CHAPTER ONE
INTRODUCTION
Health Information Technology for Economic and Clinical Health (HITECH) Act place the healthcare system as a national priority (Burke, Stewart, & Cartwright-Smith, 2010). The HITECH Act provides a legal and financial framework for implementing health information technology (HIT) and promoting meaningful use (Burke et al., 2010). Meaningful use involves “using electronic health records (EHR) technology to improve quality, safety, efficiency and reduce health disparities; engage patients and family; improve care and coordination, and population and public health; and maintain privacy and security of patient health information” (Murphy, 2010, p. 284). Adopting the EHR has implications for the social change landscape within the healthcare industry. Implementation of an EHR is currently a priority for the Nigerian healthcare system (Song et al., 2011). Electronic health records have the capability to address population and public health information needs and contribute to government health policies and financing (Friedman, Parrish, & Ross, 2013). Information accumulated in the EHR can be used to promote healthy lifestyles and environments, reveal the prevalence of diseases, and provide data to change policies (i.e., banning sale of cigarettes to minors; Friedman et al., 2013). An EHR can be routinely used to improve communication, quality of care, reduce medical errors, and eliminate waste (Song et al., 2 2011). Despite the advantages of the EHR, nurses have been reluctant to embrace the technology. A recent survey conducted by Positioning Nursing in a Digital World (2014) found that a third of nurses have not received training on an information technology system (as cited in Wright, 2014, p. 64). This lack of training affects attitudes and fosters resistance to adopting an EHR (Wright, 2014). To avoid resistance and failure to adopt, it has been suggested that simulated training on an EHR system can assist nurses in feeling less overwhelmed and more confident with technology (Haugen, 2012). This project was conducted to address the use of simulated training to foster acceptance of the EHR and was guided by the framework of Rogers’s diffusion of innovation (DOI). This project was necessary as it related to the realization among nurses that possessing computer skills is critical to their practice due to the rapid expansion of technology throughout society (Peace, 2011). In order to practice effectively, nurses must possess basic computer skills and have basic information literacy (Peace, 2011). Training nurses on an EHR system in a simulated environment promotes their confidence in skills they need to grow and addresses the fear of mistakes and failure associated with the use of technology (Wright, 2014). These skills are now a necessity for the practice of nursing and allow nurses to be part of the social change occurring in healthcare. The implementation of the EHR is viewed as a method to increase the safety, efficiency, and effectiveness of healthcare while improving the quality of patient care (Culley, Polyakova-Norwood, & Effken, 2012). Dr. David Blumenthal, current National Coordinator of HIT, stated, HIT is the means, but not the end. Getting an EHR up and running in health care is not the main objective behind the incentives provided by the federal government under ARRA: improving health is. Promoting health care reform is” (as cited in Murphy, 2010, p. 285). The health professionals must be prepared to take a leadership role in disseminating best practices by facilitating communication and supporting discussion among healthcare providers regarding meaningful use.
BACKGROUND OF THE STUDY
The idea of improving patient care is not new and the goal of representing information in a managed form has been pursued for centuries. In the 17th century, Wilhelm Von Liebnitz searched for a method to code human behavior in order to represent the information in a managed form (Cesnik, 2010). Florence Nightingale (1863) in her book Notes on Hospitals recognized the need to group information to reveal a disease pattern or cause:
I am fain to sum up with an urgent appeal for adopting this or some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even those which are best conducted, there is a vast and unnecessary waste of life … In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to … if wisely used, these improved statistics would tell us more of the 4 relative value of particular operations and modes of treatment than we have any means of ascertaining at present ... the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick and maimed poor. (pp. 175-176)
Even with this astute observation by Florence Nightingale, it would be another century before progress was made in assembling data in one area. World War II was the catalyst for the development of electronic computers. The computer was large and bulky, occupying an entire room, and ran on valves that utilized great amounts of power (Cesnik, 2010). However, it was a beginning, and from that point, computers rapidly evolved to become a powerful tools in assisting the business world including hospital systems, health related areas, and providers (Cesnik, 2010). In the 1970s, professional and scholarly journals began to publish reports of computer applications in nursing (Ozbolt & Saba, 2008). Systems were developed for nursing care planning to assist in improving the completeness and quality of charting. These were the early precursors of current protocols and pathways that are now built on evidence-based practice (Ozbolt & Saba, 2008). The 1980s and 1990s saw progress in the increasing number of healthcare professionals who recognized the benefits and necessity of standardizing data to support nursing practice and to create new knowledge (Ozbolt & Saba, 2008). Standardized terminology in nursing was needed to facilitate the ability of data to be interoperable between computer systems. It was not until 2000 that the Nursing Terminology Summit approved a reference terminology model for nursing (Ozbolt & Saba, 2008). A startling report issued by the Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century (2001) propelled public and private efforts to fully merge healthcare with technology (Ozbolt & Saba, 2008). In 2004, President George W. Bush signed into law Executive Order 13335, which urges every American to have an accessible health record by 2014 (Ozbolt & Saba, 2008; Wimberley, 2010). In 2009, President Barack Obama authorized the $800 billion stimulus package ARRA (Wimberley, 2010). Along with HITECH, ARRA aims to enhance the standard of health care and create a national electronic health record exchange (Wimberley, 2010). However, despite the mandate, a 2008 study revealed that in a survey of U.S. physicians, only 4% had enacted an EHR and 7.6% of hospitals had implemented only simple systems (Wimberley, 2010). There are an estimated 2.5 million registered nurses (RNs) employed in the United States, and a 2008 study revealed that only 17% use a complete EHR on a consistent basis (Huryk, 2010). This is expected to change rapidly in the next few years. In 2011, Medicare and Medicaid launched the EHR incentive program. This incentive will be available through 2016 and is intended to offset the initial start-up cost of an EHR. Providers (i.e., hospitals and ambulatory clinics) must show meaningful use by 2015 (McBride, Delaney, & Tietze, 2012). This will happen in stages with Stage 1 consisting of data capture and sharing, including computerized providers order entry (CPOE; McBride et al., 2012). One specific problem is related to the nurses’ inability to use computers and/or lack of training on EHR. Nurses have expressed fear of losing their jobs, losing data, spending less time spent with patients, and lacking knowledge (Huryk, 2010). These fears combined with a negative attitude affect the successful adoption of an EHR (Huryk, 2010; Kaya, 2011). There is significant need to address these fears due to current and future implementation of an EHR that will be nationwide (Huryk, 2010). Health professionals have more contact with the patient than those in other disciplines and the data that the nurses gather are crucial to meaningful use (McBride et al., 2012). The addition of EHR forces the nurses to change their workflow; therefore, it is crucial that training be provided. In offering training on a simulated EHR system, the framework of DOI was applied and the nurses were shown the benefits of the EHR. This required interdisciplinary cooperation and merging of resources in order to achieve integration of information for interoperable communication. This is consistent with Florence Nightingale’s (1863) vision of “hospital records fit for any purpose of comparison” (p. 175). On this premise, the study will examine attitude and interest of health professionals towards electronic health record system (A case study of University of Nigeria Teaching Hospital, Enugu (UNTH)
1.2 Problem Statement
An identified problem with the adoption of EHR was a lack of basic computer skills in health professionals who have no background in information technology. Up to 45% of current health professionals were in the workforce before the proliferation of technology (Furst et al., 2013). Therefore, a lack of training and/or preparation with computer skills hinder the adoption of technology and lead to cognitive and attitudinal barriers (Courtney, Demiris, & Alexander, 2005; Furst et al., 2013). This can have a significant impact on workflow. Nurses are responsible for integrating multiple sources of information along with coordination of resources in their daily management of patient care (Courtneyet al., 2005; Furst et al., 2013). The addition of HIT to the existing workload without adequate training affects productivity and the adoption of the technology (Courtney et al., 2005; Furst et al., 2013). Health information technology has the capability to decrease errors, waste and cost in healthcare (Bredfeldt, Awad, Joseph, & Snyder, 2013; Courtney et al., 2005; Nkosi, Asah, & Pillay, 2011). Health information technology’s contribution to addressing the growing crisis in healthcare includes reducing the number of medication errors, promoting efficiency in time management, monitoring adherence to treatment plan, reducing inpatient days, and tracking trends (Zhang et al., 2013). However, to reach this potential, healthcare providers must be willing and able to use the technology (Bredfeldt et al., 2013; Courtney et al., 2005; de Veer & Francke, 2010; Lu, Hsiao, & Chen, 2012; Nkosi et al., 2011). Moving from a paper-based milieu to HIT is often a disruptive process that requires training on multiple levels (Rothman, Leonard, & Vigoda, 2012). Many current healthcare professionals received their educational training before the information technology explosion and lack basic computer skills to successfully navigate an EHR (Bredfeldt et al., 2013; Furst et al., 2013). Due to the lack of computer skills, multiple training sessions are necessary to overcome the new users’ initial feeling of being overwhelmed (Bredfeldt et al., 2013; Courtney et al., 2005; de Veer & Francke, 2010; Lu et al., 2012; Nkosi et al., 2011). These training sessions should be spaced prior to an implementation to reinforce the new users’ beginning skills. This can continue to reduce anxiety related to the use of HIT and allow the time needed to become acquainted with the technology (Carayon et al., 2011; Courtney et al., 2005; Culley et al., 2012; de Veer & Francke, 2010; Nkosi et al., 2011). 8 Literature reveals that adoption barriers to information technology (IT) center on situational, cognitive, or physical, legal and/or attitudinal barriers (Courtney et al., 2005). The degree to which the technology is perceived to be of benefit is recognized as relative advantage, which is the first characteristic of innovation in the DOI process (Rogers, 2003). The acceptance of new technology can depend on the interaction and social dynamics of coworkers and the culture of the organization (Courtney et al., 2005; De Veer & Francke, 2010; Lu et al., 2012). The relevance of the influence of peers and the organization toward the adoption of IT cannot be overlooked or underestimated. Health professionals more readily accept new technology if it is perceived to be a fit with nursing practice, improves patient outcomes, and decreases the workload of the nurse (Courtney et al., 2005; De Veer & Francke, 2010; Lu et al., 2012). Health professionals are the largest discipline in healthcare and present with unique information needs. The acceptance of HIT is dependent on training, workplace culture, and the perceived benefit of the technology (Courtney et al., 2005). Therefore, it is crucial to obtain a health professionals perspective when implementing an IT system in order to promote the acceptance and integration of the system (Carayon et al., 2011; Courtney et al., 2005; De Veer & Francke, 2010; Lu et al., 2012; Nkosi et al., 2011).
1.3 Purpose Statement and Project Objectives
The purpose of this project was to evaluate Attitude and interest of health professionals towards electronic health record system (A case study of University of Nigeria Teaching Hospital, Enugu (UNTH). This project was conducted to measure (a) health practitioners knowledge, skill, and attitude toward EHR; (b) health professionals level of comfort in using the EHR; and (c) health professionals level of satisfaction with training on EHR (Culley et al., 2012; Nkosi et al., 2011). To address the problem of HIT adoption, this project was implemented to reduce the impact of lack of training on EHR through the use of simulation. Research found that health professionals with previous exposure and basic training on computers were more confident and less resistant to adopting HIT (Goldsack & Robinson, 2014; Gregory & Buckner, 2014; Nkosi et al., 2011). Simulated activities on a generic EHR offered the opportunity to practice learning computer and charting skills in a safe, nonthreatening environment that allowed the learners to feel more secure in their ability to succeed (Guise, Chambers, & Välimäki, 2011; Haugen, 2012). These activities were guided by the framework of DOI and started with presenting the relative advantage and compatibility of the EHR. Rogers (2003) found that relative advantage to be a crucial component and the first step necessary in the adoption of an innovation. Once the health practitioner recognizes the advantage, compatibility to the workflow can more readily be developed (Rogers, 2003). This project was implemented to address the gap in practice that existed locally. Although the major healthcare providers in the author’s local community (i.e., hospitals) had converted to an EHR, other healthcare providers (i.e. long-term facilities and home health care agencies) remained on paper-based systems. These community clinically based employers were in various planning stages to implement an EHR and training for healthcare professionals was necessary. As many of the nurses and staff had not charted on an EHR, simulated training was anticipated to be beneficial (Cato & Abbott, 2006; Culley et al., 2012). Providing hands-on training on an EHR in a safe environment alleviated anxiety, promoted a positive attitude toward the potential use of the EHR, and increased self-efficacy (Cato & Abbott, 2006; Courtney et al,, 2005; de Veer & Francke, 2010; Lu et al., 2012). The health professionals is in a position to lead in implementing the Quality and Safety Education for health practitioners guidelines for informatics to, “use information and technology to communicate, manage knowledge, mitigate error and support decision making” (QSEN Institute, 2014).
1.4 Research Question
The study is guided by the following research questions;
- Does simulated training on a generic EHR system improve the knowledge, skill, and attitude of health professionals with little or no experience with EHR?
1.5 Research Hypothesis
Ho1: There is a significant correlation between training on a generic EHR system and improvement of the knowledge, skill, and attitude of health professionals.
1.6 Significance of the study
Healthy People 2020 set as one of its goals to advance the use of HIT in order to enhance overall population health outcomes (U.S. Department of Health and Human Services [DHHS], 2014). Healthy People 2020 have primary objectives for HIT with each one having several sub-objectives. Objective is “Increase the proportion of persons who use the Internet to keep track of personal health information, such as care received, test results, or upcoming medical appointments” (DHHS, 2014). Another objective of the study is to increase the proportion of medical practices that use electronic health records” (DHHS, 2014). Every area related to health communication and health information technology is reporting an increase or is surpassing the set goal. This is relevant to health practitioners approach toward the community and its efforts in disseminating information. The ability of the nurse to integrate HIT into practice is a crucial component of social change in healthcare (Huryk, 2010). Every day, people in all communities across the nation use the Internet to be informed of current events and this can influence the interaction with health care (DHHS, 2014). This is in line with QSEN’s competencies goals for nurses. The necessity and importance of informatics was highlighted when the QSEN noted that the development of the remaining five competencies was reliant on basic informatics skills (Cronenwett et al., 2007). Many of today’s nurses are not digital natives and did not grow up using information technology (Bredfeldt et al., 2013). Information technology training is necessary and needs to be presented in an atmosphere that allows the user not to become overwhelmed with the new format and information (Culley et al., 2012; de Veer & Francke, 2010; Nkosi et al., 2011; Whittaker, Aufdenkamp, & Tinley, 2009). Learners can consist of multiple generations with different learning styles and levels of comfort with technology. Implementation of this project demonstrated relevance to practice by providing a safe environment in which the nurses learned a generic charting system and experimented with IT and had the ability to role play on simulated charting with varying degrees of complexity (Carayon et al, 2011; Culley et al., 2012). This project addressed different learning styles, accommodated different levels of comfort with technology and promoted the importance of IT in the future practice of the participating nurses (Culley et al., 2012; Whittaker et al., 2009). The Department of Health (DH, 2011) recommends simulation training when it is used to enhance and benefit patient care (as cited in Handley & Dodge, 2013, p. 529). There is a significant success rate with simulation and EHR. Statistics indicate up to 70% 12 higher rate of adoption of EHR after use of simulation versus a more traditional approach of “train the trainer” (Haugen, 2012). The success in the simulated approach lies in the authenticity of the scenario and the ability to offer repetition and immediate feedback in a safe environment (Handley & Dodge, 2013). Therefore, simulation with EHR becomes relevant and significant to practice when it can show benefit to the organization in the form of high adoption; to the health practitioners in reducing anxiety and improving knowledge, skill, and attitude; and to the patient in a high quality of care.
1.7 Evidence-Based Significance of the Project
This project contributes to what is known about nurses and EHR by assessing the knowledge, skills, and attitudes of a select group of health professionals with an EHR in a simulated setting. This information is crucial to understand because it reflects the n health professionals acceptance of and willingness to learn the IT system (de Veer & Francke, 2009; Lu et al., 2012; Nkosi et al., 2011). The HITECH Act (2009) clearly delineates a timeframe for hospitals and healthcare providers to implement HIT and demonstrate meaningful use by 2015 (Murphy, 2010; Wimberly, 2010). Therefore, it is was imperative that health professionals be a part of the solution and contribute to a working knowledge of integrating IT into bedside practice (Murphy, 2010). Attitudes can affect the successful adoption of an IT system. Health professionals with some previous exposure to EHR maintained a more positive attitude than those who did not have any exposure to IT (Murphy, 2010). Training to increase the knowledge and skill levels of health professionals with IT teaches nurses to use the EHR as a tool to evaluate and improve patient outcomes (Halley et al., 2009). Computer and innovation theorists have reported that the introduction of a new IT system can cause great anxiety, fear, apprehension and negative attitudes (Nkosi et al., 2011). It is recommended that institutions assess the knowledge, skills, and attitudes toward IT in order to facilitate the integration of the system (Nkosi et al., 2011). This project contributes to the existing knowledge base by examining the effectiveness of a method that addressed knowledge, skills, and attitudes of health practitioners who were new users with EHR. The project also contributes to validation of the DOI framework as a viable structure for conceptualizing nurses’ perspectives on how EHR will influence their work at a practice level.
1.8 Scope of the study
The scope of this project was limited to non-hospital-based health care facilities. These employers were chosen because of their intent to adopt an EHR system and be able to communicate via meaningful use. Qualified providers (i.e. hospitals and healthcare providers) that do not show evidence of meaningful use will be penalized 3-5% of a provider’s total government-based compensation (Wimberley, 2010). However, long-term care facilities and home health care agencies are not given the incentives to implement HIT that are extended to hospitals and healthcare providers. The long-term care facilities and home health care agencies are only required to transmit information electronically on the minimum data set (MDS), outcome and assessment information set (OASIS), and some billing information (MacTaggart & Thorpe, 2013). Problems arise when the healthcare providers utilize an EHR and the facility does not. This has motivated some long-term care facilities and home health care agencies to adopt a HIT system including an EHR at their own expense (MacTaggart & Thorpe, 2013).
1.9 Limitations of the study
This project used a quantitative, descriptive design that utilized a convenience sampling of health practitioners from local non-hospital-based health care facilities in the community. Recruitment was targeted toward all health practitioners with little to no experience with an EHR system. Participation was voluntary, limited to facilities that were in the process of adopting an EHR and that were currently using paper-based charting. Another limitation was the small sample size that could be accommodated in the simulated space. Available space was limited to 100. Due to these limitations, the results of this study should not be generalized. However, the findings may be applicable to some skilled facilities.
