 84% (Libert, Beck & Wind, 2016). Rogers (2016) states that the main reason for the high failure rate is that organisations “are not prepared to change behaviour’’. Another challenge for organisations is to deal with the so-called ‘Amazon effect’, where the customer expects the same level of customer services provided by Amazon (Cisco, 2016). Not all organisations can match these expectations (World Economic Forum, 2016).

One of the industries struggling with digitalisation and matching customer expectations is healthcare. According to a report by Chilukuri and Van Kuiken (2017), the healthcare industry has a low digital maturity rate. One example of struggling with digitalisation is the adoption of the Electronic Health Records (EHR) by healthcare providers. An EHR is “longitudinal electronic records of patient health information” (Klecun, Zhou, Kankanhalli, Wee, & Hibberd, 2019, p. 2). The Dutch government wanted to implement a national-wide EHR. Although the government invested 300 million euros, the project failed due to privacy concerns. Therefore, every healthcare provider has implemented their own EHR (Van den Berg, 2017). As a result, healthcare providers face difficulties with sharing patient data (Jongejan, 2019). This frustrates patients as they expect their patient information to be shared among healthcare providers and health professionals to be aware of their medical history (Patientenfederatie Nederland, 2011) Additionally, the use of the EHR is mentioned as a contributor to burnouts among health professionals (Beresford, 2016; Hecht, 2019). Health professionals spend 44% of their working hours on entering data, and this even spills over into their free time (Jongejan, 2019).

It becomes clear that health professionals are struggling to fully benefit from the EHR, as it is not always aligned with their clinical working routine (Blijleven, Koelemeijer, Wetzels, & Jaspers, 2017; Hecht, 2019). Therefore, some health professionals are developing alternative ways of working, such as writing down patient data on paper instead of updating the EHR. Such an alternative is an example of a workaround, defined as “behaviours users adopt to

overcome perceived limitations in a technical system” (Friedman et al., 2014, p. 78).

(6)

6 information with a nurse such that the nurse can order medication, 2) fill in data in a different field as intended by the EHR’s designers, or 3) bypass prescribed steps. Health professionals are developing workarounds to maintain their established working routines, which they believe are more efficient and effective (Alter, 2014).

Whether a workaround is perceived as efficient and effective depends on the stakeholders’ views. Health professionals who perform the workaround view it as a tactic that helps adapting the EHR to their established clinical working routines (Cresswell, Bates, & Sheikh, 2013). However, managers might view the same workaround as inefficient or as violating the agreed working process, creating unreliable patient data and decreasing patient safety. The literature shows that perspectives of workarounds are diverse and contradictory (Alter, 2014; Azad & King 2012; Malaurent & Avison, 2016).

The effect of these differ perspectives on the life cycle of workarounds is unclear. Besides, various other factors influence the life cycle of a workaround. Mechanisms such as power relations (Beerepoot et al., 2019) and negotiation about the workaround (Azad & King, 2008) also affect workarounds’ life cycle. Moreover, it is unclear what determines the duration of the workaround life cycle; some workarounds disappear quickly whereas other workarounds become routines. Alter (2014) and Blijleven et al. (2017) argue that more research is needed to understand the dynamics of workarounds, where the context in which the workaround is performed, is taken into account. This research will contribute to the literature by clarifying the dynamics of EHR workarounds by examining how various stakeholders respond to workarounds. However, many managers are unsure how to respond to workarounds

(Beerepoot & Van de Weerd, 2018). This research will help managers respond appropriately to workarounds by taking into consideration the responses of health professionals. The aim of the research is to identify and understand responses to workarounds by taking into account the context in which the workaround is performed.

This leads to the following research questions: What are the responses of stakeholders to

different types of EHR workarounds? and What are the responses for each type of EHR workaround per stakeholder? and Which solutions are used in responding to each type of EHR workaround? The research questions will be answered by performing a qualitative

(7)

7 The remainder of this thesis is organised as follows. First, we review the literature about workarounds. Second, we describe the research setting and methods. Next, we present the results regarding responses to workarounds. Finally, we answer the research question and explain the theoretical and practical contributions. Table 1 explains the terms: ‘workarounds’, ‘EHR’ and ‘health professionals’. This terminology is specified for the health care context.

Terminology Explanation Electronic Health

Records (EHR) systems

In the literature, different kinds of terminology are used for referring to a system. The overarching term is Enterprise Systems (ES), which are software packages, which combine the business process in an organisation into one system. The EHR is part of an ES. An EHR is “longitudinal electronic records of patient health

information” (Klecun et al., 2019, p. 2).

EHR workarounds In this research, workarounds mean Electronic Health Record workarounds. Workarounds are “behaviours users adopt to overcome perceived limitations in a

technical system” (Friedman et al., 2014, p. 78).

Health professional Often in the literature, users are described as persons that use a system. In this research, a health professional means a user of the EHR. The users, in this research, are physicians, nurses and administrators.

(8)

8

2. Literature review

This chapter reviews the relevant literature. First, the definition of a workaround is presented, followed by an analysis of the motivations and types of workarounds. Next, the perspectives of workarounds are explained. The last part focusses on the dynamic character of

workarounds.

To find out what future research on workarounds should focus on, a systematic review of peer-reviewed literature is conducted. The results and the search process can be found in Appendix A and B.

2.1 Definitions of workarounds

This section shows various definitions of workarounds. An analysis of the definitions of workarounds show four common characteristics:

1. Workarounds can be temporary or become routines. 2. Workarounds are goal-driven adaptations.

3. Workarounds are used to deal with a dysfunctional EHR and to continue the workflow.

4. Whether the workaround is seen as overcoming actual or perceived limitations in the EHR, depends on the stakeholder.

Kobayashi, Fussell, Xiao and Seagull (2005) view workarounds as temporary practices. However, Zhou, Ackerman and Zheng (2011) contradict this finding and argue that

workarounds can also become routines. Furthermore, Alter (2014) suggests that workarounds are goal-driven adaptations as a health professional uses the EHR to fulfil a specific goal, such as getting a status update of a patient. Besides, workarounds are created to “overcome

perceived limitations in the system” (Friedman et al., 2014, p. 78) and “bypass perceived or real barriers in the workflow” (Halbesleben, Savage, Wakefield, & Wakefield, 2010, p. 125).

Moreover, Alter (2014), Friedman et al. (2014) and Halbesleben et al. (2010) distinguish between perceived and actual limitations in the EHR and workflow.

The most used definition of workarounds in healthcare research is from Kobayashi et al. (2005). However, this definition only views workarounds as temporary phenomena. We believe that workarounds also can become routines. Therefore, we use the second most cited definition of workarounds of Friedman et al. (2014): “behaviours users adopt to overcome

(9)

9 In this section, criteria are presented that are used to categorise behaviour as workarounds. This research focuses on the EHR, so only workarounds related to the use of the EHR are included. Workarounds created in other areas, for example, a change in organisation structure or strategy, are excluded. Furthermore, a health professional should always be involved in performing the workaround because a workaround includes a behavioural aspect. Therefore, changes and updates of the EHR are not workarounds because they do not involve a

behavioural aspect, even though they can trigger workarounds. The same holds for temporary solutions when the system fails or is hacked (Halbesleben, Wakefield, & Wakefield, 2008).

2.2 Motivations and types of workarounds

The workaround literature mentions various motivations for conducting workarounds. Table 2 gives an overview of these motivations. Koppel, Wetterneck, Telles, and Karsh (2008) found 31 motivations for EHR workarounds related to the organisation, technology, tasks, persons and the environment. We will shortly mention some motivations that belong to these

categories. Others authors used the same categories (Blijleven et al., 2017; Yang, Ng, Kankanhalli, & Luen Yip, 2012).

The categories organisation, technology and tasks can be linked to a misfit, which is “a gap

between the organization needs and the extent to which ERP system can meet these needs”

(Van Beijsterveld & Van Groenendaal, 2016, p. 369). Van den Hooff and Hafkamp (2018) categorised six types of misfits: functional, data, usability, role, control and culture. Also related to organisations, is an imbalance between privacy rules and ways of working.

Workarounds created due to this can harm the organisations’ privacy compliance (Parks, Xu, Chu, & Lowry, 2017).

(10)

10 The workaround literature mentions various types of workarounds. Flanagan, Saleem,

Millitello, Russ, and Doebbeling (2013) reported two types: computer- and paper-based workarounds. Paper-based workarounds are used because health professionals find paper more reliable, prefer to view information on paper and use it as cognitive support. Flanagan et al. (2013) argue that paper has functionalities that cannot be adopted by the EHR. Table 2 gives an overview of more types of workarounds mentioned in the literature.

Type of workarounds Type of motivations References

34 workarounds were identified

and linked to the motivations. 15 motivations were identified and linked to persons, task, technology, organisational, and environmental.

Blijleven et al., 2017

- Computer-based

- Paper-based 11 motivations were identified and linked to paper- and computer-based workarounds.

Flanagan et al., 2013 None mentioned Information exchange, information entry

and internal supply chain. Halbesleben et al., 2010 None mentioned The blocks in workflows lead to

workarounds. These blocks are categorised as policies, protocols, process, technology and people.

Halbesleben et al., 2008

15 workarounds were identified and classified as:

- The omission of process steps - Steps performed out of sequences

- Unauthorised process steps

31 motivations were identified and related to technology, task, organisation, patients and environment.

Koppel et al., 2008

None mentioned Imbalance in privacy rules leads to

workarounds, Parks et al., 2017 Workarounds are linked to the

misfit categories. Misfit categories are functional, data, usability, role, control and culture. Van den Hooff & Hafkamp, 2017 Workarounds are linked to

technology, task and organisation. Technology, task and organisation Yang et al., 2012 - Data adjustments

- Process adjustments - Parallel system adjustments

None mentioned Malaurent & Avison, 2016

Table 2: Motivations and Types of Workarounds

2.3 Impact of EHR workarounds

The model developed by Blijleven et al. (2017) is a comprehensive framework that focuses on the scope and impact of workarounds on workflows, patient safety, effectiveness and

(11)

11 when assessing the impact of a workaround (Blijleven et al., 2017 p.12). The next section explains the various perspectives on workarounds.

2.4 Perspectives of EHR workarounds

Barrett (2018) proved that workarounds could be beneficial for perceptions of EHR usability. However, workarounds can also be inefficient or harmful and can distort the work process. Furthermore, an EHR provides a standard way of working and workarounds create variance. This variance has a negative influence on the efficiency and effectiveness of the work process (Yang et al., 2012). Additionally, Blijleven et al. (2017) state that: “a workaround is

suboptimal and may jeopardize patient safety, effectiveness of care, and efficiency of care”

(p.1). Furthermore, a workaround can have a downstream effect and can lead to more workarounds (Zhou et al., 2011). Malaurent and Avison (2016) showed that while local workers view workarounds as necessary to perform their work, management views workarounds as harming the uniform way of working. To conclude, the perspectives on workarounds are diverse and contradictory. Therefore, the use of workarounds in an organisation is subject to change where it depends on the stakeholders’ interaction if the workaround will be allowed, prohibited or tacitly approved. The next section elaborates on the changeability of the use of workarounds in an organisation.

2.5 Dynamics of EHR workarounds

This section explains power dynamics (Beerepoot et al., 2019), organisational culture (Azad & King, 2008) and social interaction (Zhou et al., 2011) using three articles.

First, Azad and King (2008) explain the social interaction of workarounds and link this with the culture of a hospital. They describe the culture as a hierarchical structure, with an

autonomous work style, interpretive flexibility of the policy, and cooperative nature. They argue that this kind of organisation culture promote workarounds. Also Zhou et al. (2011) confirmed this by stating that “healthcare professionals are masters at workarounds”

(p. 3353). For this reason, Azad and King showed that characteristics of organisations, such as

(12)

12 Second, Beerepoot et al. (2019) found that power relations between health professionals lead to workarounds. For example, if a physician, who has more hierarchical power than a nurse, fails to enter a medication, a nurse has to solve these issues by entering the data or calling the physician. This shows that a physician uses workarounds that have a downstream effect for a nurse. They also found that based on the EHR restrictions, a health professional uses their hierarchical power to work around the EHR, which is called “empowerment of users” (p.13). However, the EHR developers also have the power to block health professionals from performing certain tasks. Consequently, this interaction between health professionals and the EHR results in the EHR becoming less powerful because workarounds create a variance in the uniform use. Clegg (1989) agreed and state: “Empowerment of users inherently means

disempowerment of the system” (p.13).

Third, Bhattacherjee et al. (2018) discuss responses to the system. They identified four categories of responses to mandatory use. In two responses—engaged and compliant—the health professionals accepted to use the system. This is built on the acceptance literature. The other two responses—reluctant and deviant—indicated that health professionals resist the system. This is based on the resistance literature. As well, they found that responses change over time based on 1) whether health professionals view the system as a threat or opportunity and 2) whether they feel they have low or high control over their system use. They also found that the same health professional could show both ‘acceptance’ and ‘resistance’ responses to the system.

(13)

13 where it is important to understand the context in which the workaround is performed.

Furthermore, Choudrie and Zamani (2016), Azad and King (2008) and Alter (2014) emphasise that the behavioural aspect of workarounds can be better explained when the dynamics of workarounds are operationalised. To understand the dynamics of workarounds, it is necessary to understand thoughts and attitudes of health professionals about workarounds. Therefore, we focus on health professionals’ responses to workarounds. By analysing the responses of various stakeholders, we can understand how the dynamics between health professionals unfold.

Category Findings

Motivations Misfit between EHR and work routines (Van den Hooff & Hafkamp, 2018; Van Beijsterveld & Van Groenendaal, 2016)).

Imbalance in privacy rules (Parks et al., 2017).

Resistance (Azad & King, 2012; Bhattacherjee et al., 2018; Choudrie & Zamani, 2016; Ferneley & Sobreperez, 2006).

Dissatisfaction (Barrett, 2018; Laumer et al., 2017). Blocks in workflow (Halbesleben et al., 2008).

Lack of information sharing (Beerepoot & Van de Weerd, 2018; Halbesleben et al., 2010).

Type of workarounds Paper and computer based (Flanagan et al., 2013).

Data, process or parallel system adjustment (Malaurent & Avison, 2016). Change in process steps (Koppel et al., 2008).

Temporary/routine, avoidable/unavoidable and chosen/unplanned (Friedman et al., 2014).

Harmless, hindrance and essential (Ferneley & Sobreperez, 2006).

Impact Positive or negative effect on patient safety, effectiveness and efficiency of care (Blijleven et al., 2017).

Downstream effect for the creation of more workarounds (Azad & King, 2008; Beerepoot & Van De Weerd, 2018; Zhou et al., 2011).

Negative effect on efficiency and effectiveness of the EHR use (Yang et al., 2012). Perspectives Needed in everyday live for performing tasks (Gasparas & Monteiro, 2009).

Workarounds have both a positive and negative effect (Blijleven et al., 2017; Koppel et al., 2008).

Harming the uniform way of working (Malaurent & Avison, 2016).

Triggers the adaptation of the EHR and/or workprocess (Alter, 2014; Van den Hooff & Hafkamp, 2017).

Dynamics Power relations influence the development of workarounds (Beerepoot et al., 2019). Interpretive flexibility of the focal rule leads to workarounds (Azad & King, 2008). Workarounds are context dependent (Azad & King, 2008).

Social interaction, information sharing and negotiation are important aspect for understanding workarounds (Azad & King, 2008; Zhou et al., 2011).

The same health professional can show ‘acceptance’ and ‘resistance’ responses to the system (Bhattacherjee et al., 2018).

(14)

14

3. Method

In this chapter, it is described how the data was collected and analysed. In addition, more information is given about the study design and fields study methods.

3.1 Study design

This research aims to understand the responses of health professionals, managers and the EHR project team to workarounds. Therefore, an explorative research was conducted at the internal medicine department at a teaching hospital in the Netherlands because, a hospital is a breeding ground for workarounds due to the complexity and dynamics of its work processes (Azad & King, 2008). A single case study is appropriate, as “the case study is a research

strategy which focuses on understanding the dynamics present within single setting”

(Eisenhardt, 1989, p. 534). Furthermore, based on the flexible and emergent character of responses to workarounds, a qualitative approach is suitable, because this method can explore unexpected outcomes and delve deeper into understanding respondents’ meaning and

experience (Gephart, 2004). The research approach is explorative because little insight exists regarding responses to workarounds (Yin, 1981). Lastly, based on the triangulation of the research methods: document analyses, observations and interviews, we prevented the biases of using only one method.

3.2 Field study methods

In December 2017, the hospital implemented the EHR. The health professionals were

required to use the EHR. Before the implementation, most departments had its local systems, which could consist of different applications. There are still departments that have their departmental EHR. Later on, these departments will be migrated to the general EHR. The project team responsible for adopting the EHR consisted of 100 employees. Since 1 January 2020, the EHR project team disbanded and those employees returned to the regular

organisation.

3.3 Data collection

The field study took three months and started with an observation of a staff meeting. The role of the researcher in the organisation was as observer and interviewer. The researcher did not have any personal relationship with the hospital or respondents. This guaranteed the

(15)

15 The data collection consisted of semi-structured interviews, observations and a document analysis. The data was collected with another researcher who also studied workarounds with a different focus and research question. To learn about the responses of various stakeholders, we distinguished three groups of stakeholders, see Table 4. The first group consist of

physicians, nurses and medical administrators, together called health professionals. The EHR project team and managers are the other two groups of stakeholders.

Stakeholders Explanation of the stakeholders

1) Health

professionals This group consists of nurses, physicians and medical administrators. They are the ones who developed and used workarounds. 2) EHR project

team This team consisted of 100 employees and were responsible for the adoption of the EHR. They needed to manage workarounds and investigate why health professionals use them.

3) Hospital

managers Hospital managers need to detect and manage workarounds.

Table 4: Explanation of Stakeholders

The respondents were selected based on the purpose full sampling method. The respondents were chosen based on their function. This method avoids possible bias by gathering a diverse group of respondents who have various opinions about the EHR and workarounds (Corbin & Strauss, 2008). The snowball method is used to gather more respondents (Corbin & Strauss, 2008). Based on availability and the limited timeframe, 17 semi-structured interviews and 10 observations were held. Tables 5 and 6 list the respondents and their roles in the hospital. The researchers interviewed the IT-helpdesk together due to the limited timeframe.

The first step was to get a proper understanding of the organisation, the EHR and possible workarounds. Therefore, two explorative interviews with physicians were held and a staff meeting about the improvement of the EHR was observed. These helped develop the

interview protocol, which provided a guideline during the interviews. The interview protocol, which was based on the research questions, can be found in Appendix C.

(16)

16 researcher explained the cases, the respondents could mention workarounds they observed in their work field. After that, the researcher delved deeper into the responses to workarounds. Table 6 list the information regarding the interviewees and how long the interviews took.

Participant observations are useful to understand the meaning an interpretation of the

participant on workarounds and the EHR. Therefore, we choose the method observations for getting a deeper understanding of responses to workarounds. Observations were conducted during a training session in which a trainer taught the physician how to use the EHR efficiently. The observations focussed on identifying workarounds with the use of an

observation list (Appendix C). Follow-up interviews explored the motivations and responses to workarounds, see Table 5 and 6.

Additionally, two meetings and an EHR training were observed. The first was a multi-disciplinary meeting where nurses, medical administrators and physicians discussed the development of the EHR. The second was a staff meeting for nurses about the development of the EHR. These meetings were important to see how different kind of professionals

interacted. The final observation was a six-hour general EHR training for physicians. This training was observed to understand the EHR and to see how health professionals should use the EHR.

Based on the EHR training, documents and the close connection with the EHR project team we were able to use workarounds that were suitable to identify responses to workarounds.

Code Position Expertise Time

(total 940 min)

O_IT1 EHR project team Solution centre 120 min

O_IT2 EHR project team EHR trainer 360 min

O_M3 Manager Head of the department 70 min

O_P1 Physician Acute medicine 60 min

O_P2 Physician Nephrologist 60 min

O_P4 Physician Nephrologist 60 min

O_MD1 Multi-disciplinary meeting Nurses, medical administrators,

physicians 60 min

O_ST1 Staff meeting Physicians Physicians 120 min

O_NU1 Staff meeting nurse Nurses 30 min

(17)

17

Code Position Expertise Time

(total 715 min)

I_IT2 EHR project team Trainer 45 min

I_IT3 EHR project team Optimisation team 60 min I_IT4 EHR project team Optimisation team 60 min I_IT5 EHR project team Order complications 30 min I_IT6 EHR project team Patient registration complications 20 min

I_IT7 EHR project team Staff advisor 45 min

I_HD1 Helpdesk Manager IT helpdesk 40 min

I_M1 Manager Head nurse 20 min

I_M2 Manager Nephrologist 40 min

I_M3 Manager Head of department, researcher 60 min

I_P1 Physician Acute medicine 35 min

I_P4 Physician Nephrologist 45 min

I_P5 Physician Acute medicine 30 min

I_N1 Nurse Flex worker 20 min

I_N2 Nurse Nurse 25 min

I_MA1 Medical Administrator Transplants 25 min

I_MA2 Medical Administrator Transplants 25 min

Table 6: Information Respondent Interviews

3.4 Data analysis

Due to the exploratory nature of the research, mostly inductive coding was used to be as open-minded as possible (Gephart, 2004). The systems ATLAS.ti. and Excel were used to analyse the data. The coding was performed iteratively. Inductive coding involves open, axial and selective coding (Wolfswinkel, Furtmueller, & Wilderom, 2013). First, open coding was performed to find types of workarounds, motivations, and responses. Then axial coding was performed to categorise the motivations, types of workarounds and responses. This led to first and second-order codes. Finally, selective coding was performed to find connections between motivations and types of workarounds. After listing the responses to workarounds, we

searched again in the literature to find categorisation for the responses identified. Therefore, deductive coding was used to categorise responses to workarounds. We chose the

categorisation of Bhattacherjee et al. (2018) because they did similar research and

investigated the responses to system use in general. One of the responses they identified was the use of workarounds. Due to the explorative nature of this research, the categorisation makes it still possible to be open-minded because most researchers categorise workarounds as positive or negative. This study has a neutral approach to workarounds and does not state whether workarounds are positive or negative. The codebook is presented in Appendix D.

4. Results  

This chapter answers the research questions. To understand the responses to workarounds, the first section explains the types of workarounds and the motivations for conducting this

(18)

18 stakeholder and types of workarounds. The last section gives an overview of solutions to workarounds, as used by a manager, in dealing with workarounds.

4.1 Motivations and types of workarounds

The five types of workarounds and motivations are listed in Table 7 and 8. The next section explains each type of workaround and includes a motivation why this workaround is

conducted.

Type of Workaround Explanation Number of times

mentioned

1.Using scratch paper to write

down patient data Writing patient data on scratch paper instead of entering it into the EHR. 19 2. Entering data in an

inconsistent and unstructured manner

Entering data differently than it should be, such as not using templates or not filling in data at all. 18 3. Copying and pasting data Editing data from the EHR using copy and paste. 16 4. Using shadow systems Performing administration tasks that should be

performed in the EHR in another system. 14 5. Delegating a task to a nurse

or an administrator A physician delegates administrative tasks to an administrator or a nurse, either verbally, by phone or by writing a note.

6

Table 7: Types of Workarounds

Motivations Explanation of the motive

Governance The rules and protocols of the hospital concerning uniform registering of patient data.

Getting used to the EHR use The health professional has to get used to the EHR. Lack of functionality of the

EHR There is a mismatch between the EHR and the working routine. Personal contact with the

patient The health professional has perceived less personal contact with the patient when using the EHR. Time constraints The health professional has limited time to enter patient data.

Usability The health professional is not aware of the EHR’s possibilities and does not know how to perform certain steps in the EHR.

Table 8: Motivations for Workarounds

4.1.1 Using scratch paper to write down patient data

This type of workaround, mentioned nineteen times, means that a physician or a nurse, uses scratch paper to record patient data and enters these data later in the EHR. The correct method is to enter the data during the consultation.

(19)

19

4.1.2 Entering data in an inconsistent and unstructured manner

This type of workaround, mentioned eighteen times, means that a health professional enters data in a different way than prescribed; for example a patient’s temperature is entered as free text in a note rather than under the ‘functional status’ tab in the ‘patient temperature’ field. The benefit of entering data appropriately is that the EHR can analyse patient data and include them in reports.

A motive to apply this workaround is that a health professional is unaware of the governance rules of the EHR, which were developed to guarantee uniform way of administrating data. Another motive mentioned is time constraints, a health professional has to get used to the EHR and needs to know the functionalities before administration of data becomes less time-consuming.

4.1.3 Copying and pasting data

This type of workaround, mentioned sixteen times, means that a health professional copies and pastes data from the EHR to another system. An example is that a physician changes patient data from EHR in a Word document and then copies it back to the EHR. Another example is that a physician summarises data from the EHR in a Word document before copying it into the EHR.

The motive to conduct this workaround originates from usability issues. Specifically, a health professional is unaware of the functionalities offered by the EHR that makes copying and pasting unnecessary. To illustrate, there are templates in the EHR for writing notes that automatically copies patient data in the note. Moreover, reports are available that provide an overview of patient data. Currently, health professionals make their own summary of patient data in Excel or Word because they are unaware of the available report in the EHR.

4.1.4 Using shadow systems

This type of workaround, mentioned fourteen times, means that a health professional uses another system to perform tasks that should be performed using the EHR. An example is an administrator entering patient data twice, in the EHR and in Excel for a backup. One of the motivations for using a shadow system is that the EHR lacks functionalities needed for health professionals to perform their duties. Another motive is that they are afraid of losing data.

4.1.5 Delegating a task to a nurse or an administrator

This type of workaround, mentioned six times, means that the physician delegates

(20)

20 in line with the authorisations of the EHR. An example of a workaround is a physician

verbally telling a nurse to give medication to a patient instead of recording it in the EHR. This results in an incomplete medication list. One of the motivation mentioned for delegating tasks is that the physician has limited time to enter the data.

4.2 Responses to workarounds

In the next part, the following research question is answered:

How do stakeholders respond to EHR workarounds?

This study included the following stakeholders: physicians, nurses, medical administrators, the EHR project team and managers. Fifteen responses to workarounds were identified, see Table 9. The responses were divided into four categories:

1) Engaged: The stakeholder responds to a workaround in an active way, such as using

the workaround.

2) Compliance: The workaround creates a state of acceptance because it is necessary to

fulfil a task. This response is less active than engaged.

3) Non-compliant: The stakeholder has reservations about whether the workaround

should be used and express this passively, such as by not sharing the concerns they have about the effect of the workaround.

4) Reluctant: The stakeholder disapproves the workaround and tries to reduce its use.

This can be done supportively or in a frustrated way.

Category Responses The response to a workaround is: Number

of times

Engaged - Maintain autonomy - Negotiate

- Necessary

Based on the feeling of maintaining autonomy. Negotiating for re-ordering the task division. Necessary to fulfil a task.

9 8 2 Compliance - Trust - Approved - Understandable - Anticipate - Tolerated

Based on the trust that a health professional always acts in the best interest of the patient.

Based on acceptance of the workaround. Based on the circumstances in which the workaround is applied.

Anticipating the situation so that the workaround can be performed. Tolerated. 10 5 5 2 2 Non-compliance - Supportive - Powerless - Disappointment

Acting in a helpful and supportive way even when a stakeholder disapproves the workaround.

Based on the limited power. A feeling of disappointment. 20 6 3 Reluctant - Disapproved - Frustration - Ignorance - Laxity

Believes the workaround should not be performed. In a frustrated manner.

Ignores others’ feedback and concerns. Based on careless about the workaround.

15 8 4 3

(21)

21

4.2.1 Engaged

At nine times, the most cited response in the category ‘engaged’ was maintaining autonomy. By using a workaround, the physician feels that they keep control of their working routine. A physician expressed this as follows: “I think you should keep a certain freedom as a

physician. I mean, because you are used to work in a certain pattern and then you should be free in how you do your work. This is how I approach it” (I_P2). The physician also perceives

workarounds as a way to negotiate about the task division. The next sections explain this response in more detail. The last response is that a health professional believes the workaround is needed to perform a task.

4.2.2 Compliance

In the ‘compliance’ category, the health professional accepts using a workaround. The most mentioned response was ‘trust’, which is mentioned ten times. This response means that a health professional will onlyuse a workaround when it is in the best interest of the patient. Therefore, the EHR project team believes that a nurse, an administrator and a physician can decide when a workaround is legitimate to use and when it is illegitimate. Thus, the EHR project team ‘approves’ and ‘understands’ the use of a workaround, both mentioned five times. Another response, which is expressed two times by an administrator, was ‘anticipated’. In this response, an administrator adapts their work process so that the workaround can be performed. The last response is that the health professional tolerates the workaround but is unsure whether the effect of the workaround is positive.

4.2.3 Non-compliance

The most cited response in the category ‘non-compliance’ was ‘supportive’, which was mentioned twenty times. The EHR project team mostly showed this response, by giving feedback and showing the correct way to use the EHR, with the aim of making the use of a workaround redundant. The second response is ‘powerless’, which was expressed by the administrator, EHR project team and nurse, six times. They disapprove the workaround but feel powerless to change the situation. Moreover, the EHR project team and the physician showed ‘disappointment’ in the use of a workaround, which is mentioned three times. This is based on the perceived hinder of the workaround.

4.2.4 Reluctant

(22)

22 ‘ignorance’, where the physician ignores others’ feedback and concerns. The last response is ‘laxity’, which was mentioned three times. In this response, the physician does not care whether a workaround should be performed or not.

To summarise, responses to workarounds are diverse. Some disapprove of workarounds and mention that the impact of the workaround is negative for others. However, others approve them because they perceive them as a need to perform their work.

4.3 Responses per stakeholder and per workaround

In this section, the following research question is answered:

What are the responses for each type of EHR workaround per stakeholder?

As described before, the use of workarounds engenders various responses among

stakeholders. Therefore, this section explains each stakeholder responses to five types of workarounds. Table 10 to 14 give an overview of responses per stakeholder and for each type of workaround. The responses for a stakeholder may be diverging. For example, the EHR project team showed nine different responses such as ‘powerless’ and ‘approved’, see Table 10. Each Table gives an overview of all the responses mentioned by the stakeholder group.

There were eleven responses regarding this workaround, see Table 10. The EHR project team understood the use of scratch paper as physicians and nurses need to get used to the EHR. However, after two years, a health professional must be capable of not using scratch paper anymore. A respondent of the EHR project team expressed this as follows: “Before I was

frustrated when colleagues work on paper. In the meantime, I think it is really sad if you have not succeeded in paperless working, for almost two years after implementation” (I_IT7). The

EHR project team disapproves the workaround, shows frustration and feels powerless when a health professional still applies the workaround and ignores their feedback. The administrator also disapproves the workaround, explained in the following case:

“Physicians often come with notes on paper and they have to report it via a message in the

EHR. We explain this to physicians but next time it will work like this again […. .] Some physicians are a bit harsh in that regard” (I_MA1).

(23)

23 receiving scratch notes. They feel powerless because they cannot change this workaround. In addition, one in the three physicians interviewed disapprove of using scratch paper, stating that it is a waste of time and make the EHR not up-to-date.

Stakeholders EHR project team Administrator Physician Manager Nurse Responses Powerless Approved Disappointment Disapproved Frustrated Supportive Powerless Anticipate Approved Frustrated Understandable Autonomy Frustrated Ignorance Necessary Autonomy Disapproved Frustrated Supportive Necessary

Table 10: Responses to the Use of Scratch Paper

4.3.2 Entering data in an inconsistent and unstructured manner

There were ten responses regarding this workaround, see Table 11. The EHR project team, manager, nurse and physician showed frustration and disappointment. They all agree that entering data in a prescribed way is part of having a professional attitude. The EHR project team and the nurse feel powerless because they do not have the authorisation to change physicians’ behaviour when they enter the data inconsistent. Sometimes the physician even ignores the feedback of the nurse or the EHR project team. A few times, observations showed that the physician shows ‘laxity’ in fulfilling all the steps in recording data. Additionally, a physician responded to this workaround in the following way: “So I use the EHR the way I

want, within the specified framework. I claim certain freedom. For example, I delete templates that the EHR submits to me because I don't think they are relevant” (I_P1). This

shows that a physician has the autonomy in choosing his or her own working routine.

Table 11: Responses to enter data in an inconsistent and unstructured manner

There were five responses regarding this workaround, see Table 12. The manager and the EHR project team responded in a supportive way by showing options that makes copying and pasting unnecessary. At the same time, the EHR project team feels powerless it can only advise a health professional that copying and pasting is unnecessary. The manager, who has more formal power than the EHR project team, responded in a supportive way by giving feedback. Nonetheless, the manager shows frustration by arguing that this workaround does not belong to a professional attitude. The EHR project team shares this opinion. The

administrator and physician do not know this is a workaround.

(24)

24 Stakeholders EHR project team Administrator Physician Manager Nurse

Responses Powerless

Supportive Does not know it is a workaround

Trust

Laxity Trust Frustrated Supportive

No response

Table 12: Responses to Copying and Pasting Data

There were four responses regarding this workaround, see Table 13. The stakeholders were mostly unaware that certain tasks performed in Excel, Outlook and Word are workarounds. However, they agreed that the EHR lacks necessary functionalities, which means that in some cases it is necessary to perform this task in a shadow system. As a result, the EHR project team allows the use of shadow systems in some cases. When a shadow system is used by the nurse, administrator or physician unnecessarily, the EHR project team considers it as a waste of time and effort.

Table 13: Responses to the Use of Shadow Systems

There were ten responses regarding this workarounds, see Table 14. The

physician develops workarounds to delegate administrative tasks. Examples of such

workarounds are 1) auto-login the computer and let co-assistant perform the administration task on behalf of the physician 2). The physician often expressed that “before the EHR the nurse and

administrator also could do it why not now anymore? It is easier if the administrator takes over administrative tasks, they have more time for this” (I_IT3). The physicians see it as necessary to

delegate administrative tasks to an administrator. They do not understand why the administrator cannot perform certain tasks anymore. It is more efficient if the administrator takes over

administrative tasks. Also, the administrator appreciates extra work because it makes their work more varied. However, stakeholders generally agreed that a physician should take responsibility for the record and should enter the data themselves: “I think our physicians should take this

responsibility. They are responsible for the record of the patient, why should you delegate it to a medical administrator who has not studied for this?” (I_IT2). Lastly, the physician also

delegated tasks to the nurse such as giving oral permission for medication. However, the physician does not always entered this medication in the EHR. When the nurse confront the physician with the fact that the medication list is incomplete, a physician does not always respond by completing the file.

Stakeholders EHR project team Administrator Physician Manager Nurse Responses Powerless

Supportive Does not know it is a workaround

Maintain

(25)

25 Table 14: Responses Workaround Delegating a Task

4.3 Observed solutions to workarounds

This section presents solutions to workarounds. Seven solutions were identified and specified for each workaround, see Table 15 and 16.

• Which solutions are used in responding to each type of EHR workaround?

Solution Explanation

1. Adapting the work process The work process is changed.

2. Change the authorisation of the EHR The roles in EHR are changed so that a health professional gets less or more authorisation.

3. Offering education support Offering education manuals and training. 4. Adapting the EHR The EHR is changed.

5. Facilitate meetings with enhancing

mutual understanding The workaround leads to health professionals sharing their thought about the EHR and work process with each other. This gives them more understanding of the interconnection of the work processes.

6. Acceptance of the workaround The workaround is accepted and will still be performed by the health professional.

7. To give feedback Include in the performance interview how consistently the health professional enters the patient data in the EHR.

Table 15: Explanation of solutions

Workaround Observed solutions

1. Using scratch paper to write down

patient data -Offering education support -Acceptance of the workaround 2. Entering data in an inconsistent and

unstructured manner -To Give feedback 3. Copying and pasting data None mentioned

4. Using shadow systems -Adapting the work processes -Adapting the EHR

-Enhancing mutual understanding 5. Delegating a task to a nurse or an

administrator Change the authorisation of the EHR

Table 16: Solutions per Type of Workaround

The EHR project team offered personal assistance to encourage physicians, nurses and

administrators to enter data directly in the EHR instead of using scratch paper. They provided training and developed manuals to enhance computer skills. However, the EHR project team had an advisory role and could not formally attach any consequences to the use of scratch paper. The managers could set consequences, but tolerated the use of scratch paper and advised the physicians that it is more efficient to enter data directly into the EHR, but tolerated it when this is not done immediately.

(26)

26

4.3.2. Entering data in an inconsistent and unstructured manner

This workaround is still performed. The manager, who disapproves this workaround, is taking into consideration how consistently a health professional documents patient data in the

professional interview. In this interviewwith the health professional, the manager wants to give feedback about how the documentation of patient data is done.

This workaround is still performed and no solutions are identified.

Shadow systems are still used to perform tasks that should be performed in the EHR. The EHR project team tries to minimalize the use of shadow systems by aligning the EHR with the working processes. For instance, the recording schedule module lacks functionalities. Because of this, record planning was still performed in an Excel file. Eventually, the module in the EHR was adjusted after several meetings between the EHR project team and the

recording planners. In this example, both the EHR and the work processes have been adjusted. Whether the EHR project team adjusts the EHR or whether they help redesign the work

process depends on the workaround. In the example with the recording schedule, the EHR project team initiated multidisciplinary consultations to analyse the entire work process outside departmental boundaries. As a result, processes were coordinated with each other and agreements were made outside departmental frameworks. This resulted in a mutual

understanding of the work processes outside their department. The manager said: “I think in

general, it has connected the department. We all struggle with the same problem; contact with peers” (I_M3).

The EHR project team affirmed the administrative burden for a physician. As a result, the EHR project team is examining how a physician can be less burdened with administrative tasks. Currently there is a gradual shift, which adjusts roles so that the nurse gets more authorisation to perform a certain task. For instance, the EHR project team has adjusted the authorisation so that a nurse can order paracetamol. Also, a pilot has been started in which the administrator entered patient data and the physician checks if this was done correctly.

(27)

27

5. Discussion

This chapter is structured as follows. First, each research question is answered. After that, the theoretical and practical contributions are presented, followed by recommendations for future research.

5.1 Answering the research questions

What are the responses of stakeholders to different types of EHR workarounds?

We identified fifteen responses to workarounds shown by nurses, physicians, administrators, managers and the EHR project team. The most frequently observed responses are supportive’, ‘disapprove’ and ‘trust in professionals’. The scale of the responses is categorised as

‘engaged’, ‘compliance’, ‘non-compliance’ and ‘reluctant’. This scale shows that responses range from ‘engaged’, where the stakeholder wants to maintain the workaround, until reluctant, where the stakeholder is frustrated about the enactment of the workaround.

What are the responses for each type of EHR workaround per stakeholder?

We found that the stakeholder groups EHR project team, manager and administrator, show responses that belong to the following categories: ‘compliance’, ‘non-compliance’, reluctant’, and that a physician and a nurse show responses that belongs to the categories: ‘engaged’ and ‘reluctant’. Figure 1 and 2 link responses by stakeholders to the different categories (engaged, compliance, non-compliance, reluctant). The grey boxes indicate the responses given for each workaround as derived from the data. The workarounds ‘delegation of tasks’ and ‘use of scratch paper’, are used because these workarounds are followed by the highest diversity in types of responses. Figure 1 illustrates two findings. First, responses are diverse and range from ‘engaged’ to ‘reluctant’. Second, a manager and a physician both give responses in the categories ‘engaged’ and ‘reluctant’. Thus, even in the same stakeholder group, contradicting responses to workarounds are given. This result has not previously been described. The same can be observed from Figure 2, where only the physician gives contradicting responses. Besides, only the EHR project team, administrator and manager show responses in the ‘compliance’ and ‘non-compliance’ categories. We will clarify these findings now.

Concluding, responses to workarounds are divergent and contradictory. The physician shows

only responses in the categories ‘engaged’ and ‘reluctant’. The reason for this may be that a physician perceives the EHR as a threat of losing autonomy (Beerepoot et al., 2019).

(28)

28 EHR team and administrators, who have a facilitating role in the organisation (Zhou et al., 2011), mostly show responses in the category ‘compliance’, such as ‘anticipate’ and ‘supportive’. The little power these stakeholders have compared to physicians in managing and developing workarounds may be the cause of this behaviour (Beerepoot et al., 2019). Therefore, the EHR project team and administrators show other responses to a workaround then a physician. Their first response to a workaround could be ‘disapproving’. However, they adapt the response in such a way that it fits with the response of the physician, which in turn leads to a second response such as ‘anticipating’. Figure 1 illustrates this finding, where responses from the EHR project team and administrators range from ‘compliance’ to ‘reluctant’.

Which solutions are used in responding to different types of EHR workaround?

The data reveals seven solutions used by a manager in dealing with workarounds. These solutions created a change in the EHR and/or work process. Our research shows the complexity of dealing with a workaround based on the divergent responses and mutual

relationship between stakeholders. This makes it difficult for a manager to respond adequately to a workaround. The key stakeholder is a physician, as they have hierarchal power and their behaviour influences the behaviour of others (Beerepoot et al., 2019).

Figure 1: Stakeholder Responses per Category

(29)

29

5.2 Theoretical contributions

This research contributes to the literature by clarifying the dynamics of EHR workarounds by examining how various stakeholders respond to workarounds. Our theoretical contributions are threefold. First, perspectives on workarounds are further operationalised, with a broader view than just negative and positive, as used by Blijleven et al. (2017) and Koppel et al. (2008). This resulted in a scale of four categories. Second, as was explained by Azad and King (2008), the dynamics of stakeholders regarding workarounds in the EHR context seemed an understudied field of research. This study contributes to this underrepresented study area by researching the responses to workarounds and by showing that the contradiction in

responses is an outcome of the position of a health professional in the organisation. Third, our study is one of the few that assumes that workarounds are subject to change and uses this assumption as a starting point for research (Alter, 2014; Azad & King, 2008; Choudrie & Zamani, 2016). Instead of focusing on explaining the causes, types and effects of

workarounds, we focused on explaining the dynamic character of workarounds, by explaining the changeability of the workarounds as well as the various perspectives held towards these workarounds. Therefore, the theoretical contributions are framed in the paradigm of social constructivism and interpretive flexibility (Pinch, 2019). Our research confirmed and extended findings of other researchers, which we will clarify now.

We extended the findings of Bhattacherjee et al. (2018) by categorising responses to five types of workarounds and distinguishing the responses given by various stakeholders. This provides insight into the social interaction between stakeholders and shows the variance in responses to workarounds. Bhattacherjee et al. (2018) and Ferneley and Sobreperez (2006) state that workarounds are an outcome of resistance behaviour. Interestingly, this research shows that workarounds are not only caused by resistance, but also through power dynamics, EHR restrictions and usability issues. The results indicate that health professionals seem to not automatically resist the EHR but are unaware of how to use the EHR.

(30)

30 uses his autonomy and power to practice and develop a workaround, whereas a nurse, who has less power, needs to anticipate the consequence of the workaround.

We also confirm the findings of Meskó, Drobni, Bényei, Gergely, and Győrffy (2017) who show that the digitisation of the healthcare involves a cultural change, where the role of the physician changes from an authoritative to a guiding role. We found that a physician tries to maintain the same role by applying workarounds, which was seen in the type of workaround ‘delegation of tasks’ and in the response of the physician of maintaining autonomy. Also, expressed by a physician who has the autonomy to decide how to use the EHR: “So I use EHR the way I want, within the specified framework” (I_P1).

Lastly, we confirm the findings of Ash et al. (2003), Alter (2014) and Barrett (2018) by showing the positive effects of workarounds, such as enhancing mutual understanding about the work processes. Also, workarounds trigger the adaptation of the EHR and work processes. This also confirmed the finding of Rose and Jones (2005) that the interaction between humans and information technology leads to change in the working environment and technology. Furthermore, in the literature workarounds are often considered as negative (Blijleven et al., 2017; Laumer et al., 2017; Yang et al., 2012). Our research shows that workarounds could also have positive effects.

5.3 Practical implications

Our research shows the complexity of dealing with a workaround based on the divergent responses and mutual relationship between stakeholders. This makes it difficult for a manager to respond adequately to a workaround. Therefore, we recommend developing a

communication plan to align and steer perspectives on a workaround. This contributes to more consensus on decisions regarding a workaround. When implementing the

(31)

31 “You should also know that if a patient is admitted with for example comatose, then it is

relevant that all the data in the EHR is correct. However, based on the exceptions made between departments, you cannot trust all the data in the EHR is complete and correct”

(I_P5).

Therefore, health professionals must have equal opportunities to give feedback about

decisions made with respect to the EHR. This can be done, for example, by a poll or survey. This prevents inequality in dealing with complaints concerning the EHR. It also results in an increased feeling of ownership by the health professionals of the EHR, because they do not have the feeling to be stuck with the EHR and not be able to point this out.

With the implementation of the EHR, there are health professionals who show resistance and have difficulty in coping with the change. However, in some cases, for example the use of scratch paper, the transition is, for some health professionals, so large that a healthcare provider must accept that it takes several years to make this change.

The result of this study indicate that responses to workarounds could be related to how

competent a health professional is with the EHR. Therefore, a healthcare provider should give a health professional the opportunity to follow training. This leads to feeling more competent with the EHR, which affects the attitude towards the EHR and workarounds. In the training, emphasis should be placed on the reason why the EHR has been implemented and on the benefits of the EHR. Also, awareness should be created about how the future of healthcare looks like; that digitisation continues and the pace of change concerning IT will increase (Cisco, 2016). A healthcare provider should be prepared for these changes.

Also, the knowledge gap between a health professional and the EHR project team concerning EHR makes it difficult to motivate and convince a health professional about decisions and governance rules. On the other hand, the knowledge gap about the work process makes it difficult for the EHR project team to align the EHR with the work process. Therefore,

workarounds should not be ignored or viewed as failings of the EHR as they contain valuable information for aligning the EHR with the work process. This research shows the dynamic character of workarounds, which makes it important to consistently keep track of

(32)

32

5.4 Limitations and future research

This study has some limitations. First, we did not reach saturation in detecting workarounds and responses. One reason for this, is that a few observations were done and only physicians were observed. It was not possible to perform more observations within the timeframe of the research. Another reason is that workarounds that are performed unintentionally are hard to detect in an interview, because health professionals are not able to not mention these workarounds. Therefore, future researchers should devote more time to observing.

In future research, more observations need to be taken into account, whereby administrators and nurses are also observed. This will create a more complete picture of responses to more types of workarounds that also includes responses of administrators and nurses. Shadowing would be a useful method for this, as it would provide more detailed information and takes the work context into account (McDonald, 2005). However, the privacy rules for patients and the accessibility of the organisation makes shadowing a challenging method.

A second limitation is that we tracked the responses to workarounds for only three months. Future research should perform longitudinal studies to determine how responses change over time and to test the effect of solutions used in dealing with workarounds. This will help managers deal with workarounds more efficiently.

Lastly, adopting an EHR is a lengthy process and we found that workarounds are often caused by physicians to lessen the perceived administration load during this process. A study

(33)

33

References list

Alter, S. (2014). Theory of workarounds. Communications of the Association for Information

Systems, 34(55), 1041–1066. https://doi.org/10.17705/1CAIS.03455

Association for Information Systems. (2019). Senior scholars’ basket of journals. Retrieved 24 October 2019, from https://aisnet.org/page/SeniorScholarBasket

Azad, B., & King, N. (2008). Enacting computer workaround practices within a medication dispensing system. European Journal of Information Systems, 17(3), 264–278. https:// doi.org/10.1057/ejis.2008.14

Azad, B., & King, N. (2012). Institutionalized computer workaround practices in a Mediterranean country: An examination of two organizations. European Journal of

Information Systems, 21(4), 358–372. https://doi.org/10.1057/ejis.2011.48

Barrett, A. K. (2018). Technological appropriations as workarounds: Integrating electronic health records and adaptive structuration theory research. Information Technology and

People, 31(2), 368–387. https://doi.org/10.1108/ITP-01-2016-0023

Barry Libert, Beck, M., & Wind, Y. (2016). 7 Questions to ask before your next digital transformation. Harvard Business Review, 60(12), 11–13. https://hbr.org/2016/07/7-questions-to-ask-before-your-next-digital-transformation

Beerepoot, I., Koorn, J., Van de Weerd, I., Van den Hooff, B., Leopold, H., & Reijers, H. A. (2019). Working around health information systems: The role of power. Proceedings of

the Fortieth International Conference on Information Systems, 1–17. https://research

.vu.nl/en/publications/working-around-health-information-systems-the-role-of-power Beerepoot, I., & Van de Weerd, I. (2018). Prevent, redesign, adopt or ignore: Improving

healthcare using knowledge of workarounds. Proceedings of the 26th European

Conference on Information Systems: Beyond Digitization - Facets of Socio-Technical Change, ECIS 2018, 1–15.

https://research.vu.nl/en/publications/prevent-redesign-adopt-or-ignore-improving-healthcare-using-knowl

Beresford, L. (2016, 16 April). Research shows link between EHR and physician burnout

what can the hospitalist do? Retrieved 14 February 2020, from

(34)

34 Bernardi, R., Constantinides, P., & Nandhakumar, J. (2017). Challenging dominant frames in

policies for IS innovation in healthcare through rhetorical strategies. Journal of the

Association for Information Systems, 18(2), 81–112. https://doi.org/10.17705/1jais.00451

Bhattacherjee, A., Davis, C. J., Connolly, A. J., & Hikmet, N. (2018). User response to mandatory IT use: A coping theory perspective. European Journal of Information

Systems, 27(4), 395–414. https://doi.org/10.1057/s41303-017-0047-0

Blijleven, V., Koelemeijer, K., & Jaspers, M. (2019). SEWA: A framework for sociotechnical analysis of electronic health record system workarounds. International Journal of

Medical Informatics, 125, 71–78. https://doi.org/10.1016/j.ijmedinf.2019.02.012

Blijleven, V., Koelemeijer, K., Wetzels, M., & Jaspers, M. (2017). Workarounds emerging from electronic health record system usage: Consequences for patient safety,

effectiveness of care, and efficiency of care. JMIR Human Factors, 4(4), 1-16. https:// doi.org/10.2196/humanfactors.7978

Boonstra, A., van Offenbeek, M. A. G., & Vos, J. F. J. (2017). Tension awareness of stakeholders in large technology projects: A duality perspective. Project Management

Journal, 48(1), 19–36. https://doi.org/10.1177/875697281704800102

Chilukuri, S., & Van Kuiken, S. (2017, April). Four keys to successful digital transformations

in healthcare. Retrieved 6 January 2020, from

https://www.mckinsey.com/business- functions/mckinsey-digital/our-insights/four-keys-to-successful-digital-transformations-in-healthcare

Choudrie, J., & Zamani, E. D. (2016). Understanding individual user resistance and workarounds of enterprise social networks: The case of service Ltd. Journal of

Information Technology, 31(2), 130–151. https://doi.org/10.1057/jit.2016.9

Cisco. (2016). Report of The digitization of the healthcare industry: Using technology to

transform care. Retrieved 6 January 2020, from https://www.cisco.com/c/dam/en_us/

solutions/industries/docs/digitization-healthcare.pdf

Responses to Electronic Health Record workarounds

Abstract

Table of contents

1. Introduction

2. Literature review

2.1 Definitions of workarounds

2.2 Motivations and types of workarounds

2.3 Impact of EHR workarounds

2.4 Perspectives of EHR workarounds

2.5 Dynamics of EHR workarounds

3. Method

3.1 Study design

3.2 Field study methods

3.3 Data collection

3.4 Data analysis

4. Results

4.1 Motivations and types of workarounds

4.2 Responses to workarounds

4.3 Responses per stakeholder and per workaround

4.3 Observed solutions to workarounds

5. Discussion

5.1 Answering the research questions

5.2 Theoretical contributions

5.3 Practical implications

5.4 Limitations and future research

References list

4. Results  