Evaluation of an Electronic Patient Record in a Nursing Home: One Size Fits All?

Margreet B. Michel-Verkerke Saxion University of Applied Sciences

University of Twente The Netherlands

m.b.michel@utwente.nl

A.M.G.Marcella Hoogeboom Saxion University of Applied Sciences

The Netherlands a.m.g.m.hoogeboom@saxion.nl

Abstract In a nursing home an Electronic Patient Record

(EPR) is implemented to replace the paper records. Objective: The research aimed to measure the adoption of the EPR by the end-users, and to measure the suitability of the EPR for the context of a nursing home. Methods: A paper questionnaire is distributed to all 341 care providers who used the EPR daily. 130 (38%) responses were included in the research. The questionnaire comprised questions about use of the EPR, ease of use, and support of providing care. Additional twelve interviews are held based on the USE IT-framework. Results: Most appreciated is the access anywhere, anytime, and the legibility. Medical staff was less satisfied, because the EPR was less supportive to their task. Conclusion: The EPR fits the context of the nursing home and is adopted by the care providers. But additional functionalities are needed to support multi-disciplinary collaboration.

1. Introduction

Because of demographic developments, in the next decades a decreasing population of young people has to provide care for an increasing population of elderly people, who suffer from multiple diseases, such as stroke and dementia. This means that care organizations offering care for the elderly in home care and nursing homes, must prepare to work as efficient and as effective as possible, in the meantime assuring a high quality of care and a high quality of life to the residents. The use of information technology, such as Electronic Patient Records (EPR’s) can contribute to the efficiency, effectiveness and quality of care by reducing the time spent on administrative tasks by care providers, and by improving the quality of communication and documentation [1, 2].

1.1. EPR’s in nursing homes

Despite the urge of improving efficiency and effectiveness of provided care for the elderly, research publications on the use of EPR’s in the specific context of nursing homes, are scarce. Documentation in nursing homes needs improvement, according to the study of Voutilainen et al. [3]. In their study the documentation of four nursing homes (two using hand written records and two using a computerized record) was screened for presence and completeness of care plans, whether patients’ needs were met, and for evaluation of care. The overall quality index ranged from 0.65 – 0.76 (of 0-1). The paper records were not compared to the computer records [3]. Ehrenberg & Ehnfors revealed that the content of the patient record showed considerable deficiencies when records were compared with information coming from interviews with residents and interviews with nurses [4]. Continuous training and attention improved the quality of recording, as well as the use of instruments, according to Hansebø et al. [5]. Lindner et al [6] showed that an electronic medical record – with alerts – improved recording of patient preferences about life-sustaining care, resuscitation and treatment-limiting orders. With the electronic medical record the provided care was more often according to the documented preferences of the patients [6].

Yu et al [7] showed that caregivers in a nursing home, were able to adopt an electronic patient record quickly. This also held for nurses of lower educational levels. Advantages of an electronic documentation system in a nursing home were: provision of more accurate, legible and complete information, and reduction of repetition of data entry. Relevance and reliability of information, communication and decision-making abilities were similar to paper records 18 and 31 months after introduction [8].

2012 45th Hawaii International Conference on System Sciences

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DOI 10.1109/HICSS.2012.258

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This last finding suggests that in the end introduction of an EPR does not initiate a lasting improvement of quality of documentation. This contradicts the findings of other researches in hospitals and general practices [1, 9]. In this study an EPR in a nursing home was evaluated in order to measure the rate of adoption by nurses and medical staff, and to reveal what aspects are specific for the adoption of an EPR in a nursing home.

1.2. Adoption of EPR’s

The introduction and implementation of innovations, like electronic patient records or healthcare information systems, does not automatically lead to adoption of the innovation. Several models, like the Technology Acceptance Model (TAM) and USE IT can be used to measure and explain the adoption of an EPR [10, 11]. TAM2 explained adoption well in implementation of an EPR in a nursing home [12]. Key constructs in these models are perceived usefulness, perceived ease of use, intention to use, use, as well as relevance, attitude and requirements. In the subsequent versions of TAM, perceived usefulness is the main determinant for an end-user’s intention to use a specific innovation [10, 13]. Davis defines perceived usefulness as: “the degree to which a person believes that using a particular system would enhance his or her job performance” [14]. Job relevance and output quality both contribute to the perception of usefulness in TAM3 [10].

The USE IT-model theorizes that user characteristics determine adoption. These user characteristics are described by four determinants: requirements, relevance, resources and resistance, of which relevance seems the dominant factor [11]. Relevance can be assessed at two levels: Macro-relevance en micro-relevance. Relevance at the macro-level is defined as: the “degree to which the user expects that the IT-system will solve his problems or helps to realize his actually relevant goals”. Macro-relevance defined this way, matches the concept of usefulness. Micro-relevance focuses on the present situation of the individual user: “Micro-relevance is defined as the degree to which IT-use helps to solve the here-and-now problem of the user in his working process.” [15]. The constructs job relevance and output quality in TAM3 share aspects of micro-relevance.

1.3. Objectives of the study

Literature shows evidence for the improvement EPR’s can achieve in documentation in several healthcare settings (see 1.1). But whether these results apply to nursing homes, remains to be seen. Nursing

homes differ substantially from hospitals and general practices in several ways: � The purpose of providing care is to maintain or

raise the quality of life, rarely to restore health. � The nursing home is the home of the resident, care

providers are ‘visitors’. � The nurses make care plans and are the first

responsible care provider for each resident. Medical and paramedical staff provide ‘additional’ care and are employees of the nursing home.

� Most nurses in a nursing home are of a lower educational level than nurses in a hospital.

� Budget of the organization is smaller than in hospitals and the tariff is ‘all-inclusive’ i.e. including housing, activities, care and medication. These differences have consequences for the

construction and implementation of an Electronic Patient Record (EPR): the care process differs, the end-user differs, and multi-disciplinary (cross-funtional) collaboration is essential and standard. In order to fit the context of a nursing home, an EPR must: be easy to use, put the care plan central, support nurses, paramedical and medical staff, and support their collaboration. Also registration of finances and quality of provided care is essential. Whether these differences have only impact on the EPR design, or also on factors that influence the adoption of an EPR in a nursing home, was the subject of this study. The research focused on the end-users of the EPR. A broad evaluation study is performed concerning many aspects influencing adoption, but in this article the focus is on the specific aspects of adoption of an EPR in a nursing home. The following research questions are defined:

1. To what extent is the EPR adopted by the care

providers in the nursing home? 2. What aspects of the EPR are micro-relevant to the

end-users? 3. Does the EPR fit the specific context of the nursing

home?

The use of the EPR is mandatory for all end-users, so one could say that the adoption of the innovation is 100%. But adoption is not a dichotomous phenomenon: using the innovation, does not automatically mean optimal use and correct use, nor user satisfaction. Evaluation of the EPR reveals what aspects are used and appreciated by the care providers and contributes to knowledge on aspects which enhance adoption of EPR’s in nursing homes.

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2. Study context

2.1. Organizational setting

The care organization comprised of two nursing homes, and two homes for the elderly. The nursing homes provide residential care for elderly people suffering from psycho-geriatric disorders like Alzheimer disease, and for people with severe somatic disabilities, e.g. hemiplegia caused by a stroke. In the special treatment unit younger people with behavioral problems caused by neurological disorders, live. Non-residential care is provided in the hospice for palliative care, and in the rehabilitation department, where elderly people recover from surgery or strokes. In the nursing homes an Electronic Patient Record was implemented to replace the paper records. Objective of the implementation of the EPR was to improve the quality of care by improving the quality of information in the care process (documentation). Before the replacement by an electronic record, the introduction of a general multi-disciplinary paper record was completed. A multi-disciplinary team was formed to prepare the configuration process of the EPR. The EPR was implemented in 2006 and 2007 ward by ward. The members of the project team also served as trainers.

At the time of the implementation in 2006 a merger with a fellow organization for elderly care was prepared: this included a reorganization and change of management. The merger caused much turmoil especially among the medical staff; many physicians resigned after the merger in 2008, and were replaced. The new board wanted to reconsider the ICT-policy and decided not to implement the EPR in all five nursing homes of the merged organization. In 2011, the management considered expanding or replacing the EPR.

2.2. System details and system in use

The EPR is a module on the client administration IS of the care organization. It was offered as a package that could be customized by the nursing home staff. Central part is the care plan, which consists of problems, goals, and actions. Each resident has a ‘first responsible nurse’, who writes the care plan together with the resident or his representative. Reporting is related to the care plan elements, but it is possible to create ‘special’ reports, and physician progress reports. Several forms were composed for intake, orders, history, tests, and medication. The registration of quality of care and the registration of incidents remained paper-based.

The EPR is used by all disciplines, and does not

contain specific medical or medication functionality. Authorization is role based. The lowest level of authorization is a department, not a single resident. For that reason, residents cannot access the system on their own. They can ask for prints or view their data accompanied by a nurse. Care plans are printed to be signed by the resident. In each ward of 32 residents, four thin-client computers are available. Team managers, medical and paramedical staff can use the computers in their offices to access the EPR.

3. Methods

3.1. Study design

A multi-method socio-technical approach was used, containing both quantitative and qualitative methods. A paper questionnaire with closed and open questions, was contructed to evaluate the implementation of the EPR. Quantitative data were collected in order to measure computer literacy, use, perceived goals of documentation, perceived ease of use, perceived support of provision of care, and perceived technical support. Since the focus of this article is on rate of adoption and micro-relevance and because of limited reporting space, only the results on use and perceived support of provision of care, are presented. Qualitative data retrieved from open questions in the questionnaire and interviews add expectations, additional aspects, arguments, feelings and motivations in order to explain the quantitative results. The used methodology was based on Babbie [16] and Cooper and Schindler [17], and Yin [18].

The questionnaire was first constructed to measure the adoption of an EPR by medical specialists in 2003 [19], and later used for the evaluation of a Nursing Information System in a hospital [20]. Items to measure support of provision of care are partially based on the research of Garrity and Sanders [21]. These items were reformulated to fit this case. In addition, questions of TAM3 [10] were added to the questionnaire. Examples of questionnaire statements are: “Because of the EPR I can spend more time on direct care”, “With the EPR I can perform my tasks easier”, “By using the EPR I have more insight in care provided by other disciplines, than by using the paper record”, “The advantages of using an EPR compensate amply for disadvantages”, and “Using the EPR increases the quality of recording of patient data”. The respondents could express their opinion by marking a five-point-scale (fully agree – fully disagree). The questions about frequency of use of the EPR were adapted for the specific system.

Open questions were added about advantages, disadvantages and missing functionality of electronic

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and paper record, e.g. “What advantages do you experience when using an EPR?”. In this way a questionnaire was constructed with more detailed and more specific questions than usually applied for evaluation research in order to reveal what aspects were appreciated most and which were most relevant.

Complementary to the questionnaire semi-structured interviews based on the USE IT-model, which comprises five sections: working process, relevance, requirements (information quality), resources and resistance were held [11, 22]. In order to investigate differences between end-users groups, representatives of nurses, paramedical staff, physicians and team manager were interviewed. To prevent bias, the criteria for being interviewed were not related to the objective of the research. The inclusion criteria were: Availability and being able and willing to express one’s opinion and thoughts on the topics.

The study was conducted in two phases. Phase 1 consisted of a quantitative and qualitative evaluation within a year after the implementation of the EPR. In this phase a team manager (also being a nurse), a physician, a physical therapist, and three nurses were interviewed. Phase II consisted of qualitative research four years later. Since only a limited research was possible in the second phase, the researchers chose to interview two team managers (also being a nurse) to investigate the nurses opinions. For the same reason both physical therapists who served as super users were interviewed on their perception of end-users experiences and on their own experience as paramedical end-users. To be able to reflect on the results for the medical staff in phase I, a physician and a nurse practitioner were interviewed.

3.2. Study flow

The implementation of the EPR started mid-2006 and was completed in two nursing homes at the end of 2007. Phase I of the research started mid-2007 by distributing the questionnaire among all end-users of the EPR. Interviews were held between end-2007 and Jan 2008. In the following years, the system was maintained and the software was updated, but the lay-out and functionality remained unchanged. After several years of continued use, the management considered expanding or replacing the EPR. For that reason, phase II of the research was conducted in May 2011.

3.3. Methods for data analysis

The quantitative data were statistically analyzed using SPSS 18.0. Data analysis comprised splitting up the sample into three categories of care providers,

which responses were statistically analyzed using SPSS. The care providers reported actual use of the eleven most prominent functions of the EPR (a total of 103 function items were addressed in the questionnaire), were contrasted between the different care providers (paramedical, physicians and nurses). An independent samples Kruskal-Wallis and Mann-Whitney U-test were used to measure the differences in how the various care providers perceive and evaluate specific aspects of the EPR. Non-parametric-tests are chosen, because the answer categories were ordinal [23]. In order to more fully understand the factors influencing EPR adoption, the items on support of provision of care, were included in a principal component analysis using orthogonal varimax rotations. This procedure yielded four factors with eigenvalues greater than 1.0, although only the third factor had more than one item with a factor loading greater than .40. These factors accounted for 71.7% of the total variance explained. The reliability of these factors and items comprises items analysis and the calculation of the Cronbach’s Alpha. To measure statistically significant differences between the paramedical, physicians and nurses, independent samples Kruskal-Wallis and Mann-Whitney U-test were used, since the distribution is non-normal.

The answers to the open questions consisted of short statements. In several iterations these were analyzed per question by splitting them in one-topic-statements. Statements which expressed a similar opinion were grouped, labeled, and counted. The transcripts of the interviews were analyzed by isolating topics and opinions. Answers to questions were compared to find shared, contrasting and additional opinions. The resulting statements were analyzed in a similar way as the answers to the open questions. Because of the limited number of interviews, frequencies are not reported.

4. Results

4.1. Participants

The questionnaire was filled out by 38% (130) of the 341 end-users of the EPR. Of 41 respondents the function and ward was unknown, because these respondents detached the page with the personal information of the questionnaire, before sending it in. The remaining respondents are divided in four groups: Physicians, paramedical staff (physical therapists, occupational therapists, speech therapists), nurses, and others (psychologist, social worker, activity worker), to analyze the differences per function (Table 1). Respondents worked at psycho-geriatric as well as at somatic, rehabilitation and special treatment wards.

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Table 1. Participants

Function Population

n=341 Response

n=130

Response per

function Physicians 7 (2%) 5 (4%) 71%

Paramedical staff 21 (6%) 12 (9%) 57% Physical therapists 11 (3%) 9 (7%) 82%

Occupational therapists 7 (2%) 2 (2%) 29%

Speech therapist 2 (1%) 1 (1%) 50%

Dietician 1 (0%) 0 (0%) 0%

Nursing staff 284 (83%) 63 (48%) 22%

Night nurse 11 (3%) 3 (2%) 27%

Nurse (level 3)a 198 (58%) 42 (32%) 21%

Nurse (level 2)a 40 (12%) 10 (8%) 25% Nurse (level 4 or 5)a 16 (5%) 3 (2%) 19%

Student nurse 19 (6%) 5 (4%) 26%

Other 29 (9%) 9 (7%) 31%

Psychologist 3 (1%) 1 (1%) 33%

Social worker 6 (2%) 2 (2%) 33%

Activity worker 20 (6%) 6 (5%) 30%

Unknown 41 (32%)

Total End-users 341 (100%) 130 (100%) 38% aDutch educational levels: level 6 = Master, level 5 = Bachelor, level 2 - 4 = Senior secondary vocational education (www.nuffic.nl).

4.2. Use of the EPR

As indicator for adoption of the EPR, the use of the EPR is measured by asking the end-users to mark how often they used each function of the EPR. Table 2 shows the results on those parts of the EPR of which the use is mandatory for at least one discipline. The results for all respondents are listed and specified for three distinctive groups: nurses, physicians and the paramedical staff. The expected frequency of use (i.e. daily, weekly, monthly, never or rarely) for each function group is marked in bold. Table 2 shows that the adoption rate is high, and that most functions are used as frequent as expected.

The care plan should be the guide to care. The answers in table 2 prove it is. Most respondents consult the care plan very frequently (i.e. daily or weekly). The frequent use of the care plan concept, shows that the care plan is also kept up-to-date. Every user is supposed to use a ‘care plan report’ for daily reports, and a ‘special report’ as an exception. The responses show that care plan reports are read and written very frequently, but special reports are also frequently composed. This indicates that care providers feel the need to report more than what is in the care plan. Physicians have their own progress report which can be read by all care providers.

Most differences in use between nursing and medical staff, align with differences in tasks and functions. Paramedical and medical staff are supposed to fill out the form for preparing the client-meetings every month. Half of the physicians and a quarter of the paramedical staff fail to do so.

Table 2. Use of the EPR

Sample (n = 130) Nurse (n = 63) Physician (n = 5) Paramedical (n = 12) D M R n D M R n D M R n D M R n Care plan R 96 2 2 126 97 0 3 61 100 0 0 4 100 0 0 12

C 62 5 33 119 62 3 35 59 25 25 50 4 75 17 8 12 Care plan report

R 70 1 2 128 100 0 0 63 100 0 0 5 92 8 0 12 C 85 2 13 128 91 1 7 63 0.0 0 100 4 92 0 8 12

Special report R 96 1 3 130 97 0 3 63 0.0 0 100 5 92 0 8 12 C 86 3 11 127 87 2 12 63 0.0 0 100 4 81 9 9 11

Medical report R 83 5 13 126 82 4 13 63 100 0 0 5 82 9 9 11 Preparing client meeting

R 31 36 33 127 27 41 32 62 25 50 25 4 42 42 17 11 C 13 20 68 123 9 21 70 61 0.0 50 50 4 18 55 27 11

Summary client meeting

R 42 40 18 130 35 48 17 63 80 20 0 5 58 42 0 12 C 2 10 89 123 0 12 88 61 25 25 50 4 0 8 92 12

R = read, C = create, D = daily and weekly use added, M = monthly use, R = never and rarely use added. Expected frequency of use in bold. Scores in percentages of respondents per category.

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Other parts of the EPR are used as frequently or more than obliged or expected. This suggests that the information needs of the end-users are higher than expected.

4.3. Support of providing care

In order to measure the micro-relevance of the EPR, 23 statements on were listed in the questionnaire under the heading ‘support of providing care’. In the whole sample scores are positive, except for “because of the EPR I can spend more time on direct care”,

“with the EPR I can perform my tasks easier”, and “the EPR gives me more insight in care provided by others”. The scores on general statements, like, “advantages compensate amply for disadvantages”, and “the use of the EPR had many advantages, compared to the paper record”, appear to be more positive valued than scores on support of individual tasks, like “with the EPR I can perform my tasks better”. Highest scores are on “I consider the EPR useful and useable in my job”, “I can enter all information I want to lay down”, and “Using the EPR increases the quality of recording” (see table 3).

Table 3. Support of providing care

Sample (n = 130)

Nurse (n = 63)

Physician (n = 5)

Paramedical (n = 12)

Load-ing M (SD) n M (SD) n M (SD) n SD n χ2 p

Factor 1 Job support 3.06 (1.11) 129 3.23 (1.12)a 62 1.47 9.27)b 5 3.58 (.64)a 12 12.302 .002 perform tasks faster .885 3.09 (1.46) 129 3.19 (1.49)a 62 1.20 (.45)b 5 3.83 (1.12)a 12 10.661 .005 perform tasks better .773 3.00 (1.31) 129 3.16 (1.39)a 62 1.60 (.55)b 5 3.00 (1.23)a 12 6.411 .041 more time for care .849 2.60 (1.31) 129 2.76 (1.46)a 62 1.00 (.00)b 5 3.08 (.90)a 12 10.339 .006 perform tasks easier .662 2.92 (1.23) 128 3.09 (1.25)a 62 1.60 (.55)b 5 3.33 (.65)a 12 8.339 .015 useful and usable .542 3.62 (1.21) 129 3.78 (1.18)a 62 2.00 (.71)b 5 4.17 (.72)a 12 10.091 .006 do not want without .533 3.16 (1.45) 129 3.19 (1.18)a 62 1.40 (.55)b 5 4.08 (.90)a 12 10.641 .005 Factor 2 Information quality 3.29 (.94) 129 3.50 (.92) 62 1.96 (.74)b 5 3.14 (1.04) 12 9.469 .009

precisely information .634 3.23 (1.23) 129 3.37 (1.30)a 62 1.60 (.55)b 5 3.00 (1.28)a 12 8.342 .015 precisely functionality .773 3.08 (1.15) 127 3.18 (1.24) 61 2.25 (.50) 4 3.00 (1.21) 12 2.592 .274 all information I need .852 3.29 (1.16) 127 3.51 (1.15)a 62 2.00 (1.22)b 5 3.17 (1.12)a 12 6.830 .033 all functionality I need .766 3.23 (1.26) 128 3.44 (1.23)a 62 1.80 (1.30)b 5 3.50 (1.31)a 12 6.191 .045 enter all information .477 3.63 (1.31) 128 3.97 (1.12)a 62 2.40 (1.67)b 5 3.00 (1.27)b 11 8.914 .012 Factor 3Availability of information 3.39 (1.01) 129 3.56 (1.02) 62 3.02 (.90) 5 3.73 91.07) 12 2.183 .336

access anytime .430 3.50 (1.22) 128 3.79 (1.19)a 62 2.00 (1.23)b 5 3.55 (1.04) 11 8.974 .011 can use all anytime .437 3.40 (1.14) 127 3.60 (1.19) 61 2.40 (1.14) 5 3.18 (1.33) 11 4.640 .098 access anywhere .935 3.34 (1.31) 128 3.28 (1.37) 62 4.00 (1.23) 5 3.91 (1.14) 11 2.528 .283 can use all anywhere .904 3.26 (1.29) 120 3.22 (1.34) 58 4.00 (1.41) 5 3.91 (1.30) 11 2.728 .256 Factor 4 User satisfaction 3.29 (1.11) 128 3.51 (1.14)a 61 1.68 (.74)b 5 3.65 (.71)a 12 9.818 .007

collaboration .798 3.14 (1.31) 127 3.38 (1.34)a 60 1.60 (.89)b 5 3.08 (.90)a 12 8.105 .017 insight in care others .768 2.92 (1.33) 127 3.19 (1.35)a 61 1.20 (.45)b 5 2.92 (1.08)a 12 10.636 .005 quality of recording .840 3.55 (1.20) 128 3.72 (1.17) 61 2.20 (1.64) 5 3.67 (.89) 12 4.405 .111 more advantages .724 3.41 (1.26) 128 3.52 (1.28)a 61 1.60 (.89)b 5 4.25 (.62)a 12 11.722 .003 many advantages .725 3.41 (1.28) 128 3.58 (1.27)a 61 1.80 (.84)b 5 4.33 (.65)a 12 12.081 .002

Scores from 1 = fully disagree to 5 = fully agree. The Kruskal-Wallis test is used to compare the answers between function groups Nurse, Physician and Paramedical; χ2 and p-values are listed. The Mann-Whitney-U-test is used to analyze the differences between function groups. a Groups differ significantly of b group, but not from each other, p< .05.

A factor analysis is performed on these 23 items to reveal whether factors could be distinguished and to be able to test differences between the three function groups. This resulted in 20 remaining items, comprising four distinctive factors, which are labeled:

1. Job support, 2. Information quality, 3. Availability of information and 4. User satisfaction. Table 3 reports the factor loadings of the individual items. Chronbach’s Alpha for job support (α = .914), information quality (α = .825), availability of

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information (α = .818) and user satisfaction (α = .916) are good. Table 3 also shows the scores per function group and the p-value of the Kruskal-Wallis-test. The results indicate that most scores on the distinctive factors are significantly different between the three function groups. Additionally, Mann-Whitney-U-tests show that physicians’ scores are mainly responsible for this outcome. They are less positive than nurses and paramedical staff on job support, information quality and user satisfaction. Availability of information is appreciated best by all function groups. Between the nurse subsample and the paramedical subsample we found no statistically significant differences.

4.4. Open questions

The questionnaire also comprised open questions in which the respondents could express their opinion on the advantages and disadvantages of paper and electronic record (see table 4). Advantages of the EPR matched with perceived disadvantages of paper records, and disadvantages of the EPR matched with perceived advantages of paper records.

Table 4. Advantages and disadvantages

Advantages EPR n (%) More readable 72 (55%) Good overview, all information in one place 45 (35%)

Using the EPR saves time 40 (31%) Anytime, anywhere accessible 23 (18%) Disadvantages EPR n (%) EPR is time consuming 66 (51%) No overview, you cannot page through 46 (35%) More time spent in offices, not available in resident’s room,

24 (18%)

Technical problems 24 (18%) Too few computers 11 (8%) Not authorized to correct errors or alter data

12 (9%)

Not all information can be entered 7 (5%) Other disciplines visit wards less often 6 (5%)

The respondents were also asked to list what

functionality they failed (Teble 5). In table 5 items are only listed, when they are not mentioned as disadvantages. The perceived advantages correspond with the scores on the closed questions. New issues mentioned as a disadvantage are: “more time spent in offices, not available in the resident’s room”, “not being authorized to correct errors or alter data”, and “other disciplines visit wards less often”.

Table 5. Missing items What do you miss in the EPR? n (%) Personal history of resident 11 (8%) Specific forms 10 (8%) Opening two or more windows at the same time 7 (5%)

Changes for reporting 6 (5%) Specific functions for medical staff 3 (2%) Plan and report for paramedical staff 2 (2%)

4.5. Interviews

4.5.1. Phase I. In the year after the implementation, the interviewees had mixed feelings about the EPR. Two interviewees were very positive and experienced the benefits, other interviewees saw the potential of the EPR, but did not experience the implementation as relevant for them. The advantages and disadvantages mentioned correspond with the issues in Table 4. Items which were not mentioned before: Positive aspects of the EPR: � EPR contributes to quality of reporting, by

distinguishing care plan reports and special reports. You are forced to read the care plan. Nurses know the care plan better and use it.

� Updating care plans takes less time. � No need to spend time on organizing and

archiving paper records. � In the future: link with Pharmacy Information

System for medication. � In the future: automatically generating quality

indicators.

Negative aspects of the EPR: � Rehabilitation has a high admission rate: the care

plan is too comprehensive and keeping the care plan up-to-date makes you spend a lot of time using the computer.

� Composing the care plan takes a lot of time, because formulating costs a lot of time.

� I prefer to report chronologically instead of reporting on care plan items.

� You cannot search with keywords. This makes reflecting on previous reports hard.

The first and second positive item as well as the

first three negative items show that the EPR is not just a computerized version of the paper record, but influences the method of recording. The last negative illustrates that this is not seen as supportive by everyone.

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4.5.2. Phase II. Four years later, the interview results indicate that the nurses were very positive about the EPR and did not want to work without it anymore. Using the EPR did cost less time, as they were skilled to use the system. Reporting was improved, the care plan was leading, and less special reports were written. Sometimes nurses consulted each other in order to compose a good report. Often nurses quickly consulted the EPR about a resident or an appointment. Team managers read reports in the EPR to reflect on the quality of care, and on the quality of recording. The interviewed physician appreciated the EPR very much. Although the EPR still not fully supported the medical process, it offered advantages that the paper record lacks. Sharing the medical information with colleagues and accessibility of the nurses’ reports, makes the EPR an instrument for efficient care.

Other disadvantages still remained. The EPR was still not accessible in the resident’s room. Desired specific forms and overviews were not constructed, and a paramedical report or paramedical care plan was not available. An existing problem worsened: the shortlist of actual medication did not function anymore.

5. Discussion

5.1. Rate of adoption of the EPR

The first research question was: To what extent is the EPR adopted by the care providers in the nursing home? Rogers defines adoption as “the decision to make full use of an innovation as the best course of action” [24]. Adoption defined this way bares both the element of use, and the element of user satisfaction. The use of the EPR is almost 100%, and the major elements of the system are used in the intended way and as frequent as expected (Table 2). Even the physicians who are not fully satisfied with the EPR use the EPR in the expected frequency. This cannot entirely be explained by the mandatory character of using the EPR. In cases where use is obliged, users have informal power to resist, object or sabotage use. The physicians can probably be regarded as very critical users. When looking at user satisfaction, the physicians in phase I of the research distinguished themselves from the rest of the users, because they were not satisfied with the EPR, and did not consider the system supportive to their tasks. In Phase II medical staff still missed specific functionality, but appreciated other functionality – like availability and sharing the patient information – which a paper record could not supply. It is likely that the other users choose to use the system, because they see benefits, as is expressed in the positive score on the second last item

of table 3: “the advantages of using the EPR amply compensate for the disadvantages”. After several years of continued use the users, including physicians, dislike the idea of returning to paper records again. The results on use lead to the conclusion that the rate of adoption is high.

5.2. Factors influencing adoption

The second research question was: What aspects of the EPR are micro-relevant to the end-user?. The factor analysis resulted in four factors: 1. Job support, 2. Information quality, 3. Availability of information, and 4. User satisfaction. Job support and Availability of information can be regarded as aspects of micro-relevance [11], and correspond with relative advantage in the Innovation-Decision Process [24], and with Job Relevance in TAM3 [10]. Of these factors Availability of information scores best, which is confirmed in the open questionnaire questions and interviews. Even the more skeptical respondents and interviewees mention the availability anywhere, anytime as an advantage of the EPR. The scores in table 3 show that the care providers mostly appreciated the EPR for making the residents’ information available to all care providers. Combined with the high score on readability, this leads to the conclusion that the possibility to share and access the residents’ records is highly micro-relevant to all users, and contributes to the high adoption rate. This also explains why – after four years of experience – users were even more enthusiastic, even though the shortcomings of the system had not been addressed. Especially the possibility to share information seemed to be appreciated. Job support scored positive, but lowest in the entire sample. This probably has two explanations: the nurses thought the EPR did not give them more time for direct care, and the physicians did not agree with any of the items.

Quality of information is included in the concept of requirements at the micro-level [11], and output quality in TAM3 [10]. User satisfaction is merely a resultant of the adoption process and corresponds with the Net benefits in the Information System Success Model of [25]. In accordance with the findings of [12] this research makes it plausible that theories on adoption and acceptance of Information Systems are applicable to the context of the implementation of an EPR in a nursing home.

5.3. EPR in the nursing home context

The third research question was: Does the EPR fit the specific context of the nursing home? To serve the nursing home context an EPR must be easy to use, put the care plan central, support nurses, paramedical and

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medical staff, and their multi-disciplinary collaboration. This system is specifically designed for nursing homes and puts the care plan central, which is visible in the daily practice of end-users (see table 2). Ease of use was investigated, but is beyond the scope of this article and will be reported elsewhere. The nurses and paramedical staff were satisfied about the way the EPR supports them in their tasks, although the paramedical staff would like to have their own report and care plan. Except for the availability of information, physicians were not satisfied with the EPR. In contrast to other healthcare settings like general practices or hospitals, the nursing home EPR is not focused on the doctor as end-user. The EPR is designed to support the care process, and not the medical process. E.g. specific functionality for prescribing and documenting medication was not purchased. The self-constructed medication forms were less orderly and organized than the medication forms in the paper records. This probably explains why the physicians thought the EPR did not support them in their tasks, and why they were not satisfied with the EPR. Integrating the medical module (including the medication module) in the system, would not only support the medical staff better, but would also benefit the medication safety of residents. Multi-disciplinary collaboration would also benefit from adjustments of the EPR for paramedical and medical staff, since these additions would make their reports and recording more visible to other disciplines.

5.4. Strengths and weaknesses of the study

The socio-technical approach which combined quantitative and qualitative research methods proved to be a strong research policy, in which outcomes of interviews supported and explained the results of the questionnaire. Using a questionnaire carries the risk of unfaithful answers. This was anticipated by guaranteeing the respondents full anonymity. Despite the use of non-parametric tests, like the Kruskal-Wallis and Mann-Whitney-U-test, which produce weaker statistical evidence (i.e. the power of these tests is slightly weaker than of parametric tests), meaningful results were achieved. An important limitation is the small response group of five physicians, which in total accounts for 4% of the respondents. However, these five physicians represent 71% of all physicians and were rather consistent in their answers (SD’s often < 1.00). For that reason the tests are executed as presented in the article. The same holds to a smaller account, for the paramedical staff.

By including the whole targeted population, the internal validity of the study became high. Comparing the quantitative and qualitative data increased the

reliability of the outcomes. Repeating the qualitative part of the evaluation after four years of continued use created the opportunity to reflect on the earlier results. This also contributed to the internal validity.

5.5. Meaning of the study

Literature reporting on the evaluation of Electronic Patient Records in the specific context of nursing homes, is scarce. Only the study of Yu et al. [12] in which a modified version of TAM2 and the role of computer literacy was tested, had a similar sample size. The research presented in this article did not test technology acceptance or innovation diffusion theories, but applied these theories in order to reveal what aspects of the EPR are micro-relevant. Like Yu et al [12] the influence of computer literacy is investigated in the presented study. These results will be published separately. This study reports that the perceived quality of documentation has increased. It would be worthwhile to test whether an objective improvement of documentation quality can be assessed.

In the introduction is stated that an EPR for a nursing home needs to be easy to use, put the care plan central, support nurses, paramedical and medical staff, and their multi-disciplinary collaboration. This study confirms these requirements, but also shows that a system that does not meet all these requirements can be adopted.

6. Conclusion

The EPR is used by all care providers and is used in the intended way. The lower educational level of the majority of nurses in the nursing home proved to be no obstacle to implementation of the EPR. Micro-relevance constituted of job support, information quality, availability of information and user satisfaction. Most appreciated is the possibility to access anywhere, anytime, the legibility and the improved quality of reporting. Medical staff was less satisfied, because the EPR was less compatible with their medical process. But the physicians have learned to deal with the imperfections of the system. They appreciate the advantages of sharing readable information with colleagues and nurses.

Although the EPR is not perfect, the EPR is adopted as a modern, professional substitute of the paper record. But the specific software needs improvement to fit all disciplines and their collaboration.

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7. References

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