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Systematic Review of Factors Influencing the Adoption of Information and Communication Technologies by Healthcare Professionals

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Abstract

This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.

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Acknowledgements

This work was supported in part by a synthesis grant from CIHR (project number: SRR - 79141) and also by a seed grant from the CHUQ research centre to Marie-Pierre Gagnon. We want to thank Carrie Anna McGinn and Sonya Grenier who helped us in the update of the review.

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Corresponding author

Correspondence to Marie-Pierre Gagnon.

Appendices

Appendix 1. Characteristics of included studies

Study

Country

Technology

Participants/sample size (RR if appropriate)

Setting of care

Intervention

Methodology/ design

Data collection

Main findings

Quality score

Aarts 2004

Netherlands

CPOE

Project leaders, members of the pilot project/10

Teaching hospital

Implementation with a project team (key individuals representing the medical departments and the hospital board).

Qualitative/ longitudinal

Interviews, observation, document analysis

The full implementation of CPOE was halted. The information system did not fit well with work practices.

83 %

Abate 1992

USA

CIRT (online databases)

Physicians/30, nurses/23, pharmacists/12

Various (community + academic)

Access to ICT with training sessions, and instructional handouts

Quantitative/ cross sectional

Attitude survey

Lack of time was a major factor which limited use of the services. Users felt that the services did not fit in well with their daily work routine.

67%

Abdolrasulnia 2004

USA

CIRT (Internet-based guidelines

Physicians/210 (47.2%)

Community-based primary care

E-mail contacts announcing and reminding of an online guideline

Quantitative

Questionnaire

E-mail course reminders may enhance recruitment of physicians to interventions designed to reinforce guideline adoption.

100%

Abubakar 2005

England

PDA

Public health consultants/NS

On call service for health protection

Development and pilot of an on-call pack with presentation at training meeting for improvement

Mixed

Questionnaire

The system provided a fast, reliable and easily maintained source of information for the public health on-call team.

33%

Adaskin 1994

Canada

HIS

Nurses/20

Teaching hospital

An 11-month implementation period including planning, communication and training process (one 8-hour day)

Qualitative/ case study

Interviews

Recommendations: shorter training; slower pace of implementation; best planning (become familiar with the system before implementation, visible ongoing administrative support, promotion, etc.)

83%

Adler 2003

USA

Computer aided instruction software

Residents/47

Paediatric emergency department

Demonstration of the program to each resident

Mixed/ descriptive study

Questionnaire, focus group

Generally positive ratings to learning-based CAI program. Time of use and level of training may be important factors in CAI use.

75%

Af Klercker 1998

Sweden

CDSS

Nurses/4 Physician/1

Primary care health center

User manual placed by all computers

Qualitative/ action research

Focus groups

The acceptance of a new product relies upon the human rather than on the electronic communication kind. Success will depend on the introductory efforts put into the project.

83%

Al Farsi 2006

Oman

EMR

Physicians/66 (94%)

Secondary hospital

1-week training program

Quantitative/ survey

Questionnaire

Physicians are generally satisfied with the EMR, received adequate training, and believe the system can improve quality care for patients.

100%

Allen 2000

Canada

Computer and Internet

Physicians/30 (46%)

Not specified

Computer workshops (4 or 5 day-long): lecture and discussion + demonstration + practice

Quantitative/ survey

Questionnaire

The number of physicians buying and using computers has increased.

67%

Al-Qirim 2003

Australia

Telemedicine

Physicians/NS

Rural hospital

Trial and assessment with inclusion of clinicians during the assessment phase

Qualitative/ case study

Interviews

Importance of the product champion for a successful adoption and diffusion of teledermatology.

83 %

André 2008

Norway

Handheld computer (PDA)

Nurses/13, physicians/ 2, physiotherapists/2

Hospital and outpatient clinic

Implementation prepared from a study of unsuccessful previous implementation process 3 years earlier

Qualitative

Interviews

Healthcare personnel lacked a sense of ownership for the tool, which resulted in unsuccessful implementation. Need for skilled and motivated key personnel in the unit. Training program must focus on influencing participants’ attitudes of toward this kind of tool.

100%

Angier 1990

USA

CIRT (online databases)

Fellows, residents, pharmacists and nurses/29

Teaching hospital (oncology unit)

Accessibility of computers + short training (30- minute session) + manual with a user aid sheet

Mixed

Interviews

Most users perceived the system to be useful and considered immediate, direct access to it as convenient and time-saving.

67%

Bailey 2000

USA

EMR

Nurses, physicians, managers, and system staff /NS

Teaching hospital

Implementation of a clinical information system (on a 2-year period) with system training

Qualitative/ ethnography

Participant observation, interviews

Primacy of considering the complex interactions among users, information systems and organisations to assure that systems perform as tool to support information work.

100%

Barrett 2009

Australia

Telehealth program

NS

12 healthcare sites (mainly rural)

IT and clinical support available + managerial and organisational support + 1-hour small group training at each site. All individual attended a minimum of 2 training session.

Qualitative

Interviews

Of the 12 participating sites, 4 did not enrol any patients, and only 2 successfully incorporated the system into regular practice. Disease burden of the patient group, funding models and workforce shortages frustrated the successful adoption.

50%

Barsukiewiez 1998

USA

EMR

Physicians/13

Primary care sites (3)

Basic and more intensive (16 h) training + a team responsible for managing the implementation

Qualitative/ethnography

Participant observation, interviews

Substantial change in work habits, increased demands on physician time, and perceived changes in the patient-physician relation.

100%

Bartlett 2003

USA

e-Learning

Resident physicians/26 (88%)

Teaching hospital

Distribution of a CD-ROM designed to provide ready access to the department’s curricula, study materials, and Internet resources

Quantitative/ survey

Questionnaire

The CD-ROM has not been fully integrated into the residency program. The greatest obstacle to its use is the lack of computer resources in the department.

67%

Bossen 2007a

Denmark

EMR (problem oriented medical record)

Nurses, physicians and others/13 (interviews)

Hospital department

Trial test of a Computerized problem-oriented medical record + Training (2 periods: about 12 h)

Qualitative/ ethnographic case study

Interviews, participant observation, focus group

Use of the CPOMR does not adequately support complex clinical work.

83%

Bossen 2007b

Denmark

Electronic medication plan

Physicians and nurses/9

Hospitals (3)

Cooperation of clinicians in the development through a series of workshops + test of the EMP in daily clinical work (8 weeks) + training of experts and super users

Qualitative/ ethnographic case study

Participant observation, interviews

The test implementation did not become part of daily clinical work. But it brought forward a number of issues that were important for the further development of the EMP.

83%

Cabell 2001

USA

CIRT (online databases)

Residents/48 (98%)

Teaching hospital

On-hour didactic session in small group (use of well-built clinical question cards and practical sessions)

Quantitative /RCT

Questionnaire

A single educational intervention increased resident searching activity.

67 %

Cheng 2003

China

CIRT (online databases)

Physicians, nurses and allied health prof./800 (71.5%)

Public hospital

3-hour training workshop (with supervised hands-on practice)

Quantitative/ RCT

Questionnaire

The intervention increased the proportion of clinicians able to provide adequate clinical question.

67%

Chisolm 2006

USA

CPOE

Physicians/17

Teaching hospital

Participation of clinicians in the development + training (2 h hands-on training session)

Mixed

Focus groups

Relatively high use rate. Importance of administrative and clinical leaders in implementing and promoting the use of new clinical IT.

100%

Connely 1992

USA

Laboratory Reporting System

Physicians (interns, residents, others)/70 (80%)

Neonatal intensive care unit

Design committee: 5 to 8 individuals representing most of the major stakeholders in the system. No need for formal training program

Mixed

Questionnaire, observation and interviews

The system seems to be remarkably well accepted and regarded even after nearly 6 years of use.

58%

Crosson 2007

USA

Electronic prescribing

Physicians/16, and staff members/31

12 ambulatory medical practices

Implementation covered the costs of hardware, software, installation, training and ongoing support. Observational studies of practices before implementation exploring prescription workflow and expectations relating to implementation with physicians, office managers and staff members involved.

Qualitative / case study

Interviews and observation

Before implementation, physicians and ambulatory practice leaders need to be aware of the capabilities and limitations of this technology. Practices should have timely access to IT and support for managing the organizational and workflow changes that HIT implementation demands.

83%

Crowe 2004

Australia

Radiological information system/ PACS

Senior clinicians/ NS

Teaching hospital

Implementation of the ICT with training of clinicians

Qualitative

Interviews

The introduction of the RIS/PACS has been well received by clinicians and is considered to have been helpful in clinical decision making and patient management.

50%

Cumbers 1998

UK

CIRT (online databases)

Clinicians from 14 clinical firms /NS

Various (hospital and community)

Feasibility study; training sessions

Mixed

Questionnaire and interviews

7/ 14 firms developed effective ways of using the databases in their practice; 7 were dissatisfied with their training, computer facilities or lacked time.

25%

D’Alessandro 1998

USA

CIRT (online databases)

Physicians/93 (77%)

Hospitals serving rural populations

Access to computers with training sessions (an initial and follow-up on-site) + a technical support person + brief instructions affixed

Quantitative

Survey using a modified critical incident technique

One year after deployment of the network: 33% had used the DHSL.

100%

D’Alessandro 2004

USA

CIRT (online databases)

Physicians (residents and faculty)/52 (89.6%)

Children’s hospital (academic center)

10-minutes personalized training session + 1 page handout summarized the session + an online tour + free access to MD consults

Quantitative/ Before and after not controlled

Survey using a modified critical incident technique

After the intervention, pediatricians were slightly less likely to pursue answers (95% to 89%); as successful (96% vs 93%); but took less time (8.3 minutes vs 19.6 min) in finding answers

100%

Di Pietro 2008

Canada

PDA

Nurses/16

Acute care and home care

16 nurses tested the decision support system and attended a 2-hour workshop.

Qualitative / cross sectional design

Interviews

Ensuring thorough training and continued clinical support so that nurses are well prepared to use the PDA and outcomes assessment tool will ease the progression of use in everyday practice.

67%

Doolin 2004

New Zealand

HIS (medical management information system)

Various (clinical directors, managers, medical consultants and nurses)/43

Regional hospital

Series of demonstrations to doctors + organizational restructuring headed by a senior doctor acting as a clinician manager

Qualitative/ longitudinal case study

Interviews

Resistance of doctors in front of the control strategy adopted by the hospital. Reinterpretation of the role of the information system, and with the continued resistance by doctors, relegation to a less significant role.

83%

Dornan 2002

UK

e-Learning (electronic learning portfolio)

Physicians/89 (94%)

Various (continuing professional development)

1 year free use of the PC + invitation to a training workshop + mail updates and tips on diary use + on-line support

Mixed / longitudinal intervention study

Questionnaire (qualitative and quantitative components)

Poor use of PC Diary: PC Diary was used by 34% of enrolled physicians, but only 10% used it regularly.

75%

Eley 2005

Australia

CDSS (for triage)

Nurses/15

Emergency department (2 hospitals)

Training (self-directed training package) + test (use of the ICT to rate simulated scenarios)

Qualitative

Semi-structured interviews

The tool was acceptable to users and was viewed as a viable alternative to current triage practice.

100%

Firby 1991

UK

Computer

Nurses/14

Regional renal unit

Training sessions with practical sessions + written instructions at the computer station

Qualitative

Semi-structured interview

Despite initial reservations, staff was generally positive about the medium.

67%

Galligioni 2008

Italy

Electronic oncological patient record (EPR)

Physicians and nurses/NS

Hospital

User-centred design of the EPR + user education and training (2 educational sessions and training on practical stimulation) + continuous assistance (on-site during the initial 2 weeks and permanent remote assistance after)

Quantitative

Questionnaire (after 2 weeks, 6 months and 6 years)

The implementation was overall successful. User involvement in the system design, flexible web technology, education, training and continuous assistance have greatly facilitated user acceptance.

33%

Granlien 2008

Denmark

EMR

Physicians/94, nurses/129, others/9; 232/ 54%

Hospitals in one of Denmark’s five regions

Attempts to address barriers toward use since the EMR deployment 3 years before: regional organisation and vendor have tried to improve the network, the computers and the design of the EMR + standard training program for new staff + extra information and training provided continuously

Mixed

Survey with open question

After 3 years of use, the adoption of the EMR by clinicians and its integration into work practices are far from the level necessary to attain the goals that motivated its acquisition. Considerable uncertainty exists about what the concrete barriers actually are.

75%

Guan 2008

Canada

Online continuing medical education (CME)

Physicians/158 and 10 facilitators

Various (continuing medical education program)

Content developed on the basis of the educational needs identified in a pre-program survey + evaluations of each module and feedback influencing the addition of later content + ongoing technical and learning support available to participants throughout the course

Mixed / exploratory study

Survey with open-ended questions

Participation rate of physicians and facilitators in online social activities was very low. Lack of time and lack of peer response were perceived as main reasons for low participation.

75%

Hains 2009

Australia

CDSS

Physicians/16; Nurses/30; Pharmacists/4

oncology outpatient department (6 public hospitals)

CI-SCAT (the CDSS) was launched accompanied by a large-scale one-year education program

Qualitative

Interviews + observation

At 3 years post launch, clinicians’ attitudes were generally positive, which translated into relatively high levels of CDSS use. Understanding end-users and their environment, is essential to ensure long-term sustainability and use of the system to its full potential. Continuing education and endorsement are also important.

100%

Halamka 2006

USA

e-Prescribing

Various (clinicians and office staff)/ NS

Various

Implementation of regional pilots (demonstration of the software, offer a reduced rate, etc.)

Qualitative / case studies

Focus groups

Importance of a well-resourced rollout that takes into account the barriers and lessons learned in early deployment.

33%

Haynes 1990

Canada

CIRT (online databases)

Physicians, housestaff and clinical clerks/158 (84%)

University medical center

Participants were offered a 2-hour introduction to online searching + 2 h of free search time

Quantitative/ longitudinal descriptive study

Questionnaire

Most clinicians (81%) used MEDLINE after a brief introduction and they indicated that they would continue to do online searching, even if they had to pay.

100%

Hibbert 2004

UK

Home telehealth

Nurses/12

Home nursing service

Implementation of a home telehealth nursing service with weekly project meetings + nurse training sessions

Qualitative / ethnographic study within a RCT

Participant observation

The specialist nurses did not share the generally positive view of telehealth. The new technology was a dynamic entity that changed through exposure to clinical practice and professional values.

100%

Hier 2005

USA

EHR

Physicians/330 (36.3%)

Faculty and housestaff

Mandatory use of the EHR. Dictation of notes is available but incurs additional costs

Quantitative

Questionnaire

Both housestaff and faculty acceptance of an EHR was high. Central to acceptance is conservation of physician time.

100%

Hou 2006

Taiwan

Computer

Nurses (nurses and supervisors)/3 pairs

1 hospital and 2 medical centers

End user computing (EUC) strategy: 8-day training for clinical nurses who developed projects and promoted the informatics in their hospitals

Qualitative

Interviews

According to this study, end user computing strategy was successful so far.

100%

Jaques 2002

USA

CIS (point-of-care systems)

Nurses/43 in 3 surveys. Pre-implementation survey 122; Post: 89; and 12 months after: 100

Acute-care pediatric hospital

Implementation of bedside computer systems with training (lectures and hands-on training) in one four-hour session (experimental group)

Quantitative/ a quasi-experimental design

Surveys: pre- implementation, post and 12 months after

Nurses in the experimental group (who used beside computers) had more positive attitude than the control group.

100%

Joos 2006

USA

EMR

Physicians/46 (66%)

Ambulatory primary care and urgent care clinic in an academic hospital

Installation of workstations (voluntarily usage) + training in scheduled classes + availability of IT support

Mixed

Semi-structured interviews to identify themes + survey

This implementation was associated with perceived improvements in speed and communication efficiency and information synthesis capabilities.

92%

Jotkowitz 2006

USA

PDA

Residents/90 = 65 (80%) unsubsidized group; 25 (86%) subsidized group

2 teaching hospitals

Subsidized fully residents’ purchase of PDAs at one of the hospitals + introduction to basic PDA functioning

Quantitative

Questionnaire

Subsidized group of residents perceived PDA to be less useful and more fragile than residents who purchase a PDA themselves. Merely providing the PDA does not necessarily ensure its adoption. Intensive training and reinforcement are needed to increase the perceptions of positive benefit.

67%

Jousimaa 1998

Finland

CIRT (computerized guidelines)

Physician/46

General practice

Distribution of electronic guidelines (diskettes or CD-Rom) + local training sessions organised in several centers.

Quantitative / descriptive follow up study

Interview using semi-structured questionnaires (3 times)

After 1 year of use, opinions had become slightly more positive about guidelines. Usage frequency was associated with having the computer in the office. Technical support was also important.

33%

Joy 2002

USA

PDA

Residents/24

Gynaecology residency program

PDA provided to residents + general instructions given on its use

Mixed/ survey

Survey with quantitative and qualitative components (3 times)

Decreased perceived value of the PDA at follow-up intervals. Responders felt that the PDA should be available at residency programs. But the integration of the PDA did not meet the anticipated expectations of overwhelming use by residents.

33%

Kamadjeu 2005

Cameroon

EHR

Physicians and nurses/14

Urban primary care

Comprehensive implementation strategy: numerous meetings involving users and different stakeholders + training (3-day session) + new data flow added

Qualitative

Interviews and direct observation

Users generally showed good acceptance of the system. Monitoring the use of the system at the early stages of implementation was important to ensure immediate response to users’ comment and requests.

67%

Katz 2003

USA

Email (triage)

Physicians and residents/89 (90.8%)

2 university-affiliated primary care centers

Access to a triage-based email system (with a nurse navigator) promoted to the patients of physicians in the intervention group

Quantitative / RCT

A self-administrated survey

Intervention appeared to improve physicians’ perceptions of the role of e-mail in clinical communication.

66%

Keshavjee 2001

Canada

EMR

Physicians/32

Community-based physicians’ offices (18 sites)

Implementation of EHR in exchange of a monthly fee + extensive training + onsite technical and support + interactive session prior the implementation to discuss

Mixed

Questionnaires and observation

The success of implementation varied from site to site. Despite extensive training, professional practice management consultation and project case management, several physicians subsequently left the project. But their staff was successfully using the EMR

50%

Koivunen 2008

Finland

Internet-portal application for patient education

Nurses/56 (63%)

2 psychiatric hospitals

Before implementation: evaluation of nurses’ IT skills and attitudes toward computers to tailor IT education. Implementation: portal presented to administrative personnel + manual compiled for users + information sessions + practical and technical support

Qualitative

Questionnaire with 2 open-ended questions

The specific challenges are to ensure adequate technological resources and that the staff is motivated to use computers. Adequate individual time for the patient together with the nurse is a prerequisite for the successful implementation of the patient education portal.

100%

Kouri 2005

Finland

Internet-based network services

Midwives/5, public health nurses/2, physicians/3

Antenatal wards (1 university, 1 hospital, 2 clinics)

Net Clinic’s introduction with managerial support and training. Different types of training linked to three groups based on their experiences (doubters, accepters and future confidents)

Qualitative

Semi-structured interviews

Successful implementation of a comprehensive CPR that required substantial training and effort on the part of clinicians Managerial support, such as allocation of time and equipment was extremely important during the introductory phase.

100%

Lai 2006

USA

CDSS

Physicians/5 (preliminary), residents/16 (main study)

Internal medicine

Development of a tutorial designed to address barriers to use

Mixed / RCT and qualitative

Interviews

Clinicians using the tutorial reported greater understanding of how to use the instrument appropriately. Many of the identified barriers to acceptance and use involved factors that could be addressed through training.

83%

Lapinsky 2004

Canada

PDA

Physicians/17 (13 for focus group)

4 community hospital intensive care units

Distribution of handled devices + 1-hour training session + access to support by phone and email

Mixed / prospective interventional study

Focus group (for barriers and facilitators)

Acceptance was variable (just over half of the participants using their handheld devices to access information on a regular basis). It may be improved by enhanced training and newer technological innovation.

75%

Lapointe 2006

Canada

CIS

Physicians/15, nurses/14, system implementers/14

1 community and 2 university hospitals

Support to physician and redesign of IS by implementers

Qualitative/ cross-case study

Interviews, observation, document analysis

Level of resistance varied during implementation, and in 2 instances had led to major disruptions and system withdrawals. Antagonistic responses from implementers to users’ resistances behaviours have reinforced these behaviours.

83%

Larcher 2003

Italy

1) Telemedicine; 2) CPR

Physicians and nurses/57 (post) (70%)

5 general hospitals

Training before the validation phase of the teleconsultation + EPR development in strong collaboration with the users

Mixed / surveys

Questionnaires before and after validation phase

Positive attitude regarding the future use of the system in clinical field. Major difficulties encountered were in the introduction of the system into the daily routine.

67%

Lee 2009, Lee 2008a, Lee 2008b

Taiwan

Nursing information system (NIS)

Nurses/623: 71% (survey), 24 (interviews)

Medical center with 4 hospitals in different areas

Pilot test of the NIS during the design phase. Early stage of implementation: nurses were required to chart nursing documentation of at least one patient on their shift both on the computer and on paper.

Mixed/ multimethod evaluation

Questionnaire, focus group, interviews and work sampling observation

After 2 years of NIS use, the nurses generally had a positive view of its value. Concerns remain about hardware devices, response time, content design, user support, workflow change and personal interaction with physicians and patients. When using the NIS in daily practice, nurses spent more time on documentation than on direct care, indirect care, and unit-related care.

83%

Lee 2006a

Taiwan

PDA

Nurse managers /16

Inpatients units in a medical center

Involved superusers in training + encouraging hands-on practice in addition to classroom teaching.

Qualitative/ descriptive, exploratory

In-depth interviews

In addition to training strategies, improving PDA features, involving end users in the content design phase, and ensuring interdisciplinary cooperation are vital elements for a successful adoption.

83%

Lee 2006b

Taiwan

PDA

Nurses/15

Hospital

Nurses were required to use the PDA systems

Qualitative/ descriptive, exploratory

In-depth interviews

Nurses went through different change stages: initially resisted using the PDA, but finally adopted it in their daily practice. The adoption process could be shortened by an anticipatory stage to refine the PDA system for use.

83%

Leon 2007

USA

Smart phones and CIRT (online database)

Residents/31

Community teaching hospital

Special lectures, training sessions and group workshops on the use of the smart phones and Medline + one to one training provided by resident in charge of the project

Quantitative / initial survey and prospective interventional cohort study

Questionnaire

Physicians found these devices easy to use and the information retrieved useful. Proper training, technical support, familiarity with the technology, and presence of team leaders enhance the adoption of the tool.

67%

Likourezos 2004

USA

EMR

Physicians and nurses/44 (38%)

Large urban teaching hospital

Training tailored on the functionality of users + regular sessions + adaptation of some workflow processes in response to staff or managerial concerns

Quantitative / cross sectional survey

Questionnaire

Participants favour the use of an EMR despite current concerns about its effect and impact. Nurses reported greater satisfaction in assistance with their tasks, whereas physicians reported minimal change.

100%

Magrabi 2007

Australia

CIRT (online databases)

Physicians/227

General practice

Use of an online evidence system in practice + online tutorial (for all) + RTC: advanced online training (for intervention group)

Quantitative / experimental and observational components

Pre and post-trial surveys

GPs use of online evidence was directly related to their reported experiences of improvements in patient care. Post-trial clinicians positively changed their views about having time to search for information and pursued more questions during clinic hours.

67%

Marcy 2008

USA

CDSS

Physicians/NS

Primary care ambulatory clinics

Based on prior survey of physicians and clinic managers: development of a prototype CDSS + validation with an expert panel + usability testing physicians + iterative design changes based on their feedback + field tests

Qualitative /iterative ethnographic process

Interviews and observations

During field tests, physicians incorporated the CDSS prototype into their workflow. Successful integration of ICT into clinical practice requires collaborative development of these systems with physicians, patients and support staff.

83%

Martinez 2007

USA

Computer and Internet

Physicians, managers, nurses/ 9

Community health centers

A program provided computers for staff and patients (each center) + access to MD Consult database and a Web program + many workshops and classes + biweekly visits to support training

Qualitative / post test study design

Interviews

Participants recommended improving the program by: increasing sensitivity to cultural issues; identifying and supporting a champion at each center to lead the project; allocating additional resources.

100%

May 2001

UK

Telemedicine

Clinicians, technician experts, managers/15

General practice and community mental health team

GPs were invited to use the system to refer some patients to the community mental health team (CMHT) – no compulsion to use the system but it did offer speedier access to the CMHT

Qualitative/ ethnographic

Interviews and observation

Participants were initially enthusiasm about the potential of the technology; after 6 months of access, they found it problematic and ultimately, they rejected it. The main barrier was system’s incompatibility with the set of practices involved in consultations.

83%

McAlearny 2005

USA

PDA

Physicians and organisational informants/161

7 sites (not defined)

Active support for broad-based use (investments in material infrastructure, training, etc.) + active support for niche use (pursue of targeted application projects) + basic support for individual physician users

Qualitative/ organisational case studies

Interviews and focus groups

Individualised attention to existing physician users, improving usability and usefulness, promoting ICT and device use, and providing training and support would facilitate physician PDA adoption.

67%

Newton 1995

UK

CIS (computerised care planning system)

Nurses/139

Hospital

3 phases implementation: initially managed by external consultants and vendors; then by a care planning task group; gradually relegated to the hospital which became responsible for providing technical support services

Mixed/ survey and case study

Questionnaires, interviews, observations: before, 3 months and 1 year after implementation

A majority of nurses were ambivalent before the implementation; 3 months after, they held negative attitudes; 1 year after, attitudes showed a significant shift towards positive. The quality of care planning also improved significantly on the wards for which comparisons were possible.

58%

O’Connell 2004

USA

EHR

Residents/95 (99%)

Hospital (internal medicine and paediatrics)

Prior the EHR system deployment, 2 groups of residents met the team of IT implementers to design templates for a variety of visit types

Quantitative / cross-sectional survey

Questionnaire-based survey (elaborated from structured interviews)

Differences in satisfaction between the 2 groups. Previous experience may have influenced the results (experience with a different EHR, with structured data entry prior the implementation, etc.). Organisational support did not appear to play an important role in differentiating satisfaction.

100%

Ovretveit 2007

Sweden

EMR

Senior clinicians, managers, project team members, doctors et nurses/30

Large teaching hospital

Consultation before implementation: consensus about need for the system and which one was best + prioritisation and diving by management team + competent IT project leader and team + tested, user-friendly and intuitive system needing little training

Qualitative/ prospective and concurrent study

Interviews during implementation and 3 months after

Implementation successful, on time and within budget. Importance of organisational, leadership and cultural factors, as well as a user-friendly EMR, which assists clinical work, is easily modified and which saves time and increases productivity.

83%

Pagliari 2003

UK

Internet (Web-based resource)

GP, nurses, administrators: questionnaires/26 (65%); interviews/9

Local health care cooperative comprising 5 GP surgeries

User involvement in the early stage of development (testing process) of the web-based resources

Mixed

Questionnaire, interviews, observation and electronic feedback

Evaluation informed important and unforeseen improvements to the prototype and helped refine the implementation plan. Engagement in the process of evaluation has led to high levels of stakeholder ownership and widespread implementation.

75%

Paré 2006

Canada

CPOE

Physicians/91 (72.5%)

13 medical clinics network + hospital + private laboratory firm

Introduction to the COPE system: use was not mandatory + in each site, a project champion to test the system and to play role of experts in the configuration of the system and of super users when system introduced

Quantitative

A mail survey

Psychological ownership is positively associated with physicians’ perceptions of system utility and system user friendliness. Through their active involvement, physicians feel they have greater influence on the development process, and develop feelings of ownership toward the clinical system.

100%

Popernack 2006

USA

CPOE

Nurses/81 (33%)

Academic, tertiary care trauma center

Involvement of nurses from the beginning of the system selection until implementation of the CIS + training + utilisation of superusers in training

Mixed

Survey (with open questions)

Successful inpatient implementation of the fully integrated system.

75%

Pourasghar 2008

Iran

EMR

Physicians/10, Nurses/10

University hospital

The software was developed and tailored for the hospital. All staffs were trained to use the EMR system. Data were entered at different levels and by different persons

Qualitative

Semi-structured interviews

The quality of documentation was improved in areas where nurses were involved, but parts which needed physicians’ involvement were worse. Different factors involved: low physician acceptance of the EMR, lack of supervision and continuous training, high workloads, shortage of hardware, and software characteristics.

67%

Puffer 2007

USA

EMR

Physicians/101

Academic with medical and surgical specialties

Redesign of the system by participation of users: implication of a team including physician and administrative leadership in a study that was undertaken to enhance the system

Qualitative / ethnographic research

Direct observation, feedback, focus group

The study demonstrated a commitment to improving physicians’ efficiency when using the EMR. Managing physicians’ expectations for resolution of issues identified was an important success factor.

100%

Pugh 1994

Canada

CIRT (computerized databases)

Physicians/13

Emergency of university hospital (2 sites)

Initial training of up to 2 h.

Quantitative

Questionnaire (10 months after)

Database searching was found easy-to learn. Positive notes included ease-of-use, accuracy of data, and accessibility of system and value of output. Negative notes: lack of integration with other systems, lack of system completeness, and a high subscription cost.

67%

Rahimi 2009

Sweden

CPOE

Nurses/134 (67%), Physicians/176 (24%)

Primary health care centers and hospitals

Pilot project and gradual implementation by regional districts; introduction was mandatory; exceptions made for some clinics

Quantitative

Online questionnaire

More nurses than physicians stated that the CPOE worked well in their clinical setting. More physicians than nurses found the system not adapted to their specific professional practice.

67%

Ranson 2007

USA

PDA

Physicians/10

Primary care and specialised clinics

PDA given without charge + individualised training in the use of the programs and the PDAs (ranged from 1.5 to 4 h)

Qualitative/ case study

Questionnaire + interviews and observation

Use of the PDA was associated with the value of information in clinical decisions of the individual user.

100%

Rousseau 2003

England

CDSS

Physicians/8, nurses/3,practice managers/2

5 general practices

Introduction of guidelines into general practice clinical computer systems; one day training workshop for 2 members from each practice.

Qualitative / longitudinal study

Interviews and feedbacks

Clinicians did not adopt the CDSS: they found it difficult to use and did not perceive it to bring benefits for practice. Key issues: relevance and accuracy of messages, flexibility to respond to other factors influencing decision making in primary care.

100 %

Sicotte 1998

Canada

CPR

Physicians/21 and project teams/10

4 hospitals

Implementation of a large CPR in medical work with a project team involving mainly nurses

Qualitative

Interviews, focus group, observations, document analysis

Physicians had a great reluctance to using the system: lack of synchronization between the care and information processes. Several dimensions were not properly taken into account when designing and developing the CPR.

83%

Smordal 2003

Norway

PDA

Medical students/ NS

Different practical settings

Mix of activities. A team of medical students work as IT-support (or superusers).

Qualitative

Interviews, participant observation

The medical students did not use the PDA for information gathering. PDAs should be regarded as potential gateways.

67 %

Soar 1993

Australia

HIS

Physician/NS (36%)

A 700-bed teaching hospital

Doctors are encouraged to directly use HIS by many means: strong executive support, training, firm policies that other staff would not use systems on behalf of them, on-line bulletin.

Mixed

Survey and structured interviews

First successful implementation of direct doctor use of HIS in an Australian hospital (system in use for 3 years).

50%

Terry 2009

Canada

EMR

Physicians/13, other health professionals/11, administrative staff /6)

6 family practice sites

Installation of equipment and training of the participants.

Qualitative

Semi-structured interviews

Importance of being aware of factors that influence implementation and adoption: computer literacy, dedicated time for EMR implementation and adoption, training activities, supporting problem-solvers in the practice.

100%

Thoman 2001

USA

CIS (point-of-care technology)

Pilot group of nurses/6

Home care

A full 12-week training curriculum (including 9 days classroom time and 3 weeks of supervised field experiences).

Qualitative

Focus group

4 rules for the training: continually involve end-users with a “users group”, expect a learning curve for everyone, allow for varying degrees of resistance, and reinforce future benefits during the transition.

67%

Topps 2003

Canada

PDA

Physicians/24 (92%) quest; 16 (62%) focus groups

Department of family medicine

Introduction of the PDA individually in a short personal session with one expert user + technical support + shared-cost purchasing (30% paid by participant).

Mixed

Structured questionnaire and focus group

With the right support structures faculty adopt PDAs in clinical and teaching settings. The faculty support group and the cost-sharing arrangement leading to ownership have contributed to adoption.

75%

Toth-Pal 2008

Sweden

CDSS

Physicians/5

A primary health care center

Introductory demonstration of the CDSS (1,5 h) + access to the program + individual training session (CDSS applied to the medical records of own physicians’ patients) + encouragement to use the program in the every day clinical work.

Qualitative

Interviews (after the training and follow-up) + observation

Implementation of the CDSS is not successful: its actual usage remained very limited. Different profiles associated with the degree of acceptance of the CDSS. Important contributing factors: GP’s individual computer skills and attitudes towards the computer’s functions in disease management and in decision-making.

100%

Travers 1997

USA

HIS (emergency department clinical system)

Various (nurses, physicians, clerical staff)/NS

Hospital emergency department

Development of a HIS with end-user inputs + project team included members of staff at every level of development and implementation + comprehensive training plan and change strategies + regular communication

Quantitative

Questionnaire

The project team succeeded in designing a system to meet the clinical users’ needs. Key to success: the integral involvement of ED staff in the development of the system, commitment of the necessary resources, and top-level administrative support.

33%

Trivedi 2009

USA

CDSS

Physicians/13, advanced nurse practitioners/2

Public mental health clinics (5 sites)

Field testing of feasibility of implementation of CDSS in 5 sites: training of physicians about the guideline and the use of CDSS (4 h) + written instruction manual + IT support on site initially and later by phone + training sessions for directors and managers to suggest solutions to potential workflow transition issues + feedback from clinicians

Qualitative

Informal feedback

Issues regarding computer literacy and hardware/software requirements were identified as initial barriers. Concerns about negative impact on workflow and potential need for duplication during the transition from paper to electronic systems. Importance of taking account organizational factors when planning implementation of a CDSS.

50%

Tuominen 1996

USA

Internet

Physicians/18

13 family practice clinics

Introduction to Internet through seminars (13 to 30 min each) that included examples of searches on the web with searches graded for physician usefulness

Quantitative

Questionnaire

Health care professionals recognise the practical usefulness of the Web. But the real challenge is to convince those who are not computer literate to invest time in training.

33%

Vanmeerbeek 2004

Belgium

EMR

Various (doctors, nurses and others)/57 for nominal group

Eight primary care medical houses

A 2 h workplace meeting to assess indicators of current use of EMR and to define the content of an action program for removing resistances with users’ participation

Mixed

Quantitative measures of use and nominal group

The use of EMR remained slight. Practitioners are willing to computerize if: they get immediate advantages, the tool is easy to use, not time-consuming, it respects the specificity of work and organization (interdisciplinary and self-managed teams), there is external support (training, supervision)

75%

Verhoeven 2009

Netherlands and Germany

CIRT (online guidelines)

Nursing assistants, nurses, physicians, and medical microbiologists/ 20

Hospitals/ 2 Dutch and 2 German

User-centered design process including physicians, nurses and nursing assistants to gather their opinion toward the website and to generate a sense of involvement

Qualitative

Interviews with open ended questions

Involvement of potential adopters in the development and implementation process is very important. The website’s credibility is an important additional requirement. Training and feedback appear to reinforce imitation and maintenance of technology adoption.

83%

Verwey 2008

Netherlands

Electronic nursing record

Nurses/6, manager/1, members of the project group/2

Large regional hospital

Training of key users + ENR council responsible (with the project group) for the management, maintenance and updating of the system + training for all nurses (4 meetings of 2.5 h) + extra staffing scheduled

Qualitative

Participatory observation, document analyses, interviews.

Involvement of the nursing staff in the whole process promoted acceptance of the system. However, the ENR did not produce the benefits expected. Lack of time gains proved to be a major barrier to the acceptance of the system.

83%

Vishwanath 2009a Vishwanath 2009b

USA

PDA

Clinicians/244 in pre-survey, 80 in post-survey, 59 completed both

Academic tertiary care children hospital

2 phases of implementation: 1) pre-participation surveys + small-group training sessions + orientation. 2) distribution of PDA and participation in a series of patient safety initiatives

Quantitative

Web-based survey (pre and post-intervention, 12-14 months apart.

Early adopting physicians are younger and junior in experience and status, and are more likely to be aware of and own news technologies than later adopting physicians. The top barrier to PDA adoption among early adopters is cost, while for later adopters it is training.

67%

Walji 2009

USA

EPR

Implementation team/4, faculty, residents and staff /pre: 78 (11%) and post: 138 (20%)

University Health Science Center

Extensive planning phase including in-depth discussions among faculty and staff, market research and visits to other schools + EPR installation with additional IT employee + workflow defined + pilot testing + stakeholders and users engaged throughout the project’s life cycle

Mixed

Interviews, document analyses, 2 surveys (before and after)

Users had mixed feelings about the EPR in terms of efficiency and time required compared with paper charts. Many users felt that the EPR improved legibility and access to a patient chart. However, only 29% though the EPR improved productivity.

67%

Walter 2000

Australia

Computer

Various/309 (80%) survey; 212 (77%) follow up

Various (urban mental health system)

Introduction of computers and implementation of computer training (through in-service programmes)

Quantitative / observational

Questionnaire (before and 6 months after introduction)

Most respondents, especially those with computer experience or who had worked in mental health for less than 5 years, viewed computers favourably.

100%

Watkins 1999

UK

PACS

Key users from clinical and radiological staff/34

Hospital

2 trainers undertook a formal training program targeting all staff + 1/3 of each department became core trainers, and an “in-house” trainer provided training on a more flexible basis

Qualitative

Semi-structured interviews

Overall, users appeared to be satisfied with PACS. All staff said that they preferred PACS to the previous, conventional radiology service.

83%

West 2004

Scotland

CIS

Physicians, nurses and administrative staff/33

Remote rural primary health care

The project provided: data operator, inputs data to the computer system recorded on a paper, access to ongoing training, technical help line, and quality assurance processes

Qualitative

Interviews

Remote rural primary care presents a number of organisational features that require understanding for the implementation of initiatives developed in an urban working environment: primary care teams tend to be smaller, characterised by flexibility, experience less support from other services and provide care in a wider range of situations and settings.

83%

Whittaker 2009

USA

EHR

Nurses/11

Rural hospital

Training classes: 1-day (8 h) introduction and training + an additional 4-hour refresher class (after a 6-month delay)

Qualitative

Interviews

Personal, computer-related and contextual characteristics facilitated and acted as barriers to the acceptance and use of a computerised EHR system.

100%

Whitten 2004, Whitten 2000

USA

Telemedicine

Clinical providers, technical and support staff, administrators/25 (focus groups) + 36 (interviews)

A clinic, a crisis centre, a youth detention centre and patients homes

Telepsychiatry project in 4 phases: formalised training programs for each phase + project handbooks and supplementary materials provided

Qualitative (for providers)

Interviews and 4 focus groups

Telemedicine usage varied across the 4 project phases. Variation could be explained by: provider roles, organisational strategic goals and resources, inherent organisational culture, leadership and managerial factors.

67%

Wibe 2006

Norway

EHR

Head nurses and key persons/22

University hospital

Step-wise implementation strategy: introduction to computers and to EPR to all staff, training of 2–3 key persons in each unit

Quantitative

Questionnaire

On-site training by colleagues, using computers on the ward, and documenting admitted patients who received care and treatment were identified as the most important success factors in the implementation process.

33%

Wilson 1998

USA

Computer (wireless, pen-based computing)

Nurses/16

Home health nursing

Nurses used the computer for patient admissions process during a 10 week period + 3 ½ day training sessions

Qualitative

Focus groups (before and after 10 weeks)

Nurses agreed that they had been well prepared for computers. They did not want to return to paper.

83%

Yeh 2009

Taiwan (China)

Nursing Process Support System (NPSSC)

Nurses/27

5 nursing homes

Task force (consisted of nurses, physicians, computer programmers, administrators) formed to develop the NPSSC + workplace training for nurses (3 h/week for 6 weeks) + one-on-one hands-on consultation on how to use the Internet to navigate the NPSSC

Mixed/ quasi-experimental design and observation

Questionnaire and observation

NPSCC significantly improved nursing documentation and participants reported an increased satisfaction with nursing documentation.

50%

Zheng 2005

USA

Clinical reminder system

Residents/41

Ambulatory primary care clinic in urban teaching hospital

Individual training provided to all users of the clinical reminder system. Use of the system was recommended but not mandatory

Mixed / longitudinal and qualitative study

Structured interviews, surveys, on-site observation, and textual notes

A large proportion of users demonstrated a consistently low or decreasing level or usage over time. The lessons learned and experiences gained have helped system designers to re-engineer the reminder system.

83%

  1. Legend
  2. CDSS Computer-based Decision Support System
  3. CIRT Clinical Information Retrieval Technology
  4. CIS Clinical Information System
  5. CPOE Computerized Physician Order Entry
  6. CPR Computer-based Patient Record
  7. EHR Electronic Health Record
  8. EMR Electronic Medical Records
  9. HIS Hospital Information System
  10. PACS Picture archiving and communication system
  11. PDA Personal Digital Assistant
  12. RR response rate

Appendix 2. A scoring system for mixed methods research and mixed studies reviews (Pluye et al 2009)

Qualitative studies and qualitative components of mixed methods studies:

 

(1) Qualitative objective or question

__________

(2) Appropriate qualitative approach or design or method

__________

(3) Description of the context

__________

(4) Description of participants and justification of sampling

__________

(5) Description of qualitative data collection and analysis

__________

(6) Discussion of researchers’ reflexivity

__________

Quantitative experimental studies, and quantitative experimental components of mixed methods studies :

 

(1) Appropriate sequence generation and/or randomization

__________

(2) Allocation concealment and/or blinding

__________

(3) Complete outcome data and/or low withdrawal/drop-out

__________

Quantitative observational studies, and quantitative observational components of mixed methods studies :

 

(1) Appropriate sampling and sample

__________

(2) Justification of measurements (validity and standards)

__________

(3) Control of confounding variables

__________

Overall mixed methods approach of selected mixed methods studies:

 

(1) Justification of the mixed methods design

__________

(2) Combination of qualitative and quantitative data collection-analysis techniques or procedures

__________

(3) Integration of qualitative and quantitative data or results

__________

Total score in percent

__________

  1. The presence/absence of criteria (yes/no) may be scored 1 and 0, respectively. Then, a ‘quality score’ can be calculated as a percentage: [(number of ‘yes’ responses divided by the number of ‘appropriate criteria’) x 100]. For example, studies with good qualitative and quantitative observational components plus good overall mixed methods approach may be scored 100%: \( \left[ {\left( {6 + 3 + 3} \right)/12} \right] \times 100 \) (Pluye 2009)

Appendix 3. List of factors related to the success or failure of ICT adoption

1. Factors related to ICT

   

1.1

  

Design and technical concerns

1.2

  

Characteristics of the innovation

 

1.2.1

 

Relative advantage (usefulness)

 

1.2.2

 

Compatibility (with work process, values)

 

1.2.3

 

Ease of use / complexity

 

1.2.4

 

Triability

 

1.2.5

 

Observability

1.3

  

System reliability

1.4

  

Interoperability

1.5

  

Legal issues

 

1.5.1

 

Confidentiality - privacy concerns

 

1.5.2

 

Other legal issues (including security)

1.6

  

Evidence regarding benefits of IT

1.7

  

Validity of the resources

 

1.7.1

 

Scientific quality of the information resources

 

1.7.2

 

Content available (completeness)

 

1.7.3

 

Appropriate for the users (relevance)

1.8

  

Cost issues

1.9

  

Environmental issues

 

2. Individual factors or healthcare professional characteristics (knowledge and attitude)

   

2.1

  

Knowledge

 

2.1.1

 

Awareness of the existence and/or objectives of the ICT

 

2.1.2

 

Familiarity with ICT

 

2.1.3

 

Familiarity with technologies in general

2.2

  

Attitude

 

2.2.1

 

Agreement with the particular ICT

  

2.2.1.1

Applicability to the clinical situation

  

2.2.1.2

Confidence in ICT developer

  

2.2.1.3

Challenge to autonomy

  

2.2.1.4

Impact on clinical uncertainty

  

2.2.1.5

Time consuming/ time saving

  

2.2.1.6

Outcome expectancy (use of the ICT leads to desired outcome)

  

2.2.1.7

Motivation to use the ICT (readiness) /resistance to use the ICT

  

2.2.1.8

Self-efficacy (believes in one’s competence to use the ICT)

  

2.2.1.9

Impact on professional security

 

2.2.2

 

Agreement with ICTs in general (welcoming/resistant)

2.3

  

Socio-demographical characteristics

 

2.3.1

 

Age

 

2.3.2

 

Gender

 

2.3.3

 

Experience

 

2.3.4

 

Ethniciy

 

2.3.5

 

Other

 

3. Human environment

   

3.1

  

Factors associated with patients

 

3.1.1

 

Patients’attitudes and preferences regarding ICT

 

3.1.2

 

Patient/health professional interaction

 

3.1.3

 

Applicability to patients’ characteristics

 

3.1.4

 

Other factors associated with patients

3.2

  

Factors associated with peers

 

3.2.1

 

Attitude of colleagues about ICT

 

3.2.2

 

Support and promotion of ICT by colleagues

 

3.2.3

 

Others factors associated with peers (relations between colleagues)

 

4. Organisational environment

   

4.1

  

Internal environment

 

4.1.1

 

Characteristics of the structure of work

  

4.1.1.1

Setting of care (hospital, outpatient, primary care)

  

4.1.1.2

Practice size

  

4.1.1.3

Status (university/other, private/public)

  

4.1.1.4

Physician salary status and reimbursement

 

4.1.2

 

Work (nature of work)

  

4.1.2.1

Time constraints and workload

  

4.1.2.2

Work flexibility

  

4.1.2.3

Relation beetwen different health professionnels (including role boundaries, change in tasks)

  

4.1.2.4

Professional culture

 

4.1.3

 

Skill -Staff

  

4.1.3.1

Leadership

  

4.1.3.2

Staff issues (stability, shortage)

 

4.1.4

 

Resources availability

  

4.1.4.1

Resources available (additional)

  

4.1.4.2

Material resources (access to ICT)

  

4.1.4.3

Human resources (IT support, other)

 

4.1.5

 

Organisational factors

  

4.1.5.1

Training / lack of or inadequate training

  

4.1.5.2

Management (strategic plan to implementing applications)

  

4.1.5.3

Presence and use of “champions”

   

Participation of end-users in the design

  

4.1.5.4

Participation of end-users in the implementation strategy

  

4.1.5.5

Communication (includes promotional activities)

  

4.1.5.6

Relation management/health professionals

  

4.1.5.7

Ongoing administrative / organisational support

  

4.1.5.8

Incentive structures

  

4.1.5.9

Readiness

  

4.1.5.10

Other organisational or cultural aspects

4.2

  

External environment

 

4.2.1

 

Financing of ICT / financial support

 

4.2.2

 

Interorganisational relations

 

4.2.3

 

Health care policies

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Gagnon, MP., Desmartis, M., Labrecque, M. et al. Systematic Review of Factors Influencing the Adoption of Information and Communication Technologies by Healthcare Professionals. J Med Syst 36, 241–277 (2012). https://doi.org/10.1007/s10916-010-9473-4

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