ICU nurses' acceptance of electronic health records.
This is a review of the article by Carayon et al (2011) investigating the acceptance of an electronic health records (EHR) system at two intervals after implementaion.
ICU nurses' acceptance of electronic health records
Pascale Carayon, Randi Cartmill, Mary Ann Blosky, Roger Brown, Matthew Hackenberg, Peter Hoonakker, Ann Schoofs Hundt, Evan Norfolk, Tosha B Wetterneck, James M Walker,
J Am Med Inform Assoc. 2011 Nov-Dec; 18(6): 812–819. Published online 2011 Jun 22. doi: 10.1136/amiajnl-2010-000018
While there is a huge momentum to implement EHRs there is still great debate around their usability and acceptance, especially where the EHR impacts on previous workflows and practices. This is particularly the case in intensive care units (ICUs) where the workload is high and patient care is complex and critical. ICUS departments require decisions be made quickly and treatments provided timely manner so any changes to work systems by the introduction of a new EHR could have serious consequences for patients as well as clinicians and provider.
This article was about a study that looked at the acceptance of a new EHR system by ICU nurses at 3 month and 12 month intervals post implementation. The aim of the study was to examine whether there was any relationship between EHR design, implementation factors and nurses’ acceptance of the system. The way technology is implemented can influence end use satisfaction and acceptance 
The study was conducted over four ICUs in a northeastern US regional 400 bed medical center. Two cross sectional survey questionnaires that were distributed to nurses in the ICUs. Recruitment into the study was voluntary and they were surveyed 3 months and 12 months after implementation of the EpicCare Inpatient Clinical System ver. 2006 by Epic Systems.
The study was based the Nielson model of technology acceptance. This model indicates that perceptions of the two factors of usability of the technology and usefulness of the technology are indicators of system acceptance. 
decision-making involvement in the system, which involved 11 activities such as human factors assessment, multidisciplinary feedback and departmental feedback.
The researchers went to the ICU units for the two survey questionnaires to evaluate the system for usability and usefulness for :
- Computerized Provider Order Entry (CPOE) - review and sign off on entered orders
- Electronic Medication Administration Record (eMAR) – review medication administration, timing and comments about the administration
- Nursing documentation flowsheet - document vitals, patient symptoms and patient care performed
The survey questionnaires used usability scaling measures from the Questionnaire for User Interface Satisfaction (QUIS). In addition the questionnaire was first pilot tested and refined before use in the full study.
The data results of the QUIS scaling was averaged and analyzed for any biased estimates. The rationale and formulae used in the two level hierarchical model for repeated outcomes used for this data analysis are provided in the paper.
In addition parameter contrasts were also conducted based on procedures by Goldstein. 
The response rates of the study were 51% at 3 months and 72% at 12 months. Of the nurses surveyed at 3months, 71% said that they had never participated in the 11implementation activities, while 23% were involved in the team feedback and 17% in the departmental meetings. On average the nurses’ perceptions of the system were more positive after a year than at 3months.
- CPOE – usability and usefulness indicated acceptance at both 3 months and 12 months with an increase of user satisfaction at 12months
- eMAR – usability and usefulness indicated acceptance at 3 months but this perception disappeared at 12 months
- nursing documentation flowsheets – showed no change in the perception of usability and usefulness from 3 months to 12months.
The authors conclude that the difference in EHR acceptance for CPOE might be due to a greater requirement on the physician to document and complete orders for CPOE systems thus resulting in a reduction in interpreting and clarifying of orders by nurses thus improving their workload.
The improved satisfaction of eMAR at 3 months could be explained by the factor that nurses could see the benefit of the eMAR functionality as they would have up-to-date information about medication administration but that the perception of this usefulness would no longer be relevant after acceptance of this technology
Perceptions the usefulness of the nursing workflow sheets were thought not to change perhaps because many of the nurses had already been using such a system for over 2 years prior to the EpicCare system.
This was a very interesting and detailed study of the user experience of an EHR implemented in what can be a very stressful environment within hospitals. Because the participant selection was not randomized but voluntary there could be some influence in terms of personal bias in the perception of EHRs by those choosing to participate in such as study. However the methods used were particularly structured and focussed on minimizing such factors in the analysis of the results.
The findings did reflect what has been observed in other studies looking at the acceptance of technology by nurses that perceptions of usefulness change over time and increased familiarity with the technology user acceptance.
This study highlights that not only the need to involve the users in the decision making process but also to understand and review workflows and process when implementing such EHR systems to ensure user acceptance. In addition, it indicates the importance for healthcare organizations to continue to periodically review and optimize the design and use of any EHR technology in a structured manner after implementation.
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