Improving the Use of the Electronic Health Record using an Online
Documentation Manual and Its Acceptance through Technology
Acceptance Model
Carina Martins, Júlio Duarte, Carlos Portela and Manuel Santos
Centro Algoritmi, Universidade do Minho, Portugal
Keywords: Technology Acceptance Model, Electronic Health Process, Delphi Method, Agency for Integration, Archive
and Diffusion of Medical Information, Electronic Medical Record Adoption Model, Online Documentation
Manual.
Abstract: To a human it’s very complicated to access all the information correctly without a technology to help. The
healthcare information systems (HIS) preserves all the information related to a patient and the hospital. In
order to be able to share between different HIS, there must be a platform to integrate and share all the
information. In Hospital Center of Porto (CHP), the platform used is the AIDA-PCE. This article proposes
to make a prototype of an online documentation manual for the platform used and evaluate its acceptance,
through a questionnaire with 28 questions. This acceptance was guided by the constructs of the technology
acceptance model and the Delphi method. Through bench-marking was chosen the most appropriate tool for
creating this manual. The purpose is to enumerate potential improvements to the platform, to reduce and
optimize the time of its use and to increase the acceptance of this manual by the professionals.
1 INTRODUCTION
The hospital Center of Porto (CHP) is a central
hospital and school that aims at excellence in all its
activities. This article proposes improvements to the
electronic health process (EHR) so that CHP can
optimize the time of use of this technology, prevent-
ing the care of the patients.
The EHR replaced the health process on paper,
recording all relevant information about the patient
and the hospital in a hospital information system
(HIS). This allows the exchange of information
between different entities, internally or externally to
the hospital. One platform that allows this sharing is
the Agency for Integration, Archive and
Dissemination of Medical Information (AIDA). In
CHP, the platform used is AIDA-PCE.
The focus of this article is to evaluate the
acceptance of the documentation manual prepared
for the AIDA-PCE platform by the health
professionals. The CHP was sub-mitted to the
classification of EMRAM (Electronic Medical
Records adoption model), which evaluates the
maturity of the PCE and its functionalities in eight
different levels. It was proposed to investigate
whether the human dimension influences the
fulfilment of the requirements of these levels.
Analyzing all levels, it was found that users
influence directly or indirectly some requirements of
mostly all levels. The technique used to try to
optimize the use of the platform by the professionals
was the creation of an online documentation manual.
Trough a search for tools to create an online
documentation manual, a prototype of this was made
in a CHP instance. To evaluate the acceptance,
questionnaires were made using the technology
acceptance model 3 (TAM 3) and the Delphi
method. The data collected in these questionnaires
were analyzed and dashboards were made to be
more elucidative of the results withdrawn.
2 BACKGROUND
2.1 Electronic Health Record
Electronic Health Record (EHR) can be defined as
the recording of all patient clinical data (Haux,
2006). These data are inserted in an electronic
system, which allows the registration, maintenance
and storage and sharing of clinical information,
346
Martins, C., Duarte, J., Portela, C. and Santos, M.
Improving the Use of the Electronic Health Record using an Online Documentation Manual and Its Acceptance through Technology Acceptance Model.
DOI: 10.5220/0007878103460351
In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 346-351
ISBN: 978-989-758-368-1
Copyright
c
2019 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
which is fundamental for monitoring the health
status of each patient and for other purposes, such as
cost management (Duarte et al., 2011).
The Artificial Intelligence Group (GIA) of the
University of Minho has developed the Agency for
Integration, Archive and Dissemination of Medical
Information (AIDA), a multi-agent system that
integrates, disseminates and archives all information,
which allows the sharing of information with all
information systems (Duarte et al., 2011), (Marques
et al., 2010).
The GIA Group implemented a PCE, called AIDA-
PCE, which is in operation at the CHP, which
operates as an HIS subsystem in this hospital unit.
2.2 Electronic Medical Records
Adoption Model
The Healthcare Information and Management
Systems Society (HIMSS) Analytics has developed
an evaluation model for EHR, the Electronic
Medical Records adoption model (EMRAM). This
model classifies and evaluates the level of
functionalities of a PCE, and can be used as a guide
to improve it (HIMSS, 2017).
This model incorporates methodologies and
algorithms that automatically measure all hospitals
in relation to their capabilities (Analytics, 2017). In
order to submit a hospital to this mod-el, a
questionnaire must be filled out with the respective
information.
Table 1: Levels presented in EMRAM.
Stage
Electronic Medical Record adoption model
7
Complete EMR; External HIE; Data
Analytics, Governance, Disaster Recovery,
Privacy And Security.
6
Technology Enabled Medication, Blood
Products, And Human Milk Administration;
Risk Reporting; Full CDS
5
Physician Documentation Using Structured
Templates; Intrusion/Device Protection
4
CPOE With CDS; Nursing And Allied
Health Documentation; Basic Business
Continuity
3
Nursing And Allied Health Documentation;
EMAR; Role-Based Security
2
CDR; Internal Interoperability; Basic
Security
1
Ancillaries - Laboratory, Pharmacy, And
Radiology/Cardiology Information Systems;
PACS; Digital Non- Non-DICOM Image
Management
0
All Three Ancillaries Not Installed
Upon completion, HIMSS Analytics software
analyzes these data and generates a score between 0-
7000, which indicates the hospital classification.
After this classification, the PCE is framed in one of
the eight levels of EMRAM, with levels 6 and 7
being the most prestigious. At the end, when the
final result is delivered, a report detailing the current
gaps for the hospital to achieve higher stages is also
provided (HIMSS, 2017). Table 1 shows the eight
levels presented in the EMRAM.
2.3 Technology Acceptance Model
Information technologies are increasingly linked to
the success of an entity. But its design and
implementation are not crucial, the evaluation of a
certain technology is essential to understand if it is
fit for a given environment and to measure the level
of satisfaction of its users (Aguiar et al., 2013).
The purpose of technology acceptance model
(TAM) is to present an approach that analyzes the
effects of external variables on users' beliefs,
attitudes and intentions (Chooprayoon and Fung,
2010), on the internal factors of each individual
(Dillon and Morris, 1996).
This model is fundamentally based on two
constructs: the Perceived Usefulness (PU) and the
Perceived Ease of Use (PEOU). PU is the degree to
which the individual believes that using the system
will be useful to their work, increasing productivity
and effectiveness. PEOU is the degree to which the
individual believes that the system does not require
much effort and is easy to use. These two factors are
influenced by external variables and have a major
impact on an individual's Attitude in using them.
The Behavioural Intent (BI) of using the system is
modelled by Attitude and PU, and determines the
Actual Use of this (Dillon and Morris, 1996).
In 2008, Viswanath Venkatesh and Hillol Bala,
adapted the TAM 2 and the model of the
determinants of perceived ease of use, developing an
integrated model of technology acceptance,
Technology Acceptance Model 3 (TAM 3), which
compared with the models above, adds some
variables that can influence PEOU (Aguiar et al.,
2013), (Venkatesh and Bala, 2008). The variables
that influence the PEOU are divided into: anchors
and adjustments. The first type can be split in the
computer self-efficacy, perceptions of external
control, computational anxiety and computer
playfulness. The second type defines the perceptions
of enjoyment and real usability (Venkatesh and
Bala, 2008).
Improving the Use of the Electronic Health Record using an Online Documentation Manual and Its Acceptance through Technology
Acceptance Model
347
2.4 Delphi Method
The Delphi method is seen as a procedure to obtain a
reliable opinion from a group of experts, through a
series of questionnaires scattered with their feedback
(Dalkey and Helmer, 1963).
Initially, this method suggests the formulation of the
questions in the questionnaire. Next, the specialists
are selected, who have to follow four requirements:
knowledge and experience in the problem, capacity
and willingness to participate in the process, time
available to participate and good communication
skills (Adler and Ziglio, 1996). Subsequently, the
first round of questionnaires are developed and
analyzed, to formulate the second round of
questionnaires and send to the specialists. After the
dispatch and resolution by the specialists, the
answers are analyzed, and a third round of
questionnaires is elaborated, that after answer, they
are analyzed again (Skulmoski and Hartman, 2007).
This process continues until stability between expert
responses (Rowe and Wright, 1999). After this step,
the results are analyzed, and a document is drawn up
with these results.
3 ONLINE DOCUMENTATION
MANUAL
The tool chosen for creating the online
documentation manual was Dr. Explain, be-cause it
allows to integrate the documentation manual into
the AIDA platform, allows to take automatic
screenshots and allows the collaboration of different
users in the creation.
The manual features an intuitive and easy-to-work
interface. On the left side there is a side menu that
shows all the contents inserted. On the right side
there is a bar to search for specific contents. For
each task, were created the following steps to make
the tasks more efficiently. This manual also clarifies
relevant concepts to eliminate inconsistencies in
completing forms.
4 TECHNOLOGY ACCEPTANCE
MODEL APPLICATION IN THE
MANUAL
The purpose of the assessment is to determine
whether users are satisfied or not with the manual
implemented, conducting a qualitative research
through questionnaires. The questionnaires were
designed to evaluate the technical and functional
characteristics of the manual, in terms of the
constructs of the technology acceptance model 3
(TAM 3).
The questionnaire contains 28 questions and is
divided into two types of questions: scale response
and open response. Scale response questions were
developed according the Likert Scale (from one to
five). This scale is widely used because it permits a
small dispersion of results and a level of agreement
that short and long scale options do not allow (John,
2010). It should be noted that 1 means “disagree
strongly” and 5 means “agree strongly”. Open
responses are beneficial for getting feedback from
respondents.
The questionnaire was developed in an online
platform, Google Docs, which allows the creation
and editing of documents and was shared with 6
CHP health professionals. Since they were experts in
the subject under study and there was credibility in
the answers, the sample was enough to get results.
Table 2 lists how many questions each construct
evaluates.
Table 2: Number of questions of each construct.
Constructs
Number of questions
PU
12
PEOU
12
BI
12
UB
11
5 DATA ANALYSIS
Figure 1 is based on the TAM 3 construct analysis.
The four constructs were evaluated, plotting the
mean and standard deviation of the questions
associated with this construct.
Analyzing the obtained answers, it was verified that
when one question had of the six answers, two
different, the value of the standard deviation was
superior to 0,5. Then, it was determined that for
values higher than this there was dispersion of
results in the given question.
Graph (a) concludes that the answers with lower
mean were questions 2.4., 3.1. and 4.4, being the
questions in which the construct was worse
evaluated. More than 50% of these questions have a
standard deviation higher than 0.5, which indicates
that there was some dispersion in the answers given.
On the other hand, all questions on average were
evaluated with a value of 4, which explains that, in
general, respondents believe that the documentation
ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health
348
Figure 1: (a) Analysis of Perceived Usefulness.
Figure 1: (b) Analysis of Perceived Ease of Use.
Figure 1: (c) Analysis of Behavioural Intention.
Figure 1: (d) Analysis of User Behaviour.
manual is useful for their work.
Graph (b) settles that the question on which the
construct was worst evaluated was 2.4. Half of the
questions present the value of the standard deviation
less than 0.5, which indicates that in this construct, in
general, there is not much variation in the
professionals' responses. On the other hand, in
conclusion, all questions, on average, were evaluated
with a value of 4, which makes it possible to affirm
that health professionals believe that the manual is
intuitive and easy to use.
Graph (c) shows that the two responses with the
lowest mean were 4.2. and 4.3. More than half of
these questions have a standard deviation greater than
0.5, indicating that there is a wide variation in the
answers given. Finally, it is concluded that all the
questions that evaluate this construct were evaluated,
on average, with the value 4, allowing concluding that
health professionals intend to use the documentation
manual.
Graph (d) shows that the two responses with the
lowest mean were 4.2. and 4.3. Approximately half of
these questions have a standard deviation greater than
0.5, indicating that there is a large dispersion in the
responses given. Finally, it is concluded that all the
questions that evaluate this construct were evaluated,
on average, with the value 4, allowing concluding that
the health professionals intend to really use the
manual.
In summary, Table 3 was constructed, which
shows the general mean of each construct.
Although the overall averages of each of the
constructs are quite similar, the PEOU is viewed as
having the best mean. This can be considered as
advantageous because this construct influences/pre-
Improving the Use of the Electronic Health Record using an Online Documentation Manual and Its Acceptance through Technology
Acceptance Model
349
dicts PU.
Table 3: General mean of each construct.
Constructs
Number of questions
PU
4,042
PEOU
4,139
BI
3,958
UB
4
6 CONCLUSIONS AND FUTURE
WORK
One of the first conclusions drawn from the study of
the Electronic Medical Records adoption model
(EMRAM) was that users of a system have a major
impact on their success. Therefore, for a good
evaluation of the electronic health record (HER) and
to be able to reach a prestige level in the studied
model, a good formation and support to the use of
these systems is essential.
Acceptance of the respondents was very positive
(between 3 and 5 values) in the four constructs
evaluated. The conclusion to be drawn from the data
obtained by the questionnaire responses is that, in
general, health professionals are satisfied with the
manual.
It was possible to identify some factors that
influence the behaviour of health professionals in the
use of this manual, being: easy use, not requiring
much mental effort for use, being advised by co-
workers and being intuitive and appealing.
One of the major obstacles encountered is the poor
adherence to its use by health professionals, perhaps
because the benefits of its use are little shown.
In short, the documentation manual should be seen
as an added value because it brings improvements to
the system, favouring the use of AIDA, such as,
eliminates some inconsistencies of the platform,
clarifying concepts and defining the steps to follow
in the elaboration of specific tasks; brings benefits to
the work of healthcare professionals, thus brings
direct or indirect benefits to the patient, makes the
use of AIDA more efficient and effective and
provides a unique support to the system through the
implementation of the manual within the platform.
The results obtained were very encouraging for a
subsequent continuation of the development and
improvement of this documentation manual. For
this, it is fundamental to continue the realization of
the prototype and until its effective implementation
in the PCE. For a better analysis of the acceptance of
this manual, it would be necessary to continue the
rounds of questionnaires in order to clarify some
inconsistencies in the interpretation of the previous
questionnaire and that respondents may be able to
re-evaluate their responses. It would be important
that the next sample be broader so that more concise
results can be drawn.
ACKNOWLEDGEMENTS
This work has been supported by FCT Fundação
para a Ciência e Tecnologia within the Project
Scope: UID/CEC/00319/2019.
REFERENCES
Haux, “Individualization, globalization and health about
sustainable information technologies and the aim of
medical informatics Int. J. Med. Informatics., p.
75:795-808, 2006.
J. Duarte, C. F. Portela, A. Abelha, J. Machado, and M. F.
Santos, “Electronic health record in dermatology
service,” Commun. Comput. Inf. Sci., vol. 221 CCIS,
no. PART 3, pp. 156164, 2011.
J. A. Marques, A. J. G. Correia, L. Cerqueira, J. Machado,
and J. Neves, “‘Archetype-based semantic
interoperability in healthcare,’” 2010.
HIMSS, “EMRAM | HIMSS Europe,” 2017.
H. Analytics, “Electronic Medical Record Adoption
Model,” Himss Anal., 2017.
J. Aguiar et al., “Pervasive information systems to
intensive care medicine: technology aceptance model,”
2013.
Vasin Chooprayoon and C. C. Fung, “TECTAM: An
Approach to Study Technology Acceptance Model (
TAM ) in Gaining Knowledge on the Adoption and
Use of E-Commerce / E-Business Technology among
Small and Medium Enterprises in Thailand,” E-
commerce, pp. 3138, 2010.
A. Dillon and M. G. Morris, “User acceptance of new
information technology: theories and models,” Annu.
Rev. Inf. Sci. Technol. Vol. 31, vol. Vol. 31, pp. 332,
1996.
V. Venkatesh and H. Bala, “Technology Acceptance
Model 3 and a Research Agenda on Interventions,”
Decis. Sci., vol. 39, no. 2, pp. 273315, 2008.
N. C. Dalkey and O. Helmer, “An experimental
application of the Delphi Method to the use of
experts.,” Manage. Sci., vol. 9, no. 3, pp. 459468,
1963.
M. Adler and E. Ziglio, Gazing into the oracle: The Delphi
Method and its application to social policy and public
health. London: Jessica Kingsley Publishers, 1996.
G. J. Skulmoski and F. T. Hartman, “The Delphi Method
for Graduate Research,” J. Inf. Technol. Educ., vol. 6,
no. 1, pp. 121, 2007.
ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health
350
G. Rowe and G. Wright, “The Delphi technique as a
forecasting tool: issues and analysis,” Int. J. Forecast.,
vol. 15, no. 4, pp. 353375, 1999.
R. Johns, “Likert Items and Scales,” vol. 1, no. March, pp.
111, 2010.
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