The role of the professional association: A grounded theory study of Electronic Medical Records usage in Ontario, Canada
Introduction
Technology continues to advance with spending on Information Technology growing to an estimated worldwide investment of $3.7 trillion for 2013 (Lovelock, 2013). Computers are indispensable, enabling organizations and individuals to be more productive (Carr, 2003). The growth of computer capabilities has led to the design of software with multiple features, but in many cases the extra functionality available has outpaced users’ abilities to take advantage of it (Hsieh & Wang, 2007). For feature rich software, practitioners would benefit from a deeper understanding of how users can be guided to go beyond the default functions (Sundar & Marathe, 2010) and explore additional options that result in additional benefits. An example of feature rich software is the Electronic Medical Records (EMR) system, which has the potential to enhance the delivery of healthcare by physicians (Bates, 2010).
The International Organization for Standardization (ISO) defines the primary purpose of an Electronic Medical Record as the provision of “a documented record of care that supports present and future care by the same or other clinicians” (ISO, 2005). Protti (2007) has further refined this definition by describing an EMR as a system where the clinical data for an individual are location specific maintained by a single clinic and not directly accessible by other health care providers outside of that clinic. The family health team at the clinic consists of a variety of health care professionals, including doctors, nurses, nutritionists, and psychologists. As a team, they standardize on a single EMR, but there is no authority over the physicians at the work unit mandating which individual features are to be deployed other than the basic recording of patient demographic information and clinical notes. The physicians are in a position to voluntarily adopt different features according to their own level of comfort. In our study, the physician is the unit of analysis and our research methodology applies grounded theory to develop a theory that explains how physicians could be influenced to adopt more of the available core features.
From a comparison of the use of EMRs in eleven countries, Schoen et al. (2009) defined the core features as: the electronic ordering of tests, electronic access to patients’ test results, electronic prescribing of medication, electronic alerts for drug interaction, and the electronic entry of clinical notes. Beyond these core capabilities, physicians may extend features by performing searches on their patient population, creating templates to speed their entry of notes, set reminders for medical tests, and ensure that non-electronic data are scanned and linked electronically to the patient record.
System use is difficult to define (Barki, Titah, & Boffo, 2007). It has been measured in terms of duration, frequency, and intensity (Lee et al., 2003, Venkatesh, 2008), but this is inadequate when a system has multiple features and users are able to make acceptance decisions at a feature level (Beaudry and Pinsonneault, 2005, Jasperson et al., 2005, Sykes et al., 2009). Burton-Jones and Straub reconceptualised system use “as a user's employment of one or more features of a system” (2006, p. 20). Professionals are different than non-professionals in that the former are valued based on the exercise of their specialized skills and, within an organization, they operate with a higher degree of autonomy than that enjoyed by the non-professional (Walter & Lopez, 2008). There are limited studies of technology acceptance and adoption (Turner, Kitchenham, Brereton, Charters, & Budgen, 2010) that differentiate between the professional and the non-professional user and we address this gap.
In our data collection and analysis, we use our knowledge of technology acceptance as a point of departure (Charmaz, 1996), recognizing that we, as researchers, are not a ‘blank slate’ (Urquhart & Fernandez, 2006), and therefore need to be ‘theoretically sensitive’ (Glaser & Strauss, 1967). The selected context is the post-adoption use of Electronic Medical Records (EMRs) by physicians, who are professionals governed by an association, applying their clinical skills and medical expertise with a large degree of autonomy to provide patient care (Chau and Hu, 2002, Walter and Lopez, 2008). From interviews with physicians, we explore the data and develop theory consistent with the data.
The organization of this paper is as follows. Section 2 describes the research methods and includes background on grounded theory. Section 3 provides the results of the analysis and coding of the data. Section 4 is a discussion, which begins with the integration of formal existing literature with our developed theory. Next are the limitations of the research coupled with suggestions for future research. The final section is the conclusion.
Section snippets
Grounded theory
Grounded theory was selected because it is ideal for the development of theory that explains contextually rich processes (Myers, 1997) where limited theory exists. The adoption of EMRs by primary care physicians is complex, depending upon the physician, the clinic, and the professional association. Survey based quantitative analysis is limited by the need for ‘data reduction’. In order to achieve acceptable response rates for statistical analysis, a survey has to be constrained in size.
Results
The results are presented as a sequence of steps. The first step, open coding, describes the concepts developed by assigning codes from the analysis of each interview transcript. The second step is axial coding, where the concepts are grouped into related categories. The third step is the selective coding, where a hypothesis is developed that links the categories.
Discussion
An emerging concept from the data was the guidance that could be provided by the professional association. In our study, the association is represented by OntarioMD, which has the mandate to help physicians to adopt and use EMRs. OntarioMD is in contact with family physicians via e-mail, it has a website, which offers relevant medical information, and it has a roster of practice consultants who have expertise in the implementation and post-adoption use of EMRs.
The majority of the respondents
Limitations
One of the limitations of the research was the composition of the sample of physicians interviewed. Respondents voluntarily responded to an e-mail invitation from OntarioMD. We did adopt theoretical sampling, but we could only sample from within those who were willing to participate. Consequently the sample was biased in that it was not a random cross section of all EMR users. In response to the interview question, ‘why did you agree to volunteer your time’, the majority of participants replied
Conclusions
Once an IT artifact has been adopted, different benefits accrue depending upon use in the post-adoption stage. Many studies have explored the factors that have influenced the decision to adopt (Lee et al., 2003). Fewer studies have investigated the post-adoption use of feature rich systems after initial acceptance and there is a gap in the literature with respect to the special case of professional users, who act differently than non-professionals because of their autonomy and specific skills.
Norman Shaw is Assistant Professor in the Ted Rogers School of Business at Ryerson University, Toronto, Canada. He received his Doctor of Business Administration from Henley Business School at Reading University, United Kingdom. His research interests are the post-adoption use of technology with a special interest on feature rich systems. Current studies include consumer acceptance of advanced functionality becoming available on smart-phones.
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Norman Shaw is Assistant Professor in the Ted Rogers School of Business at Ryerson University, Toronto, Canada. He received his Doctor of Business Administration from Henley Business School at Reading University, United Kingdom. His research interests are the post-adoption use of technology with a special interest on feature rich systems. Current studies include consumer acceptance of advanced functionality becoming available on smart-phones.