Understanding the challenges faced by Central Valley California region ambulatory care practitioners when adopting electronic health records

Table of Contents

Chapter One: Introduction to the study
Introduction
Background of the Study
Problem Statement
Purpose of the Study
Research Question
Advancing Scientific Knowledge
Significance of the Study
Rationale for Methodology
Nature of the Research Design for the Study
Definition ofTerms
Assumptions, Limitations, Delimitations
Summary and Organization of the Remainder of the Study

Chapter Two: Literature Review
Introduction
Theoretical Foundations
Characteristics of diffusion
Innovator
Early adopter
Early majority
Late majority
Laggards
Innovation decision
Knowledge
Persuasion
Decision
Implementation
Confirmation
Rate of adoption
Characteristics of the innovation
Application of the diffusion of innovation theory
Review of the EHR literature
Understanding EHR
Administrative factors
Clinical factors
EHR: Quality, outcome, and safety
EHR: Efficiency, productivity, and costreduction
EHR: Decision-making and record access
EHR: Services and satisfaction
EHR barriers to implementation
Management during EHR implementation
Historical review ofEHR concepts
Current EHR concepts
Methodology
Quality interview instrument
Case study design
Summary

Chapter Three: Methodology
Introduction
Statement of the Problem
Research Questions
Research Methodology
Research Design
Population and Sample Selection
Instrumentation Sources ofData
Validity
Reliability
Data Collection Procedures
Data Analysis Procedures
Ethical Considerations
Limitations
Summary
Chapter Four: Data Analysis and Results
Introduction
Descriptive Data
Data Analysis Procedures
Results
Summary

Chapter Five: Summary, Conclusions, and Recommendations
Introduction
Summary of the Study
Summary of Findings and Conclusion
Implications
Theoretical implications
Practical implications
Future implications
Recommendations
Recommendations for future research
Recommendations forpractice

Conclusion

References

Appendix A

Appendix В

Appendix C

Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

List of Figures

Figure 1. Five categories of adopters within a social system affecting the diffusion process of an innovation

Figure 2. Five stages of the innovation decision making process

Figure 3. The innovation rate adoption S-curve, illustrating different products at their varying adoption social category

Figure 4. Innovation characteristics identified by Rogers (2010) as it pertains to an EHR

Figure 5. Participant’s education level

Figure 6. Participant’s gender percentage

Figure 7. Participant’s age and experience level

Chapter One: Introduction to the study

Introduction

The National Coordinator for Health Information Technology, which was created in 2004, spearheads the government’s national health information technology efforts (Denisco Barker, 2013). Its Director emphasized the necessity of implementing electronic health record nationwide:

The goal of assuring an electronic health record for every American is daunting. We at the National Coordinator for Health Information Technology office do not pretend otherwise. We know this will be hard for some clinicians and hospitals, and we stand ready to help with resources provided by Congress and the Administration. As we look at our nation’s annual healthcare expenditures of approximately $2.5 trillion, there are many ways our current system fails both patients and providers. It is clear that change is necessary. (Healthcare IT News, 2009)

In 2004, President Bush issued Executive Order 13335, establishing the Office of the National Coordinator for Health Information Technology (ONC) (Health IT, 2014). ONC is the principal federal entity charged with the coordination of nationwide efforts to implement and use health information technology and the adoption of electronic health record information exchange in the country (Health IT, 2014). Continuing with President Bush’s health information technology initiative, President Obama signed the American Recovery Reinvestment Act (ARRA) of2009 (Federal Register, 2009; GPO, 2009). ARRA contains the Health Information Technology for Economic and Clinical Health Act (HITECH), which created incentives for electronic health record (EHR) adoption using federal stimulus funds (Committee on Ways and Means, 2009; HITECH, 2009). HITECH was followed by the Patient Protection and Affordable Care Act (ACA) of 2010. The ACA established payment reforms for the U.S. healthcare industry and encouraged healthcare professionals to leverage health information exchanges (HIE) in making decisions to adopt EHR (ACA, 2010).

EHR systems are computerized health records with the potential for providing substantial benefits to practitioners and users of healthcare delivery systems (Amatayakul, 2012). An EHR is not limited to one treatment facility, organization, hospital network, or state; it is fully interoperable and can be shared between disparate healthcare stakeholders, enabling a medical provider to deliver the standard of care to the patient more efficiently (HIMSS, 2013). Many researchers have documented the benefits of using EHR systems (Chen, Garrido, Chock, Okawa, Liang, 2009; Felt-Lisk, Johnson, Fleming, Shapiro &Natzke, 2010; Hamilton, 2012; Wager, Lee, Glaser, 2009); however, healthcare providers moved slowly to adopt these technologies. (Ajami, Ketabi, Saghaeian-Nejad, Heideri, 2011; Ferris et al., 2006; Ford, Menachemi, Phillips, 2006)

Challenges that ambulatory care practitioners in the Central Valley California Region encounter when transitioning to an EHR system will be examined in this qualitative study. The theoretical framework of this research is Rogers’ (2010) Diffusion of Innovations (DOI). Rogers suggested that the fastest rate of adoption is associated with authority-innovation decisions (Rogers, 2010). In the case of anationwide EHR adoption, the government acts as the authoritative decision maker in mandating innovation compliance while a national network of EHR is the innovation that adopters would implement for compliance. Physicians have used DOI to describe how they accept and use medical technology such as electronic health records, interactive video, and telemedicine (Amatayakul, 2010).

This chapter begins with the background of the problem, the statement of the problem, the purpose of the study, and the research questions. Additionally, Chapter One contains sections on advancing of the scientific knowledge, significance of the study, and the rationale for the methodology. The chapter closes with the study’s research design, definition of terms, assumptions, limitation/delimitations, summary, and organization of the remainder of the study.

Background of the Study

Information technology development has an overarching effect on all aspects of life. These technological developments have benefited the HIE, especially the introduction ofEHR. Because health IT is relatively new and encompasses a large realm of technologies (i.e., emerging, information, and communication technologies), variation remains among healthcare providers’ level ofhealth IT utilization throughout the country.

The Robert Wood Johnson Foundation (RWJF; 2013) report included four EHR adoption rate measures. First, the EHR adaptation rate for hospitals was 44% in 2012, which was a 27% increase from 2011. Second, 40% ofU.S. office-based physicians adopted a basic EHR in 2012,a 4-percentage point increase from 2011. Third, 25.6% of solo practitioners had a basic EHR compared to 57.7% of those in practices of11 or more physicians. Fourth, physicians in rural practices (small metro and non-metro) were more likely to have a basic EHR than those in practices in large urban (central metro) areas (RWJF, 2013). More recently, Lynch and Kendall (2014) reported that nearly half (136,000) of primary care providers were assisted by HfTECH’s Regional Extension Center (REC) program in adopting an EHR system. Over 335,000 professionals and 4,400 hospitals have received incentive payments through the Medicare and Medicaid EHR Incentive Programs totaling almost $19 billion (Manos, 2014), and yet EHR adoption gaps still exist to date, even after the incentives provided by the federal government.

The Institute ofMedicine (IOM), in a conference at the National Institutes of Health (NIH), presented a report specifically regarding EHR.. IOM described the steps for a national overhaul of the way medical records are developed, maintained, and accessed in order to meet the developing needs of healthcare (Daigrepont McGrath, 2011; Davis Stoots, 2012). By the late 1990s, IOM created the healthcare quality initiative series reports, which focused on assessing and improving the country’s delivery ofhealthcare (Denisco Barker, 2013). The IOM suggested thatthe healthcare system was weak, fragmented, and provided poor quality healthcare because services were not being used effectively (Denisco Barker, 2013).

By the year 2000 and the following decade, IOM continued to publish a series of reports with an emphasis on healthcare quality and safety. The two known reports are “To Err is Human: Building a Better Health System” and “Crossing the Quality Chasm:

A New Health System for the 21st Century” (Denisco Barker, 2013). To err is Human contained issues regarding the large number of errors being committed by healthcare institutions and called for fundamental improvements in healthcare delivery (Denisco Barker, 2013). Toerris Human also contained a discussion regarding the ways to manage medical weaknesses and mistakes as well as suggestions concerning a strategic plan to reduce errors (Denisco Barker, 2013). IOM (2011) identified a need for a culture of safety, trust, and knowledge sharing at all levels of healthcare provision and processes. The IOM advocated for improvements in patient and provider safety through more streamlined workflows, as well as a better understanding regarding how information technology could be used to reduce human error (IOM, 2011). IOM noted that the gaps existed due to various failures in organizational systems, which could be reduced through the implementation of an effective EHR system to coordinate clinical services (Amatayakul, 2012; Denisco Barker, 2013). The IOM’s contribution was significant because it addressed a need and defined the scope of the transition to a national EHR framework system.

The ability to compile patient data and to assure its accessibility anywhere, at any time, has the potential to improve both the efficiency and quality ofhealthcare (Amatayakul, 2012; Hamilton, 2012). EHRs have been identified as the hub of patient health data and provide the ability for providers to share and collect patient health information and compile it electronically (Amatayakul, 2012; Hamilton, 2012; Sinha, Sunder, Bendale, Mantri, Dande, 2012). Cimino and Shortliffe (2012) concluded that it has become impossible to practice modern medicine or to conduct modern biological research without information technologies. The Bush and Obama administrations concurred that the adoption of a nationwide EHR is the primary method of reducing the cost ofhealthcare and of improving the quality ofhealthcare in the United States (Denisco Barker, 2013; Perednia, 2011).

At the end of 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act (MMA). MMA requires the Centers for Medicare and Medicaid Services (CMS) to develop standards for electronic prescribing, which would be a first step toward the widespread use of EHR. In addition, the MMA required the establishment of a Commission on Systemic Interoperability to provide guidance for interoperability standards, which marked the modern era of EHR

(Thompson Brailer, 2004). President Bush further expressed his concurrence with the adoption of a nationwide EHR in his 2004 State of the Union address. Additionally, Bush ordered the advancement ofhealth information technology, with a specific goal of developing a nationwide medical records database by 2014 (Denisco Barker, 2013; Perednia, 2011).

The Obama administration followed suite in 2009 by passing the ARRA into law (Federal Register, 2009). Within ARRA is HITECH, which created incentives for EHR adoption using federal stimulus funds (Committee on Ways and Means, 2009; HITECH, 2009). The passage of ARRA has provided ONC the financial capital, a national compliance deadline, and illustrates the federal government’s commitment to the future ofEHR in the U.S. (Health IT, 2014). HITECH Act’s cornerstone was the Medicare and Medicaid EHR Incentive Programs, which provided eligible hospitals and professionals with financial incentives for the “meaningful use” of certified EHR technology to improve patient care (CMS, 2014).The most current governmental intervention to sustain the progress made towards a national EHR adoption was through the controversial Patient Protection and ACA Act of 2010, which was upheld by the Supreme Court in2012 (ACA, 2010; U.S. Supreme Court, 2012). The ACA established payment reforms for the U.S. healthcare industry. It also led to new models of delivering healthcare to support and to encourage healthcare professionals to leverage HIE in making decisions to adopt EHR (ACA, 2010).

Problem Statement

It was unknown what challenges ambulatory care practitioners in the Central Valley California Region encounter when transitioning to an EHR system from their existing recording method. Ambulatory care practitioners play an important role in the healthcare of a large portion of the population (BPC, 2012; Huskey, 2009). For that reason, it is important to examine the challenges ambulatory practitioners encounter when implementing EHR systems. The inability or reluctance of these practices to take part in the nationwide health data exchange would deprive a large patient population base from taking advantage of advances in health information technology in their healthcare (BPC, 2012; Huskey, 2009).

Amatayakul (2012) and Hamilton (2012) reported overutilization of medical services, numerous medical errors, inefficient healthcare delivery, and inefficient healthcare systems result in costly national spending in healthcare. The healthcare industry is a significant portion of the U.S. economy as well as an exponential expense to the federal government (Wilson, 2013). National healthcare spending reached $2.7 trillion, about 17.9% of GDP and an average of$8,680 per person in2011 (Wilson, 2013). Spending is projected to increase to $4.8 trillion by 2021 (Wilson, 2013). Finding solutions to decrease federal healthcare spending often pointed to the use of available electronic information technologies that will promote quality, efficiencies, information security, and reduction in medical errors (Amatayakul, 2012; Chaudhry, et al., 2006; Schoen, et al., 2006). The Bush and Obama administrations both concurred that the adoption of a nationwide EHR is the primary method of reducing the cost of healthcare and of improving the quality ofhealthcare over the long run in the United States (Denisco Barker, 2013; Perednia, 2011).

According to a 2009 Government Accountability Office (GAO) report, the U.S. healthcare spending for 2007 was approximately $2.2 trillion or 16% of the U.S. gross domestic product. One proposed way to achieve improved healthcare delivery is through use of an EHR system nationwide (Amatayakul, 2012; Denisco Barker, 2013).

Information technology developments have an overarching impact effect in all aspects of our life. HIE has greatly benefited from these developments especially the introduction of EHRs; where the long-term goal has been: quality, efficiency, cost reductions, and information security (Chaudhry, et al., 2006; Schoen, et al., 2006). Furthermore, EHR data interoperates across other members of the healthcare delivery team (i.e. doctors, and hospitals, etc.), which facilitates healthcare portability and efficiency (Amatayakul, 2012).

The focus of this study will involve understanding the challenges that ambulatory care practitioners in the Central Valley California Region encounter when transitioning to a new EHR system from an existing recording method. This understanding will lead to the identification of processes applied by ambulatory care practitioners when adopting an EHR system. Understanding how health information technology, specifically EHRs, will be adopted in the Central Valley California Region will provide stakeholders with valuable information that can be used to assist in promoting nationwide EHR adoption. Adoption of an EHR system would assist in ensuring that ambulatory care providers stay in compliance with federal legislations; that may lead to government incentive payments for EHR use. This research is significant because many other researchers have shown that EHR adoption has been slow nationwide (Cimino Shortliffe, 2012; Jha et al., 2009; Middleton, Hammond, Brennan, Cooper, 2004; Schoen et al., 2006). Blavin and Buntin (2013) forecasted that only 65% of physicians in small group practices would employ a functional EHR by 2019. Ford et al., (2006) also forecasted that the adaptation ofEHR by 2014 would conservatively be 56.2% and optimistically 71.6%.

Gaining an understanding of the challenges that ambulatory care practitioners in the Central Valley California Region encounters during their EHR transition, may lead to identification of issues and processes from which other future adopters may learn. The results of this research could also provide is data for ambulatory care practitioner’s reciprocity to the government mandate to implement EHR nationwide. The continued use of EHR and its adoption is critical to lowering national healthcare spending (Denisco Barker, 2013; Perednia, 2011). When applied to EHR, health information technology could significantly improve healthcare delivery and reduce government healthcare spending (Blumenthal, DesRoches, Donelan, 2006; BPC, 2012; Chaudhry et al., 2006; Shekelle, Morton, Keeler, 2006).

Purpose of the Study

The purpose of this qualitative case study is to understand the challenges that ambulatory care practitioners in the Central Valley California Region encounter when transitioning to a new EHR system from their existing recording method. Understanding of the challenges may lead to the identification of processes that could be applied when adopting an EHR system, thereby providing stakeholders with valuable information for their EHR implementation. This may ensure that ambulatory care practitioners remain in compliance with federal legislation and potentially receive government incentive payments for the employment of EHR. The phenomenon with regard to this study is the understanding of the challenges that ambulatory care practitioners face when transition to a new EHR system in the Central Valley California Region. An interview ofEHR study participants will be conducted using the interview questions (Appendix B), which the researcher received permission to use (Appendix C). Each interview session will start with briefing the participant of the purpose of the study (Appendix D). Interview sessions will be conducted via face-to-face, telephone, or remote media (i.e. Skype) if permissible. The focus of the study will be the phenomenon of the challenges that exists when health care institutions in the Central Valley California Region transition into a new EHR system.

The theoretical framework for this qualitative study is Rogers’ (2010) DOI.

Unlike the invention of new technology, which often appears to occur as a single event or jump, the diffusion of that technology usually appears as a continuous and rather slow process. Yet, diffusion, rather than invention or innovation determines the pace of economic growth and the rate of change of productivity (Rogers, 2010). Until many users adopt a new technology, it may contribute little to the well-being of its users. Rogers’ DOI theory provides a fitting context for the implementation ofEHRs. The rate of innovation (e.g., the EHR) and adoption generally follows a predictable curve, reflecting the relative degree of conformity or resistance to change of individuals within the system or industry (Rogers, 2010).

Innovations have characteristics intended to change processes, structures, or outcomes; they are not value neutral undertakings (Rogers, 2010). Technological innovations are selected with the goal of changing structures, practices, and productivity for an organization (Wejnert, 2002). Among the strategic opportunities for information systems are improved efficiency and effectiveness, inter-organizational cooperation, and product development (Wejnert, 2002). The continued use of EHR and its adoption is critical to lowering national healthcare spending (Denisco Barker, 2013; Perednia, 2011). Failure to understand the challenges that ambulatory care practitioners encounter when transitioning to a new EHR system in the Central Valley California Region could deprive a large patient population base from taking advantage of advances in health information technology in their healthcare. Additionally, ambulatory care practitioners may lose the opportunity to receive government incentives for EHR use.

Research Question

The United States is at the leading edge of creating a healthcare system that is harnessing the power of health information technology to support efficient, cost-effective, and better quality care (CED, 2008). Title XIII, Division A of the ARRA of2009 signed by President Obama, is the HITECH Act (Federal Register, 2009; GPO, 2009). The HITECH Act funds a nationwide initiative to further health information technology developments as a part of the current administration’s national healthcare overhaul (Committee on Ways and Means, 2009; HITECH, 2009). The long-term intent of the HITECH Act is to promote effective utilization of EHR and to establish HIE networks nationwide, all while ensuring security, portability, and nationwide interoperability of patient healthcare data. Implementation of a nationwide EHR system will positively affect efficiency and quality in healthcare delivery, which translates to cost savings in national healthcare spending (Denisco Barker, 2013; Perednia, 2011).

Ambulatory care practitioners play an important role in the healthcare of a large portion of the population (BPC, 2012; Huskey, 2009). For that reason, it is important to examine the challenges ambulatory practitioners encounter when implementing EHR systems. The inability or reluctance of these practices to take part in the nationwide HIE would deprive a large patient population base from taking advantage of advances in health information technology in their healthcare (BPC, 2012; Huskey, 2009). The phenomenon with regard to this study is the understanding of the challenges that ambulatory care practitioners face when transition to a new EHR system in the Central Valley California Region.

Therefore, the following research questions will guide this qualitative case study:

Rl: What challenges do ambulatory care practitioners encounter when transitioning to a new EHR system from their existing recording method within the Central Valley California Region?

R2: What processes do ambulatory care practitioners implement when transitioning to a new EHR system from their existing recording method within the Central Valley California Region?

Advancing Scientific Knowledge

Previous research concerning EHR adoption was conducted in many parts of the United States, including New York, Massachusetts, California, Texas, Washington, and the country in an aggregate (CHCF, 2013; Ferris et al., 2006; Ford et al., 2006; Hamilton, 2012; Zandieh et al., 2008). However, none of the research studies was focused on the Central Valley California Region, creating a gap in research literature. Examining the challenges faced by ambulatory care practitioners in the Central Valley California Region while adopting an EHR system is an integral part of the federal government’s effort to control national healthcare costs (Denisco Barker, 2013; Perednia, 2011).

Although numerous literature exists identifying the benefits of EHR systems (Arditi, Rege-Walther, Wyatt, Durieux, Burnand, 2012; Chen et al., 2009; Felt-Lisk et al., 2010; Merrill, 2010; Milstein Huckman, 2013; Shojania et al., 2009), there are several that outline barriers for a widespread technological adoption (Amatayakul, 2010; Hamilton, 2012; Jha et al., 2009; Mandl Kohane, 2012; Wager et al., 2009). These barriers resulted in healthcare providers’ slow adoption ofhealthcare information technologies (Ajami et al., 2011; Ferris et al., 2006; Ford et al., 2006). Understanding of the EHR adoption challenges faced by the healthcare research participants in the Central Valley California Region may lead to the identification of processes that could be applied by future adopters when transitioning to an EHR system. These processes can provide stakeholders with best practice strategies for their EHR implementation, and can add to the extant literature surrounding EHR implementation, specifically concerning ambulatory care practices.

Rogers (2010) defined diffusion as the process by which an innovation is communicated through certain channels over time among the members of a social system. The four primary elements ofRogers’ DOI are innovation, communication channels, social systems, and time. First, innovation is the idea, product, method, or practice considered new by an individual or group (Rogers, 2010). Innovation can be compared to an EHR system that is new to many healthcare providers. Additionally, innovation does not necessarily have to be new; however, the potential adopter must consider it new (Rogers, 2010). In this research, the adopters will be the ambulatory healthcare practitioners in the Central Valley California Region. Second, communication channels are the means by which people create and share information with the ultimate goal of understanding each other (Rogers, 2010). Government interventions and mandates, which reward or penalize the adopters, serve as the communication line to the stakeholders of EHR implementation. Third, the social system refers to the group or groups of people through whom the innovation is diffused (Rogers, 2010). In this study, the member groups will include ambulatory care practitioners from the Central Valley California Region. The diffusion of innovation theory categorizes these groups into five categories: innovators, early adopters, early majority, late majority, and laggards (Rogers, 2010). Fourth, Rogers described the time element as the innovation-decision process when an individual moves from first-knowledge of an innovation through to its adoption or rejection (Rogers, 2010). It is evident from existing literature that current EHR

adoption is low with bleak forecasts, despite a government mandate for nationwide implementation (Blavin Buntin, 2013; Ford et al., 2006; Jha et al., 2009; Schoen et al., 2006; Cimino Shortliffe, 2012). This study will also add to the body of knowledge related to the nationwide adoption of EHR, and will provide additional data regarding the healthcare provider’s reciprocity to government mandates. Gaining an understanding of the challenges that ambulatory care practitioners encounter when transitioning to a new EHR system in the Central Valley California Region could lead to greater rate ofEHR adoption nationwide. Delivering a systems framework that accomplishes a set of functions that provides value by integrating clinical, financial and administrative data could affect healthcare quality, access to healthcare, and cost reductions (Amatayakul, 2012).

Significance of the Study

The U.S. healthcare system has long been recognized as an industry providing state of the art healthcare (Chen et al., 2009; Wager et al., 2009). Researchers also have recognized it as the most expensive healthcare system in the world, and the price tag is expected to rise (Niles, 2010). The healthcare industry is a significant portion of the U.S. economy as well as an exponential expense to the federal government’s budget. National health spending reached $2.7 trillion, about 17.9% of GDP, and an average of$8,680 per person in 2011 (Wilson, 2013). Spending is projected to increase to $4.8 trillion by 2021 (Wilson, 2013). Finding solutions to decrease federal healthcare spending often pointed to the use of available technologies that would promote quality, efficiencies, information security, and reduction in medical errors (Amatayakul, 2012; Chaudhry, et al., 2006; Schoen, et al., 2006). However, the healthcare industry has moved so slowly to adopt these technologies (Ajami, et al., 2011; Ferris et al., 2006; Ford, et al., 2006). The health care system in the United States is broken, and by some accounts, the only way to repair it is to transform it through information technology (Blumenthal, 2009; BPC, 2012).

Significant problems in healthcare, such as patient safety, medical errors, and escalating costs, can be addressed through a nationwide information technology adoption (Wager et al., 2009). Hence, accelerating information technology adoption in the healthcare industry is an important public policy issue (Denisco Barker, 2013; Perednia, 2011; Blumenthal, 2009). The Bush and Obama administrations concurred that the adoption of a nationwide EHR is the primary method of reducing the cost of healthcare and of improving the quality ofhealthcare in the United States (Denisco Barker, 2013; Perednia, 2011).

This research study is significant because it will provide an understanding of the challenges that ambulatory care practitioners in the Central Valley of California Region encounter when transitioning to a new EHR system from their existing recording method. Previous research concerning EHR adoption where conducted in many parts of the United States which includes NewYork, Massachusetts, California, Texas, Washington and the country in an aggregate (CHCF, 2013; Ferris et al., 2006; Ford et al., 2006; Hamilton, 2012; Zandieh et al., 2008); none that was focused in Central Valley California Region.

Gaining an understanding of the challenges that ambulatory care practitioners in the Central Valley California Region encounters during their EHR transition, may lead to identification of issues and processes from which future adopters could learn. The results of this research could also provide data for ambulatory care practitioner’s reciprocity to government mandate to implement EHR nationwide. Denisco and Barker (2013) and Perednia (2011) concluded that continued use and EHR adoption is critical to lowering national healthcare spending. When applied to EHR, health information technology could significantly improve healthcare delivery and reduce government healthcare spending (Blumenthal et al., 2006; BPC, 2012; Chaudhry et al., 2006; Shekelle, Morton, Keeler, 2006).

Rationale for Methodology

The adoption of EHR systems could improve the delivery of healthcare in the United States; however, the adoption rate ofEHR systems among healthcare providers is exceedingly low (DesRoches et al., 2008; Jha et al., 2009). Ambulatory care practitioners play an important role in the healthcare of a large portion of the population (BPC, 2012; Huskey, 2009). The phenomenon in this study is the understanding of the challenges that come when ambulatory care practices in the Central Valley California Region transition into a new EHR system.

The research method that will be used in this study is a qualitative research method. Open-ended interview questions will be used to collect the data. An interview of study participants will be conducted using the interview questions (Appendix B) which the researcher received permission to use (Appendix C). Each interview session will start with briefing the participant of the purpose of the study (Appendix D). Interview sessions will be conducted via face-to-face at the participant’s place of work.

The basis for qualitative research is a central phenomenon that a researcher seeks to understand and explore with a specific audience and in a predetermined location (Creswell, 2011; Maxwell, 2013). Qualitative research uses insight, inference, evidence, and verification (Creswell, 2011). Wertz et al. (2011) added that qualitative research is interpretive and includes introspection. Qualitative research provides data from the human experience and allows for data collection through interviews, observations, documented sources, and visual data (Creswell, 2011; Maxwell, 2013). Furthermore, qualitative research suggests an a priori approach based in philosophical assumptions (Creswell, 2011; Polkit Beck, 2011). A qualitative method of research is usually used to investigate and to analyze the way in which people interact with their environment, and is employed when there is very little information about a social phenomenon (Creswell, 2011; Polkit Beck, 2011).A researcher using this method constructs a multifaceted, holistic, representation of the issue or problem, analyzes data, provides a detailed view of participants, and conducts the study (Swanborn, 2010; Yin, 2014). Qualitative research is freer form than other types of research, and this makes it ideal for investigative studies used for exploratory or formative purposes (Creswell, 2011; Maxwell, 2013). For these reasons, a qualitative methodology is the most appropriate method for the in-depth study of a phenomenon such as the nationwide adoption of EHR.

Nature of the Research Design for the Study

A research design helps to structure and organize a research project (Bordens Abbott, 2010; Polkit Beck, 2011). Three main types of research designs exist: randomized or true experiment, quasi-experiment, and non-experiment (Bordens Abbott, 2010; Polkit Beck, 2011). This research study will employ a qualitative non­experimental design. Because of the unique nature of the nationwide adoption of EHR, and considering that this nationwide implementation is in its infancy, this research is considered to be an intrinsic, exploratory, single-case study.

The case study is an empirical inquiry that investigates a contemporary phenomenon within its real-life context, particularly when the borders between phenomenon and context are indistinct and the researcher believes that the contextual conditions are integral to the phenomenon being studied (Creswell, 2011;Yin,2014).

The case study is the preferred design for examining contemporary or emergent events because the researcher cannot manipulate or influence them, while it allows him to retain the holistic and meaningful characteristics of the real-life events, such as the processes of organizations, changes in communities, and the evolvement of industries (Yin, 2014). For such a study, the utilization of contextual material to describe the setting and a wide array of information must be presented to provide an in-depth picture of the case (Mason,2010; Yin, 2014).

The single-case study approach can reveal the challenges that ambulatory care practitioners encounter when transitioning to the new EHR system in the Central Valley California Region. A case study approach will enable the researcher to investigate a contemporary phenomenon (i.e., EHR adoption) in depth and within its real-world context through interview sessions with ambulatory clinic staff. The researcher will not manipulate the emerging phenomenon but will rather understand a real world case in the perspective of the consumers at the place of usage (i.e., site visits by the researcher to ambulatory clinics). The researcher will be able to see first-hand the organizational processes providing additional means of data sources of evidence. For these reasons, the case study was the most suitable design for examining EHR adoption among ambulatory care practitioners in the Central Valley California Region.

Healthcare professionals are the primary users of EHR systems. The overall population for this research is 34 ambulatory health, behavioral, and dental centers in a network of ambulatory care practices in the Central Valley California Region. The target­sampling goal is 20 centers from the 34 centers, and at least 1 healthcare administrative professional from each center. Access to the population sample is from an approved consent from the network to conduct the study. (Appendix A). An interview of a healthcare administrative professional at each sample location will be conducted using the interview questions (Appendix B) which the researcher received permission to use (Appendix C). Each interview session will begin with briefing the participant of the purpose of the study (Appendix D). Interview sessions will be conducted via face-to-face at the participant’s place of work.

Definition of Terms

Diffusion of Innovations Theory (DOI). A theory that follows the diffusion of an idea, technology, or productthrough communities or cultures (Rogers, 2010).

Electronic Health Record (EHR). A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports (HIMSS, 2013).

Health Information Technology (HIT). The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use ofhealthcare information, data, and knowledge for communication and decision-making (HRSA, 2014).

Health Information Exchange (HIE). Electronic HIE allows doctors, nurses, pharmacists, other healthcare providers and patients to appropriately access and securely share a patient’s vital medical information electronically improving the speed, quality, safety and cost of patient care (Health IT, 2014b).

Health Information Technology for Economic and Clinical Health Act (HITECH). The Title XIII Division A of the ARRA of2009 (Federal Register, 2009; GPO, 2009) signed by President Obama. HITECH Act funds a nationwide initiative to further the HIT developments as a part of the current administration’s national healthcare overhaul.

Innovation. An idea, product, or practice that is perceived as new by an individual or system that is considering adoption (Rogers, 2010).

Interoperability. The ability of two or more systems or components to exchange and to use shared data and information (ONC, 2010). The goal of interoperability is the flow of information among many disparate systems (Moorman, 2010).

Office of the Coordination for Health Information Technology (ONC). The principal federal entity charged with the coordination of nationwide efforts to implement and use the most advanced HIT and the electronic exchange ofhealth information. The position ofNational Coordinator was created in 2004 through an Executive Order, and legislatively mandated in the HITECH Act of2009 (Health IT, 2014).

Assumptions, Limitations, Delimitations

The disclosure of assumptions relating to a study contributes to its credibility and to the accurate evaluation of its quality (Leedy Ormrod, 2009). In this study, the following assumptions will be made: It is assumed that interview participants in this study will not be deceptive with their answers, and that the participants will answer questions honestly and to the best of their ability. To help assist in confidentiality, participants will be given assurances that the information provided will remain private and anonymous, and that participation was voluntary. The assumption is that the sample population had EHR knowledge and access. The assumption is that physicians will have one form ofhealth records, in either paper or electronic format. The assumption is that this study will be an accurate representation of the current situation in the Central Valley California Region. In addition, the assumption is that the research survey instrument will adequately capture the data necessary to understand the challenges that ambulatory care practitioners encounter when transitioning to a new EHR system.

The limitations represent the systematic bias that the researcher does not or cannot control and which can inappropriately affect the results (Shuttleworth, 2009). Bias refers to a predisposition or partiality. In qualitative research, bias involves influences that compromise accurate sampling, data collection, data interpretation, and the reporting of findings (Creswell, 2011). Researchers may show bias when they reach conclusions that ignore contradictory data or when the collection and analysis of data are designed to lead to predetermined conclusions (Maxwell, 2013).

One limitation of this study is the lack of generalizability. As an exploratory, single-case study that uses a qualitative design, the scope, complexity, and pervasiveness of a phenomenon for which there is little precedence in the United States will be examined. As with case studies, the inferences of this study may be difficult to generalize (Yin, 2014). However, the employment of the data from this study could result in theoretical generalization, to formulate a more precise problem, or to develop a hypothesis.

Another limitation concerns the examination of only EHRs. This is because EHRs contain the greatest potential for improved safety and quality of health care in the United States (Chen et al., 2009; Felt-Lisk et al., 2010; Milstein Huckman, 2013). Further, the federal government mandated the adoption and use of EHR for universal implementation (Denisco Barker, 2013; Federal Register, 2009; HITECH, 2009; Perednia, 2011). Although EHRs are an integral part of Health IT, this specific type of technology is but one component of the numerous health information technologies including Tele-Health, mobile devices, and electronic prescribing. Therefore, the results of this study may provide limited, if any, information about the general adoption of HIT as the study primarily focuses on EHRs.

The delimitation is bias. It is difficult to achieve completely unbiased research; however, the degree ofloss of validity is in relation to the degree of the bias. Therefore, it is imperative that the researcher acknowledges predispositions and delimitations that enable the reader to minimize misuse of the data. The researcher will make every attempt to be objective, factual, open-minded, and to support arguments with peer-reviewed documents.

Summary and Organization of the Remainder of the Study

The U.S. healthcare system has long been recognized as an industry that provides state of the art healthcare (Chen et al., 2009; Wager et al., 2009). The U.S. healthcare system is the most expensive healthcare system in the world, with an expectation of continued escalation (Niles, 2010). The healthcare industry is a significant portion of the U.S. economy, as well as an exponential expense to the federal government’s budget. National health spending reached $2.7 trillion, about 17.9% of GDP and an average of $8,680 per person in 2011 (Wilson, 2013). The projection is that healthcare spending will increase to $4.8 trillion by 2021 (Wilson, 2013).

The Bush and Obama administrations concurred that the adoption of a nationwide EHR was the primary method of reducing the cost of healthcare and of improving the quality ofhealthcare in the United States (Denisco Barker, 2013; Perednia, 2011).

EHR systems are computerized health records that have the potential to provide substantial benefits to practitioners and users ofhealthcare delivery systems (Amatayakul, 2012). Researchers have documented the benefits of using EHR systems

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