A Framework to Evaluate the Adoption of Electronic Health Record System. Essay Example

A Framework to Evaluate the Adoption of Electronic Health Record System.

A Framework to Evaluate the Adoption of Electronic Health Record System

<Student Name>

A report submitted for

300597Master Project 1

In partial fulfilment of the requirements for the degree of

< Master of Engineering>

Supervisor: <XXX>

School of Computing, Engineering and Mathematics

Western Sydney University

<June 2017>


The main objective of this study is to provide a framework for the evaluation of the adoption of Electronic Health Record system among various health care organisations in Melbourne Australia. The specific aims of the study were to; investigate the main departments and related functions to be included in an Electronic Health Record System, identify the main factors influencing the usage of an Electronic Health Record System, identify the main concerns from the users to use an Electronic Health Record System, propose frameworks that include an overview of components that needs to be considered by organization planning on an Electronic Health Record System and lastly evaluate the framework using a new Electronic Health Record System design that fulfils the results produced in the framework. A qualitative study approach to data collection and analysis was adopted. The data collection method was mainly through semi structured interviews. The respondents were sampled using snow ball as well as purposive sampling techniques. The results show that various factors indeed affect the adoption of Electronic Health Record System among these organisation and they range from individual characteristics, social factors, technical factors and organisational factors



Figure 1: The implementation of EMR 12

Figure 2: David TAM model 15

Figure 3: Demographic characteristics of the Respondents 22

Figure 4: Example of Clinical Decision Support 24

Figure 5: Clinical order Entry 25

Figure 6: Integrated View of Patient Data 27







Background 7

Purpose of the Study 10

Objectives of the study 11

EMR Adoption Model 12



Research method 17

Research Design 18

Population and Sampling 18

Data Analysis Procedures 19

Validity and Reliability 20

Ethical Considerations 21

Demographic characteristics of the Respondents 22

The main departments and related functions to be included in an Electronic Health Record System 23

Clinical Decision Support 23

Clinical order Entry 24

Integrated View of Patient Data 25

Access to Knowledge Resources 27

Integrated Communication and Reporting support 27

The main factors influencing the usage of an Electronic Health Record System 28

Organisational Leadership 28

Level of Autonomy 29

Physician involvement and participation 29

Impact in Work Place Relationships 30

Physician-Patient Relationship 30

Perceived Value and Benefits 31

The main concerns from the users to use an Electronic Health Record System 31

Difficult to operate 31

Changes in Clinical procedures 32

Trust and Safety concerns 32

Cost-Benefit Analysis 32

Lack of Standardisation 33




Electronic health record system is gradually rolling out in the health care system in Australia because of its potential benefits in boosting efficiency and quality of service. According to Berner (2008), when the electronic health system is in place there are high chances in the reduction of medication errors and improvement in health care in general. There is enhancement of client satisfaction and promotion of adherence to the set rules and procedures in a health care set up. This report is about analysis of a framework to be used in the evaluation of an electronic health record system prior to its adoption. To begin with the report will provide the conceptual framework used to structure the report as well as in presentations of the study findings. Additionally, a thorough literature review will be provided on the subject in question. Thereafter the findings and conclusions will be discussed while suggesting relevant recommendations for further research.


The contemporary advancement in technology has characterised the health sector with the introduction, development and implementation of a number of different forms of electronic health records. Globally we already have some health care organisations that are already using these electronic health records while some are yet to. Notably there is always a variation in these types of records to the extent that what some health care organisations refer to as electronic health records differs across board. There are examples from all over the world where some hospitals have fully adopted computerised patient health care information systems. According to Victor et al. (2010) many health care providers realise the importance of having these electronic health records but the only challenge is that they are costly and sometimes the required technological advancement is not yet in place. This is so especially in developing countries. Additionally sometimes change doesn’t come easily. The medical practitioners in some cases are not just willing to switch to the paperless. There are various examples of countries where the electronic health records are in use.

Historically the Health Records (HR) came into existence in the early 1960s. The first formal recognition of these records was in the Flexner report that tried to elaborate what is contained in these records and also their purpose (Bahensky et al, 2011). By this time the Mayo clinic had adopted the record keeping practice like three years prior by recording all the details of their patients. Basically the Flexner report was about adopting a scientific approach in disseminating medical information. The report went further to advocate for patient-oriented record which all physicians were encouraged to adopt. In the 1940s there was a rigorous campaign for more accurate patient records especially from health care governing bodies (Murphy, 2011). In fact health care institutions were not to be accredited unless they showed proof of well organised medical records. These bodies were very specific on what was to be including in these records; length of stay, any major procedures performed, biographic information, admission diagnosis and discharge diagnosis.

The introduction of computer based hospital information systems in the 1960s can perhaps be regarded as the official onset of the EHR. At that time the only reason why the systems were adopted it’s so as to ease communication between healthcare providers, key stakeholders and their clients. For instance this system allowed for medical issues to be taken from various nursing stations and sent to different parts of the hospital including the charges for that particular service. This electronic system eased access to laboratory results for those patients they were attending to. At this point these systems allowed only minimal exchange of information but not really in terms of giving diagnostic solutions. They were mainly able to give orders and also make charges. These systems had other disadvantages like the inability to keep the information long after the patient has been discharges, and its presentation of information in text form which made it even harder to make analysis.

However, there was turnaround in 1969 when Lawrence Weed introduced what was termed as problem-oriented medical record (POMR). This led to a paradigm shift in the way physicians though and handled medical records. Lawrence was very particular about having an organised patient record within a health care organisation whether manual or electronic (Renee, 2010). He further reiterated that a good medical record should be just about the demographic details of a patient, but it should also include information on diagnosis and treatment schedule that responds to the specific medical issue. Another important pioneer of electronic health records was Morris Collen who published extensively about this subject (Susan and Keith, 2010).

Many countries around the world have over the time put in place strategies and initiatives to adopt electronic health record system. To begin with, Korea is on record for having its eleven hospitals fully implement HER. As early as 2004 some of these hospitals had already started scanning all the manual records. In Malaysia there are two hospitals that are already operating on paperless basis. In Indonesia the electronic health system is mainly used in the hospital set up with minimal linkage to the community health care stakeholders (Susan and Keith, 2010). In china there are some hospitals that use the electronic system while many more are yet to adopt this kind of system. Examples of other countries that are on the list for the use of electronic health records include Singapore, Taiwan, Hong Kong and Thailand.

Australia is currently pursuing the HealthConnect whereby it will be a platform for the information flow across all the stakeholders in the Australian health sector. HealthConnect is a system where information related to health issues is captured, stored, managed and transmitted (NETH, 2012). Most importantly patient’s safety, privacy and confidentiality should be adhered to as per the stipulated rules and procedures. HealthConnect has been described by policy makers and academicians as a platform that will ensure efficient, quality and cheaper health care. According to the HealthConnect website the aim of this service is to ensure client satisfaction, health care organisations reputation and competitiveness, and minimise medical errors. It is against this background that the researcher endeavours to explore the framework to evaluate the adoption of Electronic Health Record System. The study scope was on several health care organisations that were sampled within Melbourne in Australia.

Purpose of the Study

As aforementioned while there is a myriad of studies on the benefits of adoption of HER, the system is slowly being implemented in Australia especially after the government launches the Health connect and the 2012 PCEHR. The main purpose of this study is to propose a conceptual framework that will identify the main components to be considered by patients when using an Electronic Health Record System within a Health Care organization, hence helping the organization to be more focused to fulfil the user’s needs while planning for Electronic Health Record System. Electronic Health Record Systems are one of the main technological advancements in health care industry. Several organizations are adapting this system to improve the overall quality of service, the reduce cost and improve workflow. However, there are several obstacles faced throughout the adopting process of an Electronic Health Record System. This paper will identify the main components and provide an overview conceptual framework that will help organization to become more focused in the adapting process (identify the main components and functions that are needed by the patients using the Electronic Health Record System), helping organisation to receive the best results from the system. To this end the researcher aims at finding answer to these critical questions;

  • What are the main departments and related functions to be included in an Electronic Health Records System?

  • What are the factors that influence the usage of an Electronic Health Record System?

  • What are the main concerns in an electronic Health Record System?

  • How can a framework help to identify the main areas to be focused in an Electronic Health Record System?

  • How can the proposed framework be tested and evaluated?

Objectives of the study

The objectives will be as follows

  • To investigate the main departments and related functions to be included in an Electronic Health Record System

  • To identify the main factors influencing the usage of an Electronic Health Record System

  • To identify the main concerns from the users to use an Electronic Health Record System

  • To propose frameworks that include an overview of components that needs to be considered by organization planning on an Electronic Health Record System.

  • To evaluate the framework using a new Electronic Health Record System design that fulfils the results produced in the framework

EMR Adoption Model

This study will employ HIMMS Analytics model in discussing the EMR adoption mechanism. This model is very important in understanding at what level the health care facility is operating as far as EMR is concerned. The model provides that there are seven stages in the implementation of EMR (Simborg, 2008). Zero being the least and seven being the best. This can be presented in a diagram as follows;

A Framework to Evaluate the Adoption of Electronic Health Record System. 1

Figure 1: The implementation of EMR

Source: HIMMS Analytics (2017)

Stage 0: At this level while may be some information may be available but it’s not implemented in three most important departments which are; laboratory, Radiology and pharmacy

Stage 1: at this level electronic systems are installed in the major ancillary department which are laboratory, Radiology and pharmacy

Stage 3: this is where we have some clinical documentation such as flow sheets and vital signs of electronic medical administration, the nurses’ notes, and clients care plans charts. There should be evidence of an integration and implementation of all these with a specific service in the health care organisation. In some cases physicians are able to access some images via the hospital facilities intranet through an established Picture Archive and Communication System (PACS).

Stage 4: A part from the CDR and nursing set up there is an additional computerised practitioner/ Physician Order Entry (CPOE). This stage is characterised by a second level support to the clinical decision making especially as regard medical protocols that are evidence based in nature.

Stage 5: at this stage the following are fully implemented; loop medication administration set up, Radio Frequency Identification (RFID), eMAR and a complete coding bar. To ensure thorough and efficiency in drug administration, all the above are then integrated with CPOE and pharmacy.

Stage 6: This level is characterised by level three clinical decision making support, full physician documentation, and full complement of radiology PACs system. The documentation is done on customised templates. Drug administration is fully electronic and there is exchange of radiology information via the facility’s intranet.

Stage 7: at this stage the health facility is operating a paperless environment. Sharing of clinical information is done via electronic transactions even up to a regional basis. This stage is a replica of the ideal electronic health record system.


This section will provide a review of literature based on the themes emanating from the research questions. The literature will tackle the following ;the main departments and related functions to be included in an Electronic Health Records System, factors that influence the usage of an Electronic Health Record System, the main concerns in an electronic Health Record System, how to identify the main areas to be focused in an Electronic Health Record System and its evaluation framework.

As regards the main components of the HER many studies to agree that there are five main functional components of an HER (Simborg, 2008; Guthre, 2001; Weimer, 2009, Gadd and Panrod, 2000). They include; integrated view of patient’s data, clinical decision support, and clinician order entry, access to knowledge resources and integrated communication and reporting. However it’s important that there are levels of EHR system adoption. Therefore there could be some variation in the way these components are utilised depending on what stage the health facility is. This study will be mainly concerned with an ideal EHR set up which has attained all the above functional components.

There exists a plethora of studies on the factors that influence the usage of EHR system. For instance according to Thomas (2012)he reiterates that some of these factors are internal while some are external. Some of the external factors are the prevailing social economic times and government regulations regarding its use. The internal factors include the level of expertise in the health facility, availability of internet connectivity to the facility, the type of management. In another study that was conducted by Hagland (2010) he noted that many health care facilities are reluctant to adopt the HER despite its numerous benefits because of the costs involved and the lack of certainty whether nt5hey will be have a guaranteed return on investment in the shortest time possible(Ash et al, 2012) on the other hand argues that the factors that determine the use of EHR is dependent on the physicians characteristics like age years in practice, health system affiliation, prior computer use and prior health system portal use. In another study by Hsu, Robertson and Frankel (2005) they add that these factors can be divided into social, physician’s characteristic and technical factors. According to hum some of the social factors include management support, physician involvement and technical factors. This is what is commonly referred to us the David TAM model as shown below (Ford et al, 2010).

A Framework to Evaluate the Adoption of Electronic Health Record System. 2

Figure 2: David TAM model

This model explains very well the objective of this study which is to determine a framework for the evaluation of the adoption of an EHR system. All the three classification of the factors that determine the use of HER are captured on the diagram. They include the personal characteristics of the doctor, social factors and technical factors.

When it comes to the concerns that face the use of the HER many scholars note they were numerous in number. For instance some medics always have issue around the need to take up new responsibilities like data entry. In a study that was conducted by Beth et al (2010) there are concerns at three levels; organisational, client level and the medical practitioner level. The organisation is mainly concerned with the ability to cost effectively implement the system plus its continuous upgrade, training of the staff maintenance among other responsibilities that fall on the shoulder off the management (Hagland, 2010). From the client’s perspective, it’s always about whether the system will ensure they get their service on a timely basis as well as the safety of their confidential health information. The medical practitioners are always concerned with learning and adapting to the new system. In another study that was conducted by David and Patricia (2010) other concerns were about the complexity of the system, the ability to take care of downtime which means the access to data won’t be available among others. Glance (2012) notes that some health care facilities are concerned by the fact that it’s not possible to have full control over the system and that system failures resulting from computer crash, virus, cyber-attacks or general human error could occur leading to a lot of confusion and time plus resource wastage in fixing the errors.

When it comes as to whether to adopt or use the EHR many scholars agree that all the above factors should be weighed against the government compliance regulations and the organisations ability to implement and continually upgrade the system. In some cases according to Sharon, Edwards and Diana (2012) the government makes it compulsory for certain health facilities for instance a referral hospital or a hospital that has various branches across the country especially if it’s private should be able to have the EHR in some of its major branches. The decision to adopt the EHR will require intensive consultations between the board, management, medical practitioners, administrators and all the concerned stakeholders (Devers, 2011). That is why it’s important for the government to consult health care providers even as they work on implementing the Health Connect in Australia.


In this section the following will be presented; the data collection tools, research method and design, sample population and the various sampling techniques that were employed. Additionally the data analysis procedures and the various ethical considerations will be highlighted and explained.

Research method

The study was explored the framework to evaluate the adoption of EHR by employing a qualitative study methodology. The researcher utilised in-depth analysis of semi structured key informant interviews. The choice of this methodology was based on the nature of the probe which required the researcher to examine the experience of health care experts with the use of EHR. The study was happening in its very natural setting. According to Thomas (2012) the use of qualitative methodology allows the researcher to gain insight into social phenomena. Additionally the qualitative methodology was fit for this study because of its ability to enable the researcher isolate himself from the phenomena under study. This is key because it takes care of any biases and prejudices arising from the researcher. According to Doolan, bates and James (2003) qualitative researchers are able to explore the objects under study through the collection and analyses of numerical data.

Research Design

Since this study was not about a particular health care organisation; the case study design was not an option. Hence the researcher resorted to ethnographic design which allowed for the investigation of the study subject. Several interviews were run in order to capture the several life experiences accounts by various staff within health care facilities that make use of HER. According to Pearsaul (20012) ethnographic studies have one peculiar advantage in that they allow for open ended discussion between the interviewer and the respondent. Additionally, ethnographic studies allow for the exploration of the cultural as well as the social setting of the environment within the interviews are taking place.

Population and Sampling

The respondents in this study were mainly care givers in health care facilities. They were drawn from different department but most importantly the department that deals with Electronic health Records. The managers of health care facilities were also interviewed. In order to get insight from external stakeholder; a few clients that were consisted consumers in these health care facilities were also interviews in order to obtain n their perspectives about their experience with the use EHR in these facilities. The respondents were selected through two techniques which included; purposive as well snowball techniques.

The researcher carried out a pilot study in order to determine which respondents would make key contributions to the research depending on their knowledge and experience with working with HER compliant facilities. Moreover the identified respondents were then requested to make further respondent on other people they knew would be important in giving invaluable information to the study. The researcher was interested in making sure that the respondents included those that had worked in a facility where initially there were no EHR but later on it was adopted. This was important in capturing the experience of before and after the adoption of HER system. The researcher made sure that the selected respondent at least demonstrated considerable knowledge about the subject under study. The total number of respondents was 80 from different health facilities. They included both employees and clients. The data collections were mainly semi structured interviews that were self-administered by the researcher.

Data Analysis Procedures

According to Deves (2011), qualitative data analysis involves classifying things, persons, events and the features that typify them. Some scholars argue that in a qualitative study like this one, data collection and analysis goes hand in hand (Doolan, Bates and James, 2003). In this study, data analysis was done in six stages.

  1. The data was organised for analysis. At this stage interviews were transcribed and field notes typed categorised. All the field from all the sources were sorted and arranged.

  2. The researcher then read and went through the data just to get the sense of the information gathered and reflect on its overall meaning.

  3. The interview extracts, descriptions and cases studies was coded and organised into themes and concepts basing on research objectives. The data coding was aided by a computer program called Dedoose.

  4. Thereafter patterns trends and relationships will be established. The said themes and patterns that will be constructed and evaluated using the research questions as a guide.

  5. Each theme was then be developed by explaining, interpreting, commenting as well as applying it to advance the arguments or issues of concern to the study. This enabled the researcher to label and classify the contents of the data in terms of headings and sub-headings.

  6. The final stage involved making an interpretation of the findings in order to determine lessons to be learnt from the study. The aim was to establish whether the study confirms previous studies or reveals new questions that need to be addressed.

Validity and Reliability

According to Shekelle et al. (2013), validity in qualitative research helps in determining the accuracy of the findings from the participants, readers and researchers points of view. In this study the researcher will employ various approaches in ensuring validity and reliability. To begin with, the researcher employed multiple methods in data collection which allowed the researcher to build a coherent justification for the emerging themes. In addition, the researcher endeavours to take time in collecting data up to three months so as to develop an in-depth understanding of the subject under study. Again, the researcher ensured that obvious errors that occur in transcription of interviews and field notes are minimised as much as possible.


Since a qualitative study is naturalistic in nature, the findings will be presented in a descriptive form. The researcher employed rich description in communicating the experiences employees and clients of health care facilities that use EHR. The contents of the final report will represent the social construction of their reality and the meanings they attach to their daily lives. This will provide readers a chance to experience the social world of the users of the EHR in a health care setting.

Ethical Considerations

Research on social phenomena requires an ethical-oriented approach. Various ethical issues needed to be addressed throughout the three phases of conducting this study; pre-field, actual data collection and report writing. To begin with, the researcher sought permission from the relevant government authorities and the university ethical committee before embarking on the study. Moreover, during the pre-test exercise of the data tool; elements of research instrument that were unclear or that could be misunderstood by the target participants were identified and rectified. Since were anticipated that sensitive information may be revealed by the participants, the researcher ensured that; 1) the main objective of the study was well explained in writing as well as verbally to the participants including how the resultant data will be utilised, 2)written consent to go ahead with the study was sought from the participants, 3)the participants were informed of all data collection tools and activities, and 4) the participants wishes, rights and interests were considered when determining what information should be included in the final report. Additionally, during the interview process, the researcher ensured confidentiality of the respondents is upheld. Finally, in the writing of the research proposal and the development of the thesis thereafter, the researcher endeavoured to avoid plagiarism and at all times acknowledge all works referred to whether academic or non-academic by rightly citing the authors.

Demographic characteristics of the Respondents

The respondents of the study were both employees and clients who make use of HER in a given health facilities. The number of the clients was 22 and the rest were employees of the health care facilities as well as key stakeholders from government departments that deal with health, Non-governmental organisation with a specific focus on Health like World Health Organisation. This can be presented as follows;

A Framework to Evaluate the Adoption of Electronic Health Record System. 3

Figure 3: Demographic characteristics of the Respondents

The researcher chose to have respondents from this all spheres so as to get a rich insight as regard the adoption of HER from a wide spectrum of people with different levels of knowledge and experience on the subject under study. A majority of the respondents were employees in EHR compliant facilities who had a hand on experience with the system.

The main departments and related functions to be included in an Electronic Health Record System

An electronic health system is multifaceted in nature. It requires proper coordination between various department, sectors, expertise and experiences in order to function efficiently and effectively. From the interviews with the EHR system is depended on many factors. They include the size of the health facility, the level at which the health care is on the seven stages of the adoption of EHR Model (See Figure 1), the kind and expertise of the employees among others. However, it was clear that the main functional components from the responses included the; integrated view of patients data, clinical decision support, clinician order entry, access to knowledge resources and integrated communication and reporting(Sharon, Edwards and Diana, 2012)

Clinical Decision Support

The health care experts suggested that clinical decision support is very helpful especially during assessment of the patient and that’s why it’s important for it to be situated at the point of care. There is also need to make the procedure easy to use such that the doctor can easily click on a button but at the same time maintain some autonomy in making the final decision (Bush, 2004). Some of the big facilities reported to be suing sophisticated system that were able to capture every little detail at every stage of medication from the point of entry into the facility to the point where they are treated and allowed to go home. See for example the figure below;

A Framework to Evaluate the Adoption of Electronic Health Record System. 4

Figure 4: Example of Clinical Decision Support

The above figure shows a system that is able to captures many details including the demographic details of the consumer, diagnosis, treatment and how long it will take.

Clinical order Entry

One of the main reasons for the adoption of EHR systems is in its ability to provide accurate information which in turn helps medics make better decision about diagnosis and treatment of clients. According to NETHA (2012) the EHR system has various components that aid in giving physicians decision support especially at the care point. For instance the laboratory component may contain certain alerts to give hint to the medic on the best possible treatment to be given. See the figure below

A Framework to Evaluate the Adoption of Electronic Health Record System. 5

Figure 5: Clinical order Entry

The figure above gives hints on the procedure to be followed for intravenous heparin orders at one of the facilities in Melbourne. It’s possible for a system to dictate cases of allergies even before a medic prescribes dose or decide on how many days the treatment will take.. These and many others are examples of how clinical order entries can be useful in providing decision support to medics in a given health facility.

Integrated View of Patient Data

An ideal EHR system should be able to provide coordinated data of all the facets of medication. While this the ultimate desirable end of many health care facilities sometimes the complex and diverse nature of the data makes it so hard to achieve this. According to Carter and Belanger (2005) the data may include integration of various facets of medical information including laboratory results, pharmacy transcriptions, community and home care agencies, blood transfusion centres among others. In the discussion about the concern of using HER system coming forth, the researcher notes that since there is no standardisation of these systems; it even becomes difficult to coordinate data flow especially in big health facility, regionally or even nationally (Gadd and Penrod, 2000). The system is customised and therefore it’s the responsibility of the administrator to read and interpret the data and make it simpler for the medics.

A Framework to Evaluate the Adoption of Electronic Health Record System. 6

Figure 6: Integrated View of Patient Data

The figure above shows a sample multi source data system that coordinates patient data storage and transmission.

Access to Knowledge Resources

Continuous access to knowledge is an important culture in the health set up. This could be through consulting a fellow employee or having access to particular documents. Access to relevant and timely information is very important to clinicians especially at the time they are making diagnosis and making treatment decision. According to Thomas (2012) there are various online rich resources that can come handy to clinicians. They include online journals and databases alike PubMed, Up-to-Date, OVID among others. Availability of such online has made it easier for physicians to consult such resources especially when they need to make crucial decisions.

Integrated Communication and Reporting support

A typical health care facility comprises of clinicians with different background and expertise. The effectiveness and efficiency of their work in a HER system set up will be dependent on how the medical information is coordinated and exchanged. The study findings revealed that since messages are usually patient specific there is always need to integrate the system with the various communication avenues in the facility. This is especially as regards laboratory tests messages and other relevant system messages. Many medics also noted that they enjoy working with a system that is able to provide patients records by just clicking a button unlike in cases where they have to go and dig for files. According to Deves (2011) in cases where the facility has branches in many geographical places then there will be need for integrated communication and reporting support. This also very ideal for referral cases where the medical health giver needs to understand the medication history of the patient from their previous clinician.

A Framework to Evaluate the Adoption of Electronic Health Record System. 7

Figure 7: Sample Integrated Communication and Reporting support

The figure above is a sample laboratory results screen which then sends a notification to the physician’s computer to notify of the diagnosis and potential treatment options.

The main factors influencing the usage of an Electronic Health Record System

The study findings revealed that a myriad of factors influences the usage of electronic facilities. They range from individual technical, organisational and professional factors. They are discussed as follows;

Organisational Leadership

From the interviews with the employees in health care facilities they noted that the type o leadership influences the usage of EHR. According to Hagland (2010) successful implementation of the HER largely depends on the efficiency on the part of the leadership of the day. Some respondent credited the health care facilities for pushing for the implementation and continuous upgrade of the system. As Hsu, Robertson and Frenkel (2005) argue for a health care facility to adopt EHR from the paper use it will require changes in strategy. Its therefore the responsibility of the organisational leadership to make strategic shift to allow for such a system to be adopted. An EHR system cannot work in an environment where the leadership is against the system. It’s something that requires support from the management in order to thrive. From the interview it was evident that many of the organisations that had fully and successfully adopted EHR had great leadership in place.

Level of Autonomy

According to Brooks and Menachemi (2006) adoption of EHR by any given health care organisation triggers changes at various levels of positions and power. This could lead to some resistances in the organisation if not handled well. For instance while it’s for a fact the HER increases efficiency sometimes physicians may be reluctant to use it thinking that it’s a way of monitoring their steps at work. Moreover as aforementioned, EHR have a way of impacting on the level of decision of the physicians which may make it uncomfortable for them. According to Ashish (2009) usually these system have some aspects like clinical support abilities which then means the decisions are not entirely by physicians. This was reported from the interviews as one of the major concern of clinicians who feel that sometimes the system limits them in a way.

Physician involvement and participation

The study findings revealed the extent to which medical health care givers agree to make use of the system will also impact on the functionality of the system. One of the respondents noted that they had to petition the management to involve the medics in the construction of the system. This was important because it allowed the informatics to design the system that can be easily understood by the employees of the facility. However, other respondents noted that they have a hard time adjusting to the new system since they never participated in its designing. The coding is strange to medics which makes their work challenging. The government officers who are interviewed recommended that health facilities have to make the adoption process a consultative and participatory in nature. The medics that were involved in the adoption of the EHR system reported that while it was generally complex but they somehow were able to adjust to its use compared to those that were never involved at all.

Impact in Work Place Relationships

The study findings revealed that since the introduction of HER brings about many changes in positions and power relation sometimes these results in so much friction to the extent that the system becomes a point of conflict. The system normally determines how information flows, changes in policies and procedures and relationships between various individuals into work place. One of the respondents who is a medic noted that he has been working in one of the facilities for twelve years now. He further explains that the EHR was introduced five years ago and this has had a lot of impact on his job description. To begin with he has always focused on treating patients but now he has to couple that with data entry something he isn’t trained for.

Physician-Patient Relationship

Some of the respondents reported that they always feel having a computer in a medical examination room as a hindrance. Some scholars argue that while this assertion remains largely unsearched some patients are happy when they are attended to with the help of the EHR. They find the experience unique and thrilling.

Perceived Value and Benefits

Collins and Wise (2010) argue that when new system are introduced in the work place many employees always want to know how they will benefit from it. In many cases it has been found out that many systems fail when the employees think that there interest were not put into consideration but the system mainly benefits the management and the organisation at large. Other factors that were mentioned by the respondents as having an impact on the usage of EHR system include; computer skills and training, motivation and peer influence, related user studies of clinical information systems, discretionary use, and the ease of use and information technology support.

The main concerns from the users to use an Electronic Health Record System

While available evidence shows that there are lots of benefits that come with the use of HER system, many health care facilities in Australia are yet to adopt it. When asked why the process is taking long; the key stakeholders mentioned the following as some of the concerns that come with the use of EHR system

Difficult to operate

Many of the health caregivers argued that it was much easier to write that to do data entry into the system. This is so especially in facilities that recently installed the HER system and the doctors were used to hand writing their clinical notes and prescriptions. Many of these medics noted that getting to learn about the new structures and how they function was tedious and again it wasn’t always guaranteed that computers will be available in every part of facility especially at those points where care is given.

Changes in Clinical procedures

The interviews revealed that while it’s possible to have the EHR custom made for a particular health practice and health facility, sometimes clinical procedures undergo changes which cannot be immediately reflected into the system unless the necessary changes are made. The point was that EHR systems have some inherent rigidity as compared to a flip chart. Therefore some medical practitioners noted that these systems have some weaknesses which make their practice difficult. This is so especially where they are still new to the system and need to adapt to the new electronic working environment. This implies that while the system may have the correct record of information sometimes its challenges to make analysis as a medical practitioner where you are met with a unique medical condition that hasn’t been installed in the system.

Trust and Safety concerns

This was a big concern for the clients that used facilities with EHR system. The employees in these facilities also shared the same concern in that it’s impossible to be totally vigilant with electronic storage. In this era of cyber-attacks it’s easier to tamper with a system in fact from any part of the world and remain anonymous. The health facilities that have adopted this system felt the pressure to assure the authorities as well as their clients that they have the ability to secure their private health information. Sometimes facilities have to work extra hard to take care of power failures, computer crashes or infestation by virus among other concern (Berner, 2008)

Cost-Benefit Analysis

The study findings noted that many health care facility owners despite wanting to fully implement the system were hesitant because they were not sure about the Return on Investment. Many expressed their reservation about acquiring systems they are not sure will have some good financial returns especially in this error where many facilities are recording few in patient clients. Many consumers are now using online platform to consult medics or go straight to pharmacy to get medication while avoiding health facilities. According to Aydin (2004) an ideal EHR system needs to be fully equipped with appropriate soft wares and hard ware computers. Moreover other expenses will be incurred when it comes to the training of the employees, maintenance customisation of the EHR system, paying for technical support and the need to upgrade the system of a regular basis. And more complicated is the fact for these facilities to determine how much they are likely to make in return they have to put into consideration so many factors ranging from patients safety, efficiency and effectiveness of the systems and customer satisfaction (Weimer, 2009). This is in fact next to impossible since all these factors are unquantifiable.

Lack of Standardisation

As aforementioned these system are custom made depending on the level of the health care facility, its size and the expertise of its employees among others. Although the government stakeholders revealed that there a few regulations that have been put in place to help in the rolling out of the HealthConnect in the entire country; a lot of uncertainties still exist about certain aspects of the system. For instance there are no clear guidelines as regards the inscription of confidential information. This then raises concerns about data integrity. Additionally managers of health care facilities noted that technology is always advancing and keeping at per with the latest technology are sometimes challenges given the cost involved. According to Glance (2012) these systems are not entirely reliable since sometimes system failure occurs which makes impossible to access the required information needed to serve clients? This is especially since the introduction of the Personally Controlled Electronic Health Record (PCEHR) in July 2012 by the Australian government (NETH, 2012). This gives the clients the ability to access their own medical information at a health facility.


The above discussion has highlighted various issues that concern the adoption and use of EHR system. The researcher highlights the following as the major recommendation that arises from the discussion. To begin with the use of PCEHR should be reconsidered or modified. This is because medical information may not be easily understood by a common patient who has no knowledge in medicine.

The various factors that determine the use of EHR should be weighed even as health care facilities endeavour to adopt or upgrade their EHR system. It is important to make sure that system comes in to make the working better efficient and enjoyable that is a source of conflict. For this to happen then there should be continuous consultation between the varies key stakeholder and most importantly the involvement of the physician in the design and modification of the system

As revealed in the study various concerns affect the functioning of EHR. This should be a wakeup call especially to the government that has been at the forefront in putting initiatives such as PCEHR and HealthConnect to continue doing so but offer support to the health care facilities that are still young and want to adopt this system. Additionally there is need to standardise the system so as to minimise errors and improve into reliability and data integrity.

In conclusion an EHR is a timely invention in this era with so many accompanying benefits. However, there is need to work on the various loopholes that have been highlighted in this study. There is need to put in place strategies that will help the EHR to be rolled out in the coming years without so much hurdles especially on the part of health care facilities. It’s a high time the government the government made it compulsory to have some mandatory training courses at the medical school to orient them with what they should expect when they go out there.


Aydin, C. E. (2004). Survey methods for assessing social impacts of computers in healthcare organizations. In J. G. Anderson, C. E. Aydin & S. J. Jay (Eds.), Evaluating health care information systems: Methods and applications (pp. 69-115). Thousand Oaks, CA: Sage Publications, Inc.

Ashish, K. et al., (2009). “Use of Electronic Health Records in U.S. Hospitals,” New England Journal of Medicine 360, no. 16. 1628–1638.

Aaronson, J. W., C. Murphy-Cullen, W. M. Chop, & R. D. Frey. (2001). Electronic Medical Records: The Family Practice Resident Perspective. Family Medicine 33, no. 2: 128– 32.

Berner, E. S. (2008). Implementation challenges for clinical and research information systems: Recommendations from the 2007 winter symposium of the American College of Medical Informatics. Journal of the American Health Information Management Association, 15(3), 281-282.

Brooks, R. G., & Menachemi, N. (2006). Physicians’ use of email with patients: Factors influencing electronic communication and adherence to best practices. Journal of Medical Internet Research, 8(1), e2.

Bush, G. W. (2004). Executive order: Incentives for the use of health information technology and establishing the position of the National Health Information Technology Coordinator. Washington, DC: The White House.

Carter, L., & Belanger, F. (2005). The utilization of e-government services: Citizen trust, innovation and acceptance factors. Information Systems Journal, 15(1), 5-25.

Chau, P. Y. K., & Hu, P. J. (2002). Investigating healthcare professionals’ decisions to accept telemedicine technology: An empirical test of competing theories. Information & Management, 39(4), 297-311.

Collins, D. & Wise, P. (2010). Meaningful Use: Lessons Learned on the Path to EHR Excellence in Ambulatory Care. Retrieved June 1, 2017 from <http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/M/PDF%20MeaningfulUseLessonsLearnedPathEHRExcellenceAmbCare.pdf>.

Beth, E. D. et al. (2010). “Prescriber and Staff Perceptions of an Electronic Prescribing System in Primary Care: a Qualitative Assessment,” Bmc Medical Informatics and Decision Making 10.

Ford, E. W. et al. (2010). Hospital IT Adoption Strategies Associated with Implementation Success: Implications for Achieving Meaningful Use. Journal of Healthcare Management 55, no. 3: 175–188.

Ash, J. S. et al. (2012). Recommended Practices for Computerized Clinical Decision Support and Knowledge Management in Community Settings: a Qualitative Study. Bmc Medical Informatics and Decision Making 12. doi:10.1186/1472-6947-12-6.

Devers, K. J. (2011). The State of Quality Improvement Science in Health: What Do We Know About How to Provide Better Care? Retrieved June 1, 2017 from <http://www.urban.org/uploadedpdf/412454State-of-Quality-Improvement-Science-in- Health.pdf>.

Hsu, J., Huang, J., Fung, V., Robertson, N., Jimison, H., & Frankel, R. (2005). Health information technology and physician-patient interactions: Impact of computers on communication during outpatient primary care visits. Journal of the American Medical Informatics Association, 12(4), 474-480.

Hagland, M. (2010). First Place. Children’s Hospital of Pittsburgh. Improving Patient Care through Data Availability in the ICU. Healthcare Informatics : the Business Magazine for Information and Communication System. 27, no. 3: 20–26.

Shekelle, P. G. et al. (2013). Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities. (Office of the National Coordinator for Health Information Technology). Washington, DC. RAND Corporation.

Thomas W. Cooley et al. (2012). Implementation of Computerized Prescriber Order Entry in Four Academic Medical Centers, American Journal of Health-System Pharmacy 69, no. 24: 2166–2173.

Silow-Carroll, S., Edwards J. N. & Rodin, D. (2012). Using Electronic Health Records to Improve Quality and Efficiency: The Experiences of Leading Hospitals. Issue Brief (Commonwealth Fund) 17 (July 2012): 1–40.

Glance, D. (2012). Everything you need to know about Australia’s e-health record, The Conversation. Retrieved June 2, 2017 from <http://theconversation.edu.au/everything- youneed-to-know-about-australias-e-health-records-5516>

Gadd, C. S., & Penrod, L. E. (2000). Dichotomy between Physicians and Patients Attitudes Regarding EMR Use During Outpatient Encounters.‖ Proceedings of the AMIA Symposium (2000): 275–79.

Hannan, T.J, (2011). E-health in Australia: time to plunge into the 21st century. Medical Journal of Australia. 194(4) (2011) 211.

NETHA, (2012). Overview of the National eHealth Strategy and the Personally Contorlled Electronic Health Record. Retrieved June 2, 2017 from <http://www.nehta.gov.au>

Connections to Care (2002). How Technology Makes Information Accessible. Journal of the American Health Information Management Association 73, no. 6 (2002): 28–31.

Weimar, C. (2009). Electronic Health Care Advances, Physician Frustration Grows. Physician Executive Journal. 35, no. 2 (2009): 8–15.

Doolan, D. F., Bates, D. W., & James. B. C. (2003). The Use of Computers for Clinical Care: A Case Series of Advanced U.S. Sites. Journal of the American Medical Informatics Association 10, no. 1 (2003): 94–107.

Guthrie, M. B. (2001). Get Real: What Will Draw Physicians to the Web? Physician Executive 27, no. 2 (2001): 36–40.

Simborg, D. (2008). Promoting Electronic Health Record Adoption. Is It the Correct Focus? Journal of the American Medical Informatics Association 15, no. 2 (2008): 127–29.

Bahensky, J. A. et al. (2011). “HIT Implementation in Critical Access Hospitals: Extent of Implementation and Business Strategies Supporting IT Use. Journal of Medical Systems 35, no. 4 (August 2011): 599–607.

Murphy, J. (2011). Leading from the Future: Leadership Makes a Difference During Electronic Health Record Implementation. Frontiers of Health Services Management 28, no. 1 (2011): 25–30

Lluch, M. (2011). “Healthcare Professionals’ Organisational Barriers to Health Information technologies-A Literature Review. International Journal of Medical Informatics. 80, no. 12: 849–862,

Susan D. DeVore and Keith Figlioli, “Lessons Premier Hospitals Learned About Implementing Electronic Health Records,” Health Affairs 29, no. 4 (April 2010): 664–667, doi:10.1377/hlthaff.2010.0250.

Shield, R. R. et al. (2010). “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation. Annals of Family Medicine 8, no. : 316–326.

Castillo, V. H. Martinez-Garcia, & A. I. & Pulido, J. R. G. (2010). A Knowledge-based Taxonomy of Critical Factors for Adopting Electronic Health Record Systems by Physicians: A Systematic Literature Review. Bmc Medical Informatics and Decision Making 10. doi:10.1186/1472-6947-10-60,


Example of Knowledge Resources Database

The figure is a representation of a patients record can be linked to online resource of information.

A Framework to Evaluate the Adoption of Electronic Health Record System. 8