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

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

Complete EMR; External HIE; Data

Analytics, Governance, Disaster Recovery,

Privacy And Security.

Technology Enabled Medication, Blood

Products, And Human Milk Administration;

Risk Reporting; Full CDS

Physician Documentation Using Structured

Templates; Intrusion/Device Protection

CPOE With CDS; Nursing And Allied

Health Documentation; Basic Business

Continuity

Nursing And Allied Health Documentation;

EMAR; Role-Based Security

CDR; Internal Interoperability; Basic

Security

Ancillaries - Laboratory, Pharmacy, And

Radiology/Cardiology Information Systems;

PACS; Digital Non- Non-DICOM Image

Management

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

PEOU

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

4,042

PEOU

4,139

3,958

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.

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