Available online at www.sciencedirect.

com

Procedia Technology 5 (2012) 706 – 715

HCIST 2012 - International Conference on Health and Social Care Information Systems and
Technologies

Adoption of Electronic Health Care Records: Physician

Heuristics and Hesitancy
Jerald D. Hattona*, Thomas M. Schmidtb, Jonatan Jelenc
a
University of Phoenix, 3157 East Elwood Sreet, Phoenix, AZ 85034
b
Dean, Engineering and Information Sciences, DeVry College of New York, 180 Madison Avenue, New York, NY 10016
c
Parsons The New School for Design - School of Design Strategies, 2 West 13th Street, New York, NY 10033, USA

Abstract

Political, economic, and safety concerns have militated for the adoption of Electronic Health Records by
physicians in the United States, but current rates of adoption have failed to penetrate the 50% level. A
qualitative phenomenological study of practicing physicians reveals stumbling blocks to adoption.
Maintaining a physician’s perceived sense of control of the process is key. Electronic Health Records
(EHRs) are critical to the support of research, quality control, cost reduction, and implementation of new
technologies and methods in healthcare. Progress in the USA towards adoption of standardized EHRs has
been halting. We discuss the results of a phenomenological study of physicians and draw conclusions that
will assist all stakeholders in building a more consistent, comprehensive, and cost-effective healthcare
system. When attempting to persuade physicians to migrate to an EMR-based solution, a strong focus on
the control that physicians will have should be emphasized. The transition to an EHR system is eased by
clearly articulating early in the process the potential benefits and the degree of control physicians can have
in the use of the applications.

© 2012 Published by Elsevier Ltd. Selection and/or peer review under responsibility of CENTERIS/SCIKA -
© 2012 Published by Elsevier Ltd..
Association for Promotion and Dissemination of Scientific Knowledge Open access under CC BY-NC-ND license.

Keywords: Electronic Health Records; Electronic Medical Records; Health Information Technology

* Corresponding author. E-mail address: Jerald@Hatton.com.

2212-0173 © 2012 Published by Elsevier Ltd. Selection and/or peer review under responsibility of CENTERIS/SCIKA - Association for Promotion
and Dissemination of Scientific Knowledge Open access under CC BY-NC-ND license.
doi:10.1016/j.protcy.2012.09.078
 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715 707

1. Introduction

Technology adoption by informed health care consumers, increasingly responsible for the personal health
care of children and dependent adults, has outpaced that of most physician practices. According to Police,
Foster, and Wong [28] health information technology (HIT) can potentially improve clinical outcomes for
patients, increase physician productivity, and decrease healthcare costs. Although most patient care is
delivered in physician offices, the adoption and use of available technology continues to lag [p. 245]. The
slow adoption rate of electronic medical record (EMR) applications by physician practices illustrates the issue
[14]. While most patient health-related information remains formatted in paper charts located in physician
offices (24), access to personal health history, medications, inoculations, and treatments becomes more
important in the evolving mobile, technology-driven environment [1].
President Obama stated: “The biggest threat to our nation’s balance sheet, by a wide margin, is the
skyrocketing cost of health care” [29]. Health care accounts for $1 out of every $6 spent in the United States
and those costs are increasing at twice the rate of inflation [29]. According to a United Nations report, the
United States has the most expensive health care system in the world, yet 24 countries have longer life
expectancies and 34 have lower infant mortality rates.
Despite the huge expenditures by individuals and corporations, health care quality in the United States
compares poorly against many other first-world countries [20]. Healthcare has failed to keep up with other
industries in the adoption of technology. One estimate is that health care technology in the United States is 20
years behind the rest of the nation’s industries [16]. One medical provider stated, “This is a $2.4 trillion
industry run on handwritten notes” [29].

2. Purpose of the Study

The purpose of our qualitative study was to investigate physician perceptions of increased technology
adoption in physicians’ medical practices. Understanding of the physician’s view of EMR technology will
eliminate barriers and accelerate the adoption of currently available technology that improves patient care and
the accessibility of patient records. Sparse research exists concerning physician perceptions of the
technology-enabled changing dynamics in health care [25]. We focus specifically on the slow rate of
technology adoption into physician medical practice [37].
A qualitative phenomenological research design questioning a sampling of physicians located in south-
central Indiana revealed information regarding participants’ lived experiences, and helped clarify genuine
human motivations and discover relationships involving economic or social phenomena [17]. The initial
intent of this study was to interview at least 15 physicians; however, after 10 physician interviews, the study
appeared to reach a saturation with no new information being provided.

3. Methodology

Little research is available on physician perceptions associated with the adoption of new technology in the
practice of medicine. Stewart and Shamdasansi [33] noted that qualitative questioning could provide
researchers with an opportunity to capture components of collective, yet seldom-discussed, opinions held by
professionals. The insights and opinions provided through this method provided an opportunity to explore
and understand the underlying issues associated with slow technology adoption rates.
The focus of our study was to identify physician perceptions of increased technology adoption in medical
practices. Physicians were asked to provide perspective on why health care providers have been slow to
incorporate technology into medical practices. Demographic questions were asked to gather data on the
708 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715

participants, and open-ended questions were used to explore the reasons a majority of physicians have failed
to adopt currently available technical innovations. Our qualitative phenomenological approach supports the
gathering of personal perspectives that are not known or available. The study included a sampling of a
homogeneous grouping of 10 physicians out of a larger pool of 15 candidates in south-central Indiana.
Criteria for participants in the study included the following: (a) the provider had to be a currently active,
practicing physician, (b) family practice physicians and adult internal medicine physicians were preferred
because they are more often the primary care physicians for the patient community, and (c) physicians who
employ EMR applications might be included in the population along with providers who are still using paper
charts.
Vishnevsky and Beanlands [36] note that the qualitative researcher aims “to create a rich description of the
phenomenon of interest” (p. 234). To accomplish this, qualitative phenomenological research designs analyze
words, phrases, and constructs to describe the phenomenon studied. Qualitative research seeks to derive
meaning rather than make generalized hypothesis statements [8]. After conducting interviews with 10
actively practicing physicians, a keyword prevalence analysis using the NVivo 9© software assisted in the
determination that theoretical saturation had occurred: we reached a saturation point where no new
information, insights, or coding categories were produced regardless of increasing the sampling population
[4].
Interviews occurred between November 15, 2011, and December 15, 2011 in the physician’s office or in an
office of an affiliated physician. In each case, the discussions were private and lasted between 40 and 75
minutes. Ten open-ended questions guided the conversations. A Zoom H2 portable digital stereo recorder
captured the interviews allowing an accurate transcription of the participant responses. Those transcripts were
used in conjunction with NVivo 9© software for coding the data and performing the thematic analysis.
Demographic information gathered included sex, years in practice, and medical specialization. The
participants interviewed were eight male and two female family practice physicians. The physicians are
members of a larger affiliation of medical practices involving 75 total practitioners in 16 separate practices.
Beginning in 2005, the initial six practices in the affiliation chose to implement an EMR application. As
additional practices joined the affiliation over the years, they had the option to implement the EMR
application or remain with the existing paper-based system. As of this study, all but one of the practices has
adopted the EMR. The affiliated physicians do all patient interactions and charting through the computerized
system. The physicians serve patients from a five-county area with a total population of 350,000 people [5].
Physicians chosen for this study had to be in active practice for at least five years, to have previously
employed traditional paper-based patient charting techniques, and to have migrated to using an electronic
medical record (EMR) application in their medical practice. For our phenomenological study, it was
important to involve physicians who had lived through the experience of using the traditional paper charting
methods and utilized the capabilities of a computerized medical record application. The physicians in the
study have been in practice for five to 35 years (see Table 1).

Table 1. Summary of Participant Years in Practice

5 – 10 Years 1 (10%)
10 – 15 Years 2 (20%)
16 – 20 Years 2 (20%)
21 – 25 Years 2 (20%)
26 – 30 Years 2 (20%)
 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715 709

31 or more Years 1 (10%)

Note: n = 10

4. Findings

The interviews produced discussions beyond the scope of the questions. Shown in Table 2 are the major
and minor emergent themes of the research study. The themes fell into a categorization of either benefits or
challenges to the physicians’ practice of medicine. Participants referred to challenges more frequently (199
references or 64.6%) than to benefits (109 references or 34.4%). Relationships between these themes exist
that link many of the observations together. As a result, none of the themes are mutually exclusive.

Table 2. Emergent Themes

Challenges Comments
Major Theme – Challenges
Loss of Control 68
Minor Themes - Challenges
Attitude of Providers 34
Financial Negatives 28
Continuity of Care 27
Total Challenges 199
Benefits
Major Themes – Benefits
Supporting Physician Decisions 29
Physician Access to Information 25
Financial Improvements 25
Minor Themes – Benefits
Time Improvements 18
Patient Access to Information 12
Total Benefits 109

4.1. Challenges Theme

4.1.1 Challenges major theme: Loss of control

The references to loss of control were prominent in the conversations and included references to (1)
procedural or workflow challenges, (2) the EMR causing them to work more slowly, (3) the pace of
technology obsolescence, (4) too much information available to patients or that needed to be gathered from
710 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715

patients, and (5) the cognitive distraction that occurs when the physician interacts with a computer in the
examination room.

4.1.2 Challenges major theme: Attitude of providers

Moving from any established process to a different process can be difficult. Moving from a paper-based
medical practice to an electronic medical record environment is especially challenging for physicians [32]. In
many cases, the physician had created the paper-based system to match his or her individual interpretation of
best practice.
Migration to an EMR from a paper-based system can be categorized as a second order change. Second-
order changes, in the context of this study, would involve a fundamental shift in the way physicians perceive
themselves and the world. This is different from a first order change, which could be comprised of minor
changes to the way things are done. A second order change would transform an existing paradigm into
something very different [27].
The success physicians experience adjusting to these changes can affect their attitude toward the new
technology. The challenges noted by the participant physicians included 34 distinct references to the attitude
of physicians toward the technology used in their practices. The areas noted included: 1) the sense that paper
charts were easier to use than computerized record systems, 2) the technical ability, or lack of technical skills,
of the physician, and 3) the age of the physician. Physicians who had long used paper charting in their
practice appeared to have more ingrained habits that were difficult to change. As one physician noted,
“Physicians are such creatures of habit. We write the same drugs all the time. We are comfortable and
sometimes you have to get out of your comfort zone for this technology” (P3).

4.1.3 Challenges minor theme: Financial Negatives

Cost of the software, cost of the maintenance, and cost of the support personnel to ensure the application
continues to run, the data is backed up, and the networks are secure were comments heard from each of the
participants. In total, 29 comments from the physicians referred to the cost of obtaining and maintaining
computerized medical record systems.

4.1.4 Challenges minor theme: Continuity of Care

Liss et al. [21] noted most physicians have neither the time nor the needed expertise to address all patient
medical needs. Referrals to other physicians are a normal in the current healthcare environment. Because
services are comingled among many providers, and no single model of care coordination is universally
applicable across patient populations, ensuring that patient care is coordinated is a challenge (p. 323). Many
physicians believed that electronic medical record applications would facilitate improved coordination of
patient care across the practitioner community, but that has not happened as quickly or effectively as they had
hoped.

4.2. Benefits Theme

The physicians interviewed for this study described a number of benefits. Analyzing transcripts of the
interviews using the NVivo 9 software facilitated the discovery of major themes relating to the capability of
technology to support physician decisions, provide physicians with improved access to information, and the
financial improvements associated with the incorporation of technology into medical processes. Minor
themes emerged related to time improvements that can be realized from using computerized medical record
applications and the potential for improved patient access to his personal health information.
 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715 711

4.2.1 Benefits major theme: Supporting Physician Decisions

Much of the technology implemented in medical practices is designed to support the decisions made by
physicians concerning the care they provide to patients. The EMR is particularly useful in noting drug
allergies and drug-to-drug interactions [7].

4.2.2 Benefits major theme: Physician access to information

Physicians need access to timely and accurate information to make decisions about patient care. EMRs
can provide that access in a structured, retrievable format. Then, it was a significant challenge to just locate
the folder containing the patient’s past care information. An electronic medical record integrates patient
information systems so that demographic, financial, and medical information can be collected, accessed,
transmitted, and stored in a readily available digital format [31]. In most cases, an EMR provides physicians
with improved access to needed patient information supporting a prompt diagnosis and treatment plan [3].
Better information can translate to improved patient care and a healthier patient population.

4.2.3 Benefits major theme: Financial Improvements

Physicians have a sense that the EMR makes them more cost effective and more efficient. They cited
anecdotal evidence that the EMR is helping them to code more accurately and more consistently capture
charges for services rendered. Several practices have begun to mine patient data to search for patients who
qualify for or require medical examinations or procedures. By being proactive in the interactions with
patients, physicians are finding an increase in patient loads. The government of the United States is providing
more than $20 billion in incentives to encourage physicians to implement electronic medical record
applications by 2014 [13]. The incentive program provides a total financial incentive, “of $44,000 for each
physician who adopts EMRs in 2011 or 2012, $39,000 for those who adopt in 2013, and $35,000 for those
who adopt in 2014” (p. 44). Should physicians wait until later to implement an EMR, they will receive a 1%
decrease in Medicare reimbursement with an accelerating decrease in years thereafter.

4.2.4 Benefits minor theme: Time Improvements

Physician participants in this study equated efficiency with time improvements. Noted improvements in
this area include improved communication with staff through the EMR messaging capability. Instead of
scribbling a note, as they might have done in the past, the EMR provides an internal system for sending and
receiving information between all persons in the office.

4.2.5 Benefits minor theme: Patient access to information

Most of the physicians participating in this study recognized that patients could benefit from the increased
incorporation of technology into the medical practice. Six of the physicians noted the “increased availability
of information” would be a benefit for the patient population. Three of the physicians observed that better-
informed patients can provide opportunities for improved care and healthier outcomes.

5. Interpretation of the Findings

Several studies of the health care system recognize how the dramatic changes affecting the industry, such
as the introduction of more technology, are causing physicians to perceive a loss of control over how they
practice medicine [18]. The systemic uncertainty occurring in the healthcare system today is particularly
difficult for physicians [32]. Physicians may deal with this perception of loss of control in many ways:
712 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715

x Positive Assertive - the physician focuses on changing themselves or the environment by becoming
decisive, leading the effort, and communicating needs
x Negative Assertive – the physician becomes very involved trying to control and manipulate the change
x Positive yielding – the physician becomes more patient, trusting, accepting, and yields active control
efforts
x Negative yielding – the physician becomes very passive, timid, indecisive, and gives in to feelings of
helplessness [32]

Physicians in this study shared these sentiments. Possessing a sense of control is particularly relevant for
physicians [32]. Medical training of physicians focuses on learning how to take control of problematic
situations. With the realities of the current healthcare environment and the intrusion of new tools, techniques,
and technologies often required by external agencies, physicians are recognizing that, “despite knowledge,
skill, and expertise, there remains much in medicine and patient care that they are unable to control through
active, instrumental efforts” (p. 16).
Overcoming this obstacle is critical to implementing EHRs and improving healthcare quality. Given the
increased expenditure on health care in the United States, it is puzzling that the outcomes compare so poorly
to other industrialized nations. Infant mortality can be an important indicator of national health. The
stagnation of the United States infant mortality rate since 2000 concerns both researchers and policymakers
[22]. The United States has both the highest infant mortality rate and the lowest life expectancy rate for those
persons 60 and older [22; 30] in the comparison countries. Using 37 indicators of health quality, equity,
access, and outcomes, the United States scored an average of 66 out of 100. As a percentage of gross
domestic product, the United States spends more on health care than any other industrialized nation [12; 30].
Critics of the current health care system point to evidence of overuse, inappropriate care, duplication,
waste, inefficient use of resources associated with poor access, regional variations in both quality and costs,
and lack of information systems that foster efficiency [19]. At the heart of the issues highlighted by critics of
the current system is the primary care physician. These doctors act as gatekeepers and repositories of patient
health information. If the internal processes within these medical practices are paper-based, inefficient, or
poorly organized, the other components in the continuum of care experienced by the patient will reflect those
inefficiencies.
The health care industry has long recognized that physicians resist change. Understanding that even
simple attempts at standardization, such as ordering common blood chemistry tests, can be challenging
provides some perspective into the challenges associated with implementing an electronic medical record
application. The use of an EMR can help to standardize many of these processes, but in the United States,
less than 30% of physicians use an EMR compared to 60-90% in other industrialized nations [19]. This
difference in technology utilization is important to consider when contrasting both the quality and cost of
health care provided in differing world areas.
Although the attitude issues that emerged as a major challenge theme are comprised of several factors, it
also contributes to the sense that physicians perceive they are being forced to practice medicine in ways
different from what they were accustomed to doing when they were paper-based and could do as they pleased.
The advent of electronic medical records and the expectation that the information is formatted in a standard
way to be shared securely with other health care related entities changed the dynamics of the process. The
themes that emerged from this study highlight the challenges associated with these dynamics.
One way to develop the needed attitudes toward the technology and need for control is to help physicians
become more aware of their own control dynamics. Helping physicians understand the ways these factors can
affect interactions with patients, colleagues, and staff may help to begin the process of developing a more
 Jerald D. Hatton et al. / Procedia Technology 5 (2012) 706 – 715 713

accepting attitude toward the technology. The loss of control that physicians experience should be addressed
if the nation is to move forward with effectively implemented technology in medical practices.
Physicians are waiting for technology to adapt to their methods and processes rather than adapting to what
others may determine to be optimum. If the physicians perceive they do not have control over the processes,
or the associated costs, they will remain reluctant to adjust to a new system, regardless of the potential
benefits to the larger community. The attitude professed by a majority of the physicians in the United States
is preventing the adoption and use of technologies that can save patient lives, improve the quality of care
provided, and lower the cost of healthcare to individuals, employers, and the nation.
The movement toward accountable care organizations (ACO) may provide the catalyst to begin the
standardization of processes and information flow that would demonstrate the inherent value of electronic
medical record keeping to physicians [6]. Most EMR functionality is isolated to the internal workflow of the
practice and the personal preferences of the physician. As the circle of integration for the digitally shared data
expands, the need to ensure that standardization improves across all members of the care organization will
grow. As reimbursements become increasingly tied to the improved care received by the larger patient
community, additional inducements to effectively use technology will come into play.

6. Future Research

A future study might contrast the perceptions of EMR technology of more recent medical school graduates
who have less experience with paper-based systems and who may have learned to practice medicine using
electronically integrated tools. This comparison may help to project when the true value of an integrated
health care continuum might become the norm rather than the fragmented system that exists at present.
Medical students who have a higher comfort level with computer systems may not perceive the same
challenges as the more experienced physicians who had to migrate from paper-based to computer-based
processes.

7. Conclusion

Physician perceptions and attitudes associated with their perceived sense of control over EMR technology
significantly influence the decision to implement, and effectively use, an EMR. Knowing these factors play a
critical role in the successful promotion of these applications can help focus the effort to define the
advantages and potential uses of EMR technology. When attempting to persuade physicians to migrate to an
EMR-based solution, a strong focus on the control that physicians will have should be emphasized. Those
areas that would influence process flows or tasks required by the physician will need to be identified and
accepted, as should any potential added costs that may be required in future years. Physicians do not like to
be surprised by added complexities and added costs. If these elements are clearly articulated early in the
process, it could ease the transition to the new system.

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