Abstract
The adoption of healthcare information technologies (HITs), such as electronic health records (EHRs), has become a necessity in modern healthcare settings. However, the pressure from the legislative regulations (HITECH Act and Meaningful Use stages in the U.S. case) often forces healthcare organizations to implement EHRs without considering various factors affecting staff members’ behavior. As a result, behavioral barriers preventing effective EHR adoption and operation emerge. Those barriers lead to frustration and resistance among the personnel and undermine EHR adoption efforts. Additionally, behavioral barriers impede the application of learning theories since the personnel becomes reluctant to obtain new knowledge. This paper utilizes a narrative literature review methodology to examine potential factors behind the behavioral barriers emergence and explore possible approaches for overcoming them within the framework of the positive reinforcement technique. In addition, the paper provides practical suggestions for overcoming behavioral barriers which may emerge during the EHR implementation in specific healthcare settings. Overall, the positive reinforcement technique shows potential for establishing behaviors necessary for resolving resistance stemming from organizational, technological, stakeholder involvement, and personal factors.
Keywords: EHR, EHR implementation, learning theories, learning styles, behavioral barriers, approaches to overcoming behavioral barriers, positive reinforcement.
Introduction
Healthcare becomes increasingly more digitalized in an attempt to improve patient outcomes and keep the costs manageable simultaneously. Healthcare information technology (HIT) plays a vital role in helping providers to reach compliance with statutory laws and regulations. In the case of the United States, the changes happened in 2009 with the passage of acts aimed at increasing the efficiency of healthcare delivery and payment models (Beth Shanholtzer & Ozanich, 2015, p. 207). One of those acts, the Health Information Technology for Economic and Clinical Health Act (HITECH), introduced subsidies for providers to allow them to purchase electronic health records (EHRs) systems (Beth Shanholtzer & Ozanich, 2015, p. 207). However, the incentive payments of more than $44,000 per doctor are not unconditional. At first, healthcare providers and hospitals must show that they are capable of using information captured by the EHR in a “meaningful” way (Beth Shanholtzer & Ozanich, 2015, p. 207). The concept of Meaningful Use is multi-staged and imposes a complex of criteria on healthcare organization’s personnel. As such, implementing the EHR in accordance with Meaningful Use criteria requires significant emotional investment and dutiful cooperation from the staff.
In this regard, the human factor may serve as a potential source of problems during the EHR implementation. Behavioral barriers stemming from the reluctance to understand the EHR and use it in daily work may become a significant obstacle in a way to meeting the Meaningful Use criteria. Therefore, it is necessary to explore the possible reasons behind the behavioral barriers emergence and examine existing approaches to overcoming them. In theory, behavioral resistance of the personnel can be overcome with the use of positive reinforcement — a technique of behavioral learning theory that encourages positive behavior with support and rewards. As such, psychological and technological means of positive reinforcement could be the element that would increase EHR acceptance in the face of Meaningful Use requirements.
Learning Theories and Learning Styles in the EHR Implementation Context
The EHR implementation process requires significant effort in explanation and learning from the medical professionals’ part. Those activities fall into the medical education, adult learning, and experiential learning categories. Lewis and Thompson (2017) provided an overview of newer educational theories which explain specific experiential adult learning scenarios. Reflective practice theory emphasizes learning through immediate responses to an event. In regard to EHR implementation, it can be deployed in the form of regular discussions and the incorporation of self-reflective questions. Situation learning theory includes social interaction scenarios, visualization, and real-life context. This theory is mostly based on simulations, which makes it less suitable for such practical activities as EHR adoption. On the contrary, the “communities of practice” (CoP) concept focuses on social interaction as an integral part of learning. Therefore, CoP would be valuable for reinforcing team roles and spheres of responsibility during the EHR implementation process.
The other two experiential learning theories have seemingly different usefulness in EHR adoption. On the one hand, transformative learning theory perceives significant life events or exposures as potent sources of learning in a medical setting (Lewis & Thompson, 2017). EHR implementation can be considered such an event; however, the application of transformative learning may also increase staff stress levels in already stressful circumstances. On the other hand, the critical consciousness theory is based on reflecting on inequalities and oppressed groups’ experiences (Lewis & Thompson, 2017). Whereas the EHR implementation is not intended to be an oppressive and traumatizing measure, it still can result in stress for the medical staff. In this regard, considering the perspective of struggling staff members can be beneficial for enhancing their experience during EHR adoption.
In addition, the understanding of a new HIT would be affected by the personal learning styles of the medical staff members. David Kolb’s theory explains that different people naturally prefer a single learning style (McLeod, 2017). Therefore, healthcare personnel responsible for the EHR implementation should take notes on which ways of explanation lead to better learning outcomes. For instance, people with diverging learning styles prefer working in groups, generating ideas, gathering information, and receiving personal feedback. As such, the EHR implementation team should emphasize teamwork and group meetings while educating those staff members. On the contrary, personnel with assimilating learning preferences would be less focused on people and benefit from a solid and clear explanation. Medical professionals with a converging learning style would likely become the best allies during the EHR implementation since their learning preference creates an affinity for technical and technology-related tasks. Finally, the accommodating learning style relies on intuition rather than logic and benefits plan execution. Therefore, staff members with accommodating learning styles would work most effectively as a direct executive force of the EHR implementation plan.
However, behavioral barriers may add unwanted complexity to the EHR implementation procedure. Learning theories and learning styles work under the assumption that learners are not reluctant to obtain new knowledge. As a result, they are primarily aimed at enhancing learning outcomes. In the case of behavioral barriers, a situation may arise where medical personnel actively resist learning how to operate the EHR. Overall, behavioral resistance must be overcome before the effective application of learning theories becomes possible. A positive attitude towards the EHR must be established and reinforced within a healthcare organization in order to achieve this goal.
Possible Factors of Behavioral Barriers Emergence in EHR Implementation
Before examining behavioral barriers which may arise during the EHR adoption process, it would be helpful to explore the concept of Meaningful Use in its complexity. Meaningful Use is divided into three stages; a healthcare provider must attain specific objectives in order to move from the starting stage to more advanced ones (Beth Shanholtzer & Ozanich, 2015, p. 208). For example, stage 1 demands such proficiencies in EHR use as electronically capturing health information, using it to track key clinical conditions, and communicating it for care coordination (Beth Shanholtzer & Ozanich, 2015, p. 209). As one can see, even the initial stage of EHR implementation sets significant extra requirements for staff competencies. In addition, a healthcare organization must show its capability to consistently meet the Meaningful Use requirements in a span of 2-3 years before progressing to another stage. As a result, medical personnel who never worked with EHR systems or previously got familiar only with basic versions of that technology may become overwhelmed and resist its adoption. Such resistance may lead to a failure to meet the Meaningful Use criteria despite the availability of sufficient financial resources for the EHR implementation.
Organizational Factor
Quantitative data suggests several conditions, which determine the EHR acceptance rates by the personnel. According to Beglaryan et al. (2017), healthcare information technology acceptance depends on the following factors: group-level clinical concerns, required effort from physicians, interference with patient-provider relationships, and resistance to change. In the case of EHR, group-level clinical concerns can be described as collective disbelief in EHR’s usefulness in the sense that the system increases workload and adds confusion without providing immediate benefits. The required effort factor determines physicians’ perception of the difficulties associated with EHR’s use and the approximate effort necessary to learn the technology. Interference with patient-provider relationships is attributed to the negative influence of the EHR on communication with the patients. Finally, resistance to change can be attributed to physicians’ reluctance to alter their work style and professional habits due to discomfort and uncertainty.
All previously mentioned factors of EHR acceptance may lead to the emergence of behavioral barriers during the adoption process. For instance, the organizational culture of a particular healthcare facility may contradict the EHR philosophy. Personnel may become worried that the EHR would disrupt intra-personal relations between employees and administration (Beglaryan et al., 2017). Staff members may oppose the EHR since they perceive it as an unnecessary bureaucratic, inhuman link in the care delivery process. In addition, personnel may become disillusioned and mistakingly conclude that EHR worsens the organization’s performance due to the initial inability to use the system effectively. Lastly, the required effort evaluation against the immediate benefits may lead staff members to the conclusion that EHR is not worthy of implementation. Overall, the organizational factor can be defined as the first major cause of behavioral barriers in the EHR adoption procedure.
Technological Factor
One may assume that technologically-induced behavioral barriers in EHR implementation are restricted to developing countries and lower-income settings. However, technological issues may lead to resistance even in developed countries, although their underlying cause will be different. In regard to developing countries, the main technological factor in opposition to EHR adoption was the low level of basic computer difference (Afrizal et al., 2019). On the other hand, the EHR implementation rates in developed countries were lowered due to the staff’s lack of training in the use of particular EHR applications. As such, line healthcare personnel, particularly nurses, can be perceived as the most likely source of resistance to the changes due to the possible lack of digital literacy.
In this regard, healthcare organizations located in more economically developed regions still hold a considerable advantage. In general, line healthcare personnel, such as nurses, is at increased risk of developing stress and nervousness during the EHR implementation (Afrizal et al., 2019). Learning to use an EHR system is significantly easier if a staff member has at least basic computer knowledge. Healthcare personnel in developing countries and lower-income settings may face total uncertainty, whereas their colleagues in economically developed locations may be affected only by the initial inconvenience. As such, technological factors may serve as a cause of behavioral barriers even in developed regions; however, the strength of that barrier will likely be significantly lower.
Stakeholder Involvement Factor
EHR system, especially at advanced stages of Meaningful Use, affects a significant number of stakeholders. Medical professionals have to use the EHR in daily work; fund providers wait for the return of investments, and, most importantly, patients are expected to experience improvement in care quality. Consequently, it would be logical to assume that the interests of all key stakeholder groups should be considered during the EHR adoption. However, this perfect case scenario is not always happening, which leads to the possible emergence of behavioral resistance towards the EHR.
Given that medical workers are expected to work with the EHR daily, one may expect that this stakeholder group must be actively involved in the adoption process. In reality, healthcare professionals, the essential EHR users, are often not sufficiently involved in the system’s implementation (Fragidis & Chatzoglou, 2018). Such negligence toward staff members’ professional opinions and feedback may lead to reluctance in the use of the EHR and the eventual emergence of a behavioral barrier.
In the U.S. case, HITECH Act promises incentive payments only to healthcare organizations that adopt the EHR and comply with the Meaningful Use criteria. Therefore, a scenario in which the administration implements the EHR without properly involving an essential stakeholder in the form of employees is quite probable. In such a situation, the medical personnel may become unable to work effectively in the inconvenient system or resist its adoption altogether out of frustration.
Personal Factor
The last factor contributing to the emergence of behavioral barriers in the EHR implementation is staff members’ various personal attitudes and beliefs. Most importantly, physicians and nurses may oppose the necessary changes in workflow and working routine. According to Kruse et al. (2016), resistance to changing work habits belongs to one of the most common barriers to EHR adoption. The resisting personnel members may be coping with the EHR implementation by diminishing the system’s usefulness. The strength of personal factors may vary but is usually more significant in small and rural practices (Kruse et al., 2016). In addition, staff members may express dissatisfaction with the EHR by using ethical arguments, such as patient privacy concerns and risks of data loss (Tsai et al., 2020). Another personal factor consistently leading to behavioral barriers among clinicians is emotional exhaustion and mental burnout (Tsai et al., 2020). Overall, personal factor serves as one of the common reasons to clinicians’ psychological resistance during EHR adoption.
A significant share of responsibility for increasing the influence of personal factors behind the opposition to EHR implementation lies with policymakers. Kruse et al. (2016) argued that HITECH Act started by offering monetary incentives but ultimately began to threaten healthcare organizations that implement EHR too slowly with reduced reimbursements. As a result, administrations have to deploy aggressive EHR implementation strategies, sacrificing the psychological comfort of their employees in favor of incentive payments. Such disrespect to employees’ positions potentially leads to a haphazard introduction of the system and the eventual emergence of a strong behavioral barrier in the way of the EHR adoption effort.
Approaches to Overcoming Behavioral Barriers in EHR Implementation
The reasons behind the emergence of behavioral barriers during the EHR adoption stage can be fairly easily explained with logic. Poor organization of changes and inability to prepare staff members for changes in intra-organizational and patient-provider relationships leads to confusion and psychological resistance. The lack of familiarity with particular EHR applications or even basic digital literacy in the case of economically-developing settings makes clinicians nervous. Insufficient stakeholder involvement in the EHR implementation process results in their mistrust directed at the system. Lastly, a disregard for employees’ emotional conditions and ethical concerns may also create opposition towards the EHR based on personal grounds.
Regardless of whether the reasons for the behavioral barriers’ emergence are justified, their existence reinforces a negative stance towards EHR adoption and undermines the system’s operational efficiency. In certain healthcare settings, such as in the USA, the problems in EHR adoption may result in failure to comply with the legislation. For instance, the HITECH Act and Meaningful Use concept leave American healthcare organizations small room for maneuver. An introduction of the EHR system becomes essentially mandatory, a necessity for the organization’s survival. Therefore, the possible behavioral barriers must be addressed before they start posing a serious threat to the EHR adoption process. Since the staff members’ resistance often stems from the behavioral aspect, the possible solution may also lie in the behavioral learning theory framework. Therefore, positive reinforcement of desired behavior through certain psychological and technological approaches can eventually overcome behavioral barriers and improve acceptance of the EHR technology.
Psychological Approach
A psychological approach to overcoming behavioral barriers implies the use of positive reinforcement techniques to achieve a gradual shift of stance towards the EHR implementation through spiritual support and encouragement. Several practical means of positive reinforcement may be used depending on the initial reason for the barrier’s emergence. For instance, the negative influence of organizational factors can be mitigated by a clear reinforcement of staff’s roles and responsibilities in EHR use (Dasari et al., 2016). In addition, positive leadership also serves as one of the key domains impacting the implementation process. As such, a leader of the EHR adoption program — the head of a healthcare organization’s Informatics Department, or an informatics nurse, must be ready to provide the personnel with a clearly-explained workflow.
A barrier stemming from insufficient stakeholder involvement can be overcome through continuous positive dialogue with all possible stakeholder groups. For example, in the case of a rural primary care clinic operating with limited resources, those stakeholder groups would include the organization’s management, physicians, and local populations (Mason et al., 2017). Additionally, this type of barrier may be prevented from emerging if early planning, benefit selling, and staff assistance in implementation are discussed at the early stages (Wilkinson et al., 2020). People enjoy feeling empowered, and continuous positive reinforcement would provide them with the desired sense of empowerment. This notion also spreads to the policymakers who coerce healthcare organizations towards poor EHR implementation with threats of reduced reimbursements.
Lastly, one should acknowledge that healthcare personnel may initially perceive EHR adoption as a problem on a personal level. Therefore, the positive reinforcement technique should also be aimed at staff members experiencing frustration and exhaustion due to the initially increased workload. McAlearney et al. (2015) developed psychology-based strategies for the EHR deployment, which derive from the “five stages of grief” framework. During the denial stage, the leader establishes a sense of urgency and creates a vision of a better future. The former part can be explained through the current legislation, while the latter should provide the personnel with a promise of clear benefits. The anger stage is addressed by recruiting more accepting staff members without neglecting the concerns of the EHR opponents. The bargaining stage includes providing the personnel with proper training in EHR use and tweaking the system’s functionality according to user feedback. Finally, the adaptation process becomes reinforced and institutionalized among well-prepared clinicians. As a result, the EHR implementation process becomes a much less stressful and traumatizing experience for the personnel.
Technological Approach
Psychological measures for overcoming behavioral barriers can also be supplemented with certain means within the technological approach. Personnel-friendly application of the auxiliary information technologies may act as an additional source of positive reinforcement for the staff. For example, physicians in lower- and middle-income settings (countries or rural regions) commonly request making the EHR application available on tablets and smartphones (Dasari et al., 2016). Adhering to similar requests may allow to overcome or even avoid the emergence of behavioral barriers based on technological or stakeholder involvement factors.
In addition, technological measures aimed at mitigating the chaos and stress of the transitional period may further improve the perceived satisfaction and involvement feelings among the staff members. For instance, the use of a custom-developed mobile applications for coordination needs helped EHR users during the adaptation stage (Threatt et al., 2020). A smoother implementation phase would allow to avoid the emergence of technology-based behavioral barriers and enable the personnel for effective system operation.
Lastly, the transformation of technological issues into severe behavioral barrier may be avoided by organizing continuous training for personnel with a perceived lack of digital literacy. Afrizal et al. (2019) suggest providing continual training programs and assistance in order to enhance the computer skills of medical staff. In this case, the positive reinforcement technique would prevent the rise of nervousness due to unfamiliarity with complicated new technology. As a result, staff members would not experience abandonment and distress and eventually gain confidence in EHR use. In the end, positive reinforcement would enable medical personnel to operate the EHR system efficiently, in compliance with such complex requirements as Meaningful Use.
Conclusion
An increasing spread of HITs, such as EHRs, sets new demands for healthcare organizations and medical professionals. In some instances, EHR adoption becomes a de-facto policy imposed by legislative bodies. For example, the HITECH Act and Meaningful Use concept virtually made the EHR systems necessary for U.S. healthcare facilities. The inability to comply with requirements set in the Meaningful Use stages leads to a significant loss of incentive payments and reduced reimbursements. As a result, healthcare organizations often have to implement EHRs in a hurry without paying the necessary attention to organizational, technological, stakeholder involvement, and personal factors.
The lack of attention to those factors may result in the emergence of behavioral barriers in the way of the EHR implementation. Frustrated, angered, and nervous staff members may start resisting the EHR adoption by diminishing the system’s usefulness and sabotaging changes. Their intentions can be justified and hardly called malicious; however, such behavioral barriers would likely lead to a suboptimal EHR introduction and operation. Therefore, a leader of the EHR implementation program must strive to reveal and overcome the existing behavioral barriers among the personnel.
This goal can be achieved by using positive reinforcement — a technique from the behavioral learning theory which emphasizes spiritual support and encouragement in order to spread desired behaviors. A combination of psychological and technological approaches to overcoming behavioral barriers can lead to a gradual acceptance of the EHR implementation by anti-EHR stakeholders. Overall, the use of positive reinforcement in various forms shows a potential for reducing stressful experiences among the personnel and establishing conditions for an effective EHR implementation and operation. Future research in this area may include an evaluation of the practical experience with positive reinforcement technique implementation in different healthcare settings, such as rural or economically developed regions.
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