Perception on workflow interference

Several studies revealed perceived interference with workflow to be detrimental for acceptance of innovations. Workflow interference was reported to lead to dissatisfaction with new applications (Castillo, Garcia and Pulido 2010). Therefore, Castillo et al (2010) suggested the proper consideration of workflow interference study during the planning stages in order to optimize the implementation of eHealth in the routine clinical care practices. Castillo et al (2010) showed that the workflow impact could modify the perceived usefulness of the innovation which could be critical in the persuasion stage of the decision process for system introduction. Concerns of health care providers with the use of computers during patient care were difficult data entry and typing (Boonestra and Broekhuis 2010), extra time to acquire new skills and the resulting time-cost (Miller and Sim 2004, Boonestra and Broekhuis 2010), increased work demands (Eley et al 2008) and increased time spent on computers (Lo et al 2007, Asaro and Boxerman 2008, Yen et al 2009).

According to a review done by Boonestra and Broekhuis (2010), data entry and typing had been difficult, time consuming and uncomfortable for physicians using EMRs.

Furthermore, since these skills are not traditionally part of the medical practice, physicians are required to take a significant amount of time away from patient care to acquire the new skills (Boonestra and Broekhuis 2010).

Loss of clinical productivity and decreased job performance, particularly during the transition period, were perceived as barriers which have cost implications (DesRoches et al 2008, Boonestra and Broekhuis 2010). DesRoches et al (2008) identified concern about loss of productivity during transition by 35% of EMR adopters and 41% of the non-adopters. Actually, the degree of concern by the non-adopters was significantly higher than that of the non-adopters.

In a research study made by Eley et al (2008), increased work demands were among the principal barriers reported by the healthcare providers. In this study, 82.5% of the nurses reported that using computer was an extra demand to the already existing work.

Miller and Sim (2004) identified that most physicians using EMRs spent more time per patient for months or even years after EMR implementation. The study also showed that the increased time costs resulted in longer workdays or fewer patients examined during the initial period of implementation.

Yen et al (2009) studied the effect of the introduction of computer physician order entry to a paediatric emergency department (ED). The time spent per patient increased from 5.0 minutes to 9.5 for the attending physician and from 5.5 to 14.3 minutes for the resident physicians. The increases in both cases were statistically significant. For nurses, on the other hand, the time spent per patient before and after the introduction did not differ significantly. However, their communications for consulting with staff about patient-care significantly decreased from 24.5 minutes before the introduction to 13.3 minutes after the introduction.

Asaro and Boxerman (2008) measured the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow. According to Asaro and Boxerman (2008), the time spent on computers significantly increased from 15.7% to 27.0% for physicians and from 9.5% to 25.7% for nurses. The time for direct patient care by nurses slightly decreased from 56.9% to 55.3%, while by the physicians decreased from 36.8% to 29.1%, but the

decrease was not statistically significant in both cases. In contrast, care-planning by nurses decreased from 9.4% to 6.4% and by physicians from 21.7% to 19.5% and the decrease was statistically significant for the nurses.

A study by Poissant et al (2005) on computerized provider order entry (CPOE) showed time inefficiency to be the major barrier to successful implementation. In this study, CPOE increased physician‟s work-time by three folds highlighting that a goal of decreased documentation time in an EHR project is not likely to be realized.

A study by Lo et al (2007) found that the average adjusted total time spent per patient across all specialties increased slightly from 28.8 to 29.8 minutes and concluded that EHR use in these specialty clinics did not result in a significant difference in clinic visit time.

Another concern raised in the study by Linder et al (2006) among 501 primary care clinicians (nurses and doctors) was loss of eye contact during patient care. According to Linder et al (2006), nearly two-thirds (62%) the respondents did not like the loss of eye contact with patients when using computers. A third (31%) of the respondents reported that using computers in front of the patient to be rude. Furthermore, nearly a third of them (32%) reported difficult typing and more than half of them (52%) complained that the computer would make to fall behind schedule.

In contrast to the previous studies which mentioned significant work flow interference, time-cost and increased work demand, other studies reported that the use of computers speeded up services (Hollingworth et al 2007 and Hellström et al 2009) and improved work efficiency and communication (El-Kareh et al 2009)

Hollingworth et al (2007) studied the impact of e-prescribing on workflow and found that e-prescribing took less time for writing, but time-savings were offset by increased computer tasks and they concluded if it is carefully implemented, It will not greatly disrupt workflow.

Hellström et al (2009) in did a survey in Sweden and showed that most physician respondents believed they were able to provide the patients better service by ePrescribing (92%), and regarded ePrescriptions to be time saving (91%) and to be safer (83%), compared to handwritten prescriptions.

El-Kareh et al (2009) showed that work efficiency improved after the providers had got acquainted with the system through time. For example, the proportion of clinicians who reported increased time spent on medical documentation reduced from 78% in the first month of implementation to 68% after 12 months of implementation showing significant improvements in perceptions. McGinn et al (2011) argues that the use of EHRs was often perceived as a facilitator which is positively influencing workplace efficiency and communication in studies related to health professionals, managers, and patients.

In summary, most of the studies mentioned showed a significant increase in the workload and time during computers use which could be detrimental to eHealth acceptance. However, it was suggested that with careful planning and implementation, the impact of workflow interference could be minimized (Hollingworth et al 2007, Castillo et al 2010). Another area to take into consideration to reduce workflow interference is to ensure fit-between-the-task and the technology. Fit-Between-the-task and the selected technology is important for user acceptance since poor fitness for use can have a negative effect on the time spent and the quality of patient care (Ammenwerth et al 2003).