Advice for Decision Makers Based on an Electronic Health Record Evaluation at a Program for All-inclusive Care for Elders Site
21 September 2010
accepted: 01 January 2011
16 December 2017 (online)
Objective: Provide evidence-based advise to “Program of All-inclusive Care for the Elderly” (PACE) decision makers considering implementing an electronic health record (EHR) system, drawing on the results of a mixed methods study to examine: (1) the diffusion of an EHR among clinicians documenting direct patient care in a PACE day care site, (2) the impact of the use of the EHR on the satisfaction levels of clinicians, and (3) the impact of the use of the EHR on patient functional outcomes.
Methods: Embedded mixed methods design with a post-test design quantitative experiment and concurrent qualitative component. Quantitative methods included: (1) the EHR audit log used to determine the frequency and timing during the week of clinicians’ usage of the system; (2) a 22-item clinician satisfaction survey; and (3) a 16-item patient functional outcome questionnaire related to locomotion, mobility, personal hygiene, dressing, feeding as well the use of adaptive devices. Qualitative methods included observations and open-ended, semi-structured follow-up interviews. Qualitative data was merged with the quantitative data by comparing the findings along themes. The setting was a PACE utilizing an EHR in Philadelphia: PACE manages the care of nursing-home eligible members to enable them to avoid nursing home admission and reside in their homes. Participants were 39 clinicians on the multi-disciplinary teams caring for the elders and 338 PACE members.
Results: Clinicians did not use the system as intended, which may help to explain why the benefits related to clinical processes and patient outcomes as expected for an EHR were not reflected in the results. Clinicians were satisfied with the EHR, although there was a non-significant decline between 11 and 17 months post implementation of the EHR. There was no significant difference in patient functional outcome the two time periods. However, the sample size of 48 was too small to allow any conclusive statements to be made. Interpretation of findings underscores the importance of the interaction of workflow and EHR functionality and usability to impact clinician satisfaction, efficiency, and clinician use of the EHR.
Conclusion: This research provides insights into EHR use in the care of the older people in community-based health care settings. This study assessed the adoption of an EHR outside the acute hospital setting and in the community setting to provide evidence-based recommendations to PACE decision makers considering implementing an EHR.
- 1 Berg M. Patient care information systems and health care work: a sociotechnical approach. Intl J Med Inf 1999; 55 (Suppl. 02) 87-101. doi:10.1016/S1386-5056(99)00011-8.
- 2 Maekawa Y, Majima Y. Issues to be improved after introduction of a non-customized Electronic Medical Record system (EMR) in a Private General Hospital and efforts toward improvement. Stud Health Technol Inform 2006; 122: 919-920. PMid:17102464.
- 3 Moller-Jensen J, Lund Pedersen I, Simonsen J. Measurement of the clinical usability of a configurable EHR. Stud Health Technol Inform 2006; 124: 356-361. PMid:17108548.
- 4 Berg M. The search for synergy: interrelating medical work and patient care information systems. Methods Inf Med 2003; 42 (Suppl. 04) 337-344. PMid:14534631.
- 5 Starfield BH, Simborg DW, Horn SD, Yourtee SA. Continuity and Coordination in Primary Care: Their Achievement and Utility. Med Care 1976; 14 (07) 625-636. doi:10.1097/00005650-197607000-00008 PMid:940406.
- 6 Campbell EM, Guappone KP, Sittig DF, Dykstra RH, Ash JS. Computerized provider order entry adoption: implications for clinical workflow. J Gen Intern Med 2009; 24 (01) 21-26. doi:10.1007/s11606-008-0857-9 PMid:19020942 PMCid:2607519.
- 7 Goldzweig CL, Towfigh A, Maglione M, Shekelle PG. Costs and benefits of health information technology: New trends from the literature. Health Aff 2009; 28 (02) w282-w293. doi:10.1377/hlthaff.28.2.w282 PMid:19174390.
- 8 Crosson JC, Ohman-Strickland PA, Hahn KA, DiCicco-Bloom B, Shaw E, Orzano AJ. et al. Electronic medical records and diabetes quality of care: results from a sample of family medicine practices. Ann Fam Med 2007; 5 (03) 209-215. doi:10.1370/afm.696 PMid:17548848 PMCid:1886493.
- 9 Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin CT. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res 2004; 6 (Suppl. 02) 4/06.
- 10 Daly JM, Buckwalter K, Maas M. Written and computerized care plans. Organizational processes and effect on patient outcomes. J Gerontol Nurs 2002; 28 (09) 14-23. PMid:12240516.
- 11 Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E. et al. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144 (Suppl. 10) 742. PMid:16702590.
- 12 Resnick HE, Alwan M. Use of health information technology in home health and hospice agencies: United States, 2007. JAMIA 2010; 17: 389-395. doi:10.1136/jamia.2010.005504 PMid:20595305.
- 13 CMS.. Program of All inclusive Care for the Elderly (PACE). Available at: http://www.cms.hhs.gov/PACE. Accessed 1/11, 2010.
- 14 Mukamel DB, Peterson DR, Temkin-Greener H, Delavan R, Gross D, Kunitz SJ. et al. Program characteristics and enrollees’ outcomes in the Program of All-inclusive Care for the Elderly (PACE). Milbank Q 2007; 85 (03) 499-531. doi:10.1111/j.1468-0009.2007.00497.x PMid:17718666.
- 15 Blumenthal D. Stimulating the Adoption of Health Information Technology. N Engl J Med 2009; 360 (15) 1477-1479. doi:10.1056/NEJMp0901592 PMid:19321856.
- 16 CCHIT certification for ambulatory electronic health records –CCHIT Certification Commission for Healthcare Information Technology. Available at: http://www.cchit.org/certify/ambulatory/index.asp. Accessed 9/9/2008, 2008.
- 17 Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. JAMIA 2003; 10 (03) 229-234. doi:10.1197/jamia. M1204 PMid:12626376 PMCid:342045.
- 18 Banker RD, Chang H, Kao YC. editors. Measurement of user satisfaction with web-based information systems: an empirical study. Proceedings of the Eighth Americas Conference on Information Systems; 2002 Atlanta, GAAIS 2002
- 19 Sockolow PS, Crawford PR, Lehmann HP. Broadening a general framework for evaluating health information technology through health services research evaluation principles. Methods of Medical Information. In Review.
- 20 Ammenwerth E, de Keizer N. An inventory of evaluation studies of information technology in health care –Trends in evaluation research 1982-2002. Methods Inf Med 2005; 44 (01) 44-56. PMid:15778794.
- 21 Sockolow PS, Weiner JP, Bowles KH, Lehmann HP. A new instrument for measuring clinician satisfaction with electronic health records. CIN in press. PMid:18091616
- 22 Sands LP, Xu H, Craig BA, Eng C, Covinsky KE. Predicting change in functional status over quarterly intervals for older adults enrolled in the PACE community-based long-term care program. Aging Clin Exp Res 2008; 20 (05) 419-427. PMid:19039283.
- 23 Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. 2nd ed. Thousand Oaks CA: Sage; 2011
- 24 Morse JM. Principles of mixed methods and multimethod research design. In: Tashakkoru A, Teddlie C. editors. Handbook of mixed methods in social and behavioral research. 1st ed. Thousand Oaks CA: Sage; 2003. p. 189-208.
- 25 Greenacre MJ. editor. Theory and applications of correspondence analysis. Orlando: Academic Press; 1984
- 26 Fine MJ, Murkofsky RL. editors. Trends in clinician perceptions of a new electronic health record. JGIM; Apr 9, 2008; Washinton,DC: Springer; 2008
- 27 Sittig DF. Work-sampling: a statistical approach to evaluation of the effect of computers on work patterns in healthcare. Methods Inf Med 1993; 32 (02) 167-174. PMid:8321135.
- 28 Ash J. Organizational factors that influence information technology diffusion in academic health sciences centers. JAMIA 1997; 4 (02) 102-111. PMid:9067876 PMCid:61499.
- 29 StataCorp LP.. Stata Statistical Software. 2007 Release 10.
- 30 Bazeley P. Computerized data analysis for mixed methods research. In: Tashakkoru A, Teddlie C. editors. Handbook of mixed methods in social and behavioral research. 1st ed. Thousand Oaks CA: Sage; 2003. p. 385-422.
- 31 Tang PC. et al. Key capabilities of an electronic health record system: Letter Report. 2003 available at: http://www.nap.edu/catalog.php?record_id=10781. accessed 1/18, 2011.
- 32 Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. JAMIA 2008; 15 (04) 408-423. doi:10.1197/jamia. M2616 PMid:18436903 PMCid:2442264.
- 33 Kossman SP. Perceptions of impact of electronic health records on nurses’ work. Stud Health Technol Inform 2006; 122: 337-341. PMid:17102276.
- 34 Lee T, Mills ME, Bausell B, Lu M. Two-stage evaluation of the impact of a nursing information system in Taiwan. International Journal of Medical Informatics 2008; 77 (10) 698-707. doi:10.1016/j.ijmedinf.2008.03.004 PMid:18457988.
- 35 Ammenwerth E, Mansmann U, Iller C, Eichstadter R. Factors affecting and affected by user acceptance of computer-based nursing documentation: Results of a two-year study. JAMIA 2003; 10 (01) 69-84. doi:10.1197/jamia. M1118 PMid:12509358 PMCid:150360.
- 36 Simpson G, Kenrick M. Nurses’ attitudes toward computerization in clinical practice in a British general hospital. Comput Nurs 1997; 15 (01) 37-42. PMid:9014392.
- 37 Moody LE, Slocumb E, Berg B, Jackson D. Electronic health records documentation in nursing: nurses’ perceptions, attitudes, and preferences. Comput Inform Nurs 2004; 22 (06) 337-344. PMid:15602303.
- 38 Smith K, Smith V, Krugman M, Oman K. Evaluating the impact of computerized clinical documentation. Comput Inform Nurs 2005; 23 (03) 132-138. doi:10.1097/00024665-200505000-00008.
- 39 Tornvall E, Wilhelmsson S. Nursing documentation for communicating and evaluating care. Journal of Clinical Nursing 2008; 17 (16) 2116-2124. doi:10.1111/j.1365-2702.2007.02149.x PMid:18710374.
- 40 les JB, Weiner JP, Chan KS, Coon PJ, Krizak JT, Dancha L. et al. Performance measures using elec-tronic health records: Five case studies. The Commonwealth Fund 2008; 1132.
- 41 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. JAMIA 2004; 11 (02) 104-112. doi:10.1197/jamia. M1471 PMid:14633936 PMCid:353015.
- 42 Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L. et al. Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg 2006; 202 (05) 746-752. doi:10.1016/j.jamcollsurg.2006.01.017.
- 43 Pronovost P, Weast B, Rosenstein B, Sexton JB, Holzmueller CG, Paine LDR. et al. Implementing and validating a comprehensive unit-based safety program. Journal of Patient Safety. 2005 1. 01 doi:10.1097/01209203-200503000-00008
- 44 Baggs JG, Schmitt MH, Mushlin AI. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med 1999; 27: 1991. doi:10.1097/00003246-199909000-00045 PMid:10507630.