CAH Staff Perceptions of a Clinical Information System Implementation

A recent survey by the American Hospital Association found that small, rural, and critical access hospitals (CAHs) had consistently lower levels of rates of adoption of electronic health records (EHRs) as compared with their large or urban counterparts.¹ The major models of information technology (IT) use indicate that perceptions of the impact on work and outcomes are significant determinants of technology use and adoption.² Research has shown that users’ attitudes regarding risks to service quality and disruptions in work flow play a large role in the use of health information technology (HIT).^3-5 Research on the evaluation of IT systems in healthcare organizations is quite limited, with the available studies differing in organizational settings, IT approach, and evaluation techniques.⁶ In addition, there is a shortage of studies on measurement tools for IT evaluation.^7-9

Research on the effect of IT implementation in small, rural, and CAHs is limited and needed in order to explore the healthcare users’ role and viewpoint related to the lagging EHR adoption in these hospitals. For small hospitals, IT implementation represents a significant investment and hence evaluation is critical to guarantee its success.This study examines staff perception in 7 CAHs of patient care quality and the processes before and after implementation of a comprehensive clinical information system (CIS). It follows Kaplan and Shaw’s recommendations for IT evaluation and examines how well a system works with affected users in a particular setting.¹⁰

METHODS

Study Hospitals

Mercy Health Network—North Iowa consists of Mercy Medical Center—North Iowa (MMC-NI), 9 CAHs, and a primary physician network. MMC-NI is a rural referral hospital owned by Trinity Health in Novi, Michigan, and it in turn owns 1 of the CAHs and manages the others. Seven of the 9 network CAHs collaborated in a comprehensive EHR and computerized provider order entry (CPOE) system implementation (termed the EHR10 project) as part of Trinity Health’s extensive CIS initiative.¹¹ As shown in Table 1, the 7 study CAHs have 25 or fewer acute care beds (1 includes a 10-bed psychiatric unit) and 2 have attached nursing homes.¹² Full-time inpatient personnel range from 75 to 180 employees; all perform surgical services, and all but 2 offer obstetrics services.

CIS Implementation and Survey Timing

The EHR10 implementation process extended over several years of planning and execution.¹¹ A well-formulated readiness process documented the progress through project milestones. The CAHs, along with MMC-NI, worked together to define the structure for communication and the decision making that would enable effective change management across the 7 CAHs. To meet the implementation goals, the CAHs worked collaboratively to create standardized processes and system designs. Major activities involved setting the stage for network collaboration, which included identifying both local and network-wide structures for communication and decision making. CAH staff, identified to fill key project roles, were freed from their regular duties and educated as to the use of the readiness plan and project tools. Electronic communication was ongoing and included monthly in-person meetings of each task-defined affinity group and the overall leadership team.

The study survey was administered 3 times at annual intervals. The first survey (administration 1) was timed to precede major changes related to the EHR implementation and captured the steady state baseline (March 2007).

The second survey (administration 2) occurred a year later (March 2008) after phase 1 of readiness had occurred. At this point, CAH personnel had become used to the read-only electronic capacity (eg, online laboratory reports), work flow processes had been redesigned, hardware had been acquired and tested, and “super users”—staff who had earlier and more hours of training and practice—were being trained. The administration 2 survey was distributed a few months before the “Go-Live” date of phase 2—the specific date when the EHR/CPOE system was activated. At this point most of the CAH personnel had not yet undergone training for full EHR/CPOE implementation, but were generally aware of the planned changes in work flow, communication, and care processes.

The CAHs followed the Trinity Health readiness process, which pays particular attention to end-user training.¹¹ Training was conducted for all employees who would use the system over a 3-month period immediately preceding Go-Live. Each CAH identified trainers and super users.¹³ The CAHs varied somewhat in how they managed work schedules during training; most used the weekly 4-hour formal training sessions with ongoing practice sessions. For implementation purposes the 7 CAHs were divided into 2 cohorts; the first activated Go-Live in July 2008, and the second in September 2008.

The third survey (administration 3) occurred 1 year later (March 2009). Administration 3 surveys occurred 6 to 8 months after Go-Live and just after the automated medicine dispensing cabinet installation and bar-code medication administration were implemented.

Survey Design and Administration

A previously validated version of the instrument (the Information Systems Expectations and Experiences [I-SEE] survey) was designed to assess expectations and experiences regarding the impact that CISs have on work processes and outcomes.^13,14 For the previous version, the instructions asked respondents to indicate how each item would change (or had changed) as a result of the new CIS, with response options ranging from “much worse” to “no change” to “much improved.”