The Electronic Health Record in Austria: s Influenced by Negative Emotions

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1 140 Medical Informatics in a United and Healthy Europe K.-P. Adlassnig et al. (Eds.) IOS Press, European Federation for Medical Informatics. All rights reserved. doi: / The Electronic Health Record in Austria: s Influenced by Negative Emotions Werner HACKL a,1, Alexander HOERBST b, Elske AMMENWERTH a a Institute for Health Information Systems, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria b Research Division for ehealth and Telemedicine, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria Abstract. Negative emotions like anxiety and fear due to a lack of information electronic health record (ELGA) in Austria. Qualitative, problem-centric interviews were conducted with eight physicians. The results point out that the physicians feel uninformed and snubbed. They fear unknown changes, increased costs, workload and surveillance without having advantages from using electronic health records in their daily practice. Impartial information campaigns, tailored to d questions as well as comprehensive cost-benefit analysis Keywords. electronic health record (EHR), change barriers, organizational change, risk management, acceptance management 1. Introduction In Austria a heated debate concerning the intended implementation of an obligatory national electronic health record (ELGA) [1] was held charged with emotions between politicians and doctors. Emotions may play an important role whenever humans have to make decisions [2]. Doctors having negative emotions, such as anxiety and fear related to the ELGA implementation, may develop resistance change-barriers against the implementation. Change barriers motivated from anxiety and fear represent a major risk for the success of a project and can even lead to complete failure [3]. Many stories describing failure of implementing changes in health information systems could be told. It is important to gain a better understanding of these failures to be able to learn from mistakes in the past. The amount of change -reality between the current situation and the expected new situation seems to be a major factor for failure or success of changing health information systems [4]. 1 Corresponding Author: Werner Hackl, Institute for Health Information Systems, UMIT University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Zentrum 1, 6060 Hall in Tirol, Austria;

2 W. Hackl et al. / The Electronic Health Record in Austria 141 Introducing a nationwide electronic health record represents a huge amount of change for the different stake holders. Whereas public opinion (state of knowledge, interest and acceptance of electronic health records) has been investigated by interviewing Austrian citizens [5, 6], a comparable study analyzing systematically the Therefore the goal of this study was to determine, if anxiety and fear can be observed in physicians, to detect, what kinds of anxiety and fear can be found, how distinct they are and foremost, what can be done about those fears. 2. Methods 2.1. Data Collection This study was conducted in the middle of 2008 and included general practitioners and specialists in private practice from the central region of Tyrol. Doctors listed in the yellow pages were contacted and asked to take part in an interview by fax or . The number of experts was determined using the method of theoretical sampling described in [7]. Eight physicians, one surgeon, one dermatologist, one ophthalmologist, one psychiatrist, one gynecologist, one radiologist and two general practitioners were interviewed. - [8] and adapted by Lamnek [9] and Mayring [10] was chosen as method for data collection. An interview guideline was developed, tested and adapted. The eight problem-centric interviews had a mean duration of 16 minutes (±6) Data Evaluation All interviews were recorded using an audio recorder. They were transcribed literally. The resulting 40 text pages were interpreted using the method of qualitative content analysis described in [11] [12] was used to support the qualitative content analysis. In order to augment the information content and to increase the comparability and to facilitate the prioritization of the resulting categories, the gained data was also evaluated quantitatively. 3. Results 328 passages in the transcribed text were selected, tagged and paraphrased. These passages were assigned to 139 different primary categories. The primary categories were then merged to families. Finally 18 main categories in the form of statements were derived. The categories were correlated and a theoretical model was formed to explain the genesis of the detected fears and anxiety. Graphical networks were developed for each category. Figure 1 shows the network lectronic Health Records (EHRs)

3 142 W. Hackl et al. / The Electronic Health Record in Austria Figure 1. Example of network o Accustomed workflows have to be changed by reason of 3.1. Anxieties and Fear Associated with the EHR The following list summarizes the 18 final categories sorted by grounded value (number of mention) in descending order: Physicians are unsettled due to missing, insufficient or negative information (43) Data privacy and data protection is not warranted (41) EHRs cause additional workload and loss of time (36) Unauthorized third party will use EHR data (35) Physicians will be other-directed due to EHRs (21) EHRs lead to a controllable, transparent doctor (19) Accustomed workflows have to be changed by reason of EHRs (19) Cost of EHRs will be shifted to the physicians (18) Benefit of EHRs is not known (17) EHRs lead to a controllable, transparent patient (19) Usability of EHRs will be insufficient (12) EHR data will be used punitive against physicians (11) The time is not ripe for EHRs (11) EHRs lead to two-class medicine (9) EHRs will be implemented imperfectly (7) EHRs will fail due to scarce cooperation of physicians (6) Too much information narrows, blurs the vision (4) A system change always causes media breaks, causes loss of information (1)

4 W. Hackl et al. / The Electronic Health Record in Austria Summarization of the Results The interviews showed that there is a great deal of uncertainty concerning the implementation of the national EHR ELGA in Austria among physicians. The general state of knowledge regarding EHRs is low. There is a lack of tailored information for physicians. They do not know what ELGA will bring for their future. Hence they feel fear and anxiety of something unknown, they can t imagine working with EHRs in the future. They have no concr t imagine how they can benefit from EHR use. On the other hand the doctors fear that ELGA will lead to considerable additional workload and cost. They fear also that the usability of the system will be poor and they assume that they will have to change accustomed workflows. The interviewed physicians also suspect additional workload due to information overload and increased responsibilities in medical documentation. They fear that against their wishes they could be forced to use ELGA, which does not bring improvements and benefits for their daily work. Therefore they believe that they will be other-directed due to the obligatory use of EHRs. There is a clear and solid fear, that data from ELGA will be used by not authorized third party. The interviewed physicians consider medical data to be invaluable for many companies, e.g., private insurance companies, pharmaceutical industries or manufacturers of medical devices. In addition the physicians fear that the precious, unauthorized use of these data could lead to detriment and additional control of patients and physicians and further to the transparent patient and transparent doctor finally medical care to bypass ELGA. 4. Discussion This qualitative study was planned and conducted conscientiously, but may not claim general validity of the obtained results. However, it could be shown that fear and anxiety connected with ELGA exists. This study could further explain that change-barriers and resistance against the implementation of ELGA can be motivated by negative emotions. It could be shown, that the assessed project risks in the ELGA feasibility study [13] and Masterplan [14] really exist. Additionally the causes of these risks could be described in detail for at least one important stakeholder the physicians. Furthermore some recommendations can be derived from the results to improve [15]. The interviewed doctors were not completely negative. They also mentioned positive aspects of EHRs, e.g., the reduction of double examinations and possible reduction of healthcare cost. The preparation and publication of comprehensive and detailed cost-/benefit analyses especially focus recommended. Based on this study impartial information campaigns, tailored to the physicians to get the ELGA discussion in Austria back to the facts.

5 144 W. Hackl et al. / The Electronic Health Record in Austria References [1] Hofmarcher, M. (2008) Electronic health record: Developments and debates. Health Policy Monitor [serial on the Internet], [2] Zimbardo, P.G. (1992) Psychologie. 5th edition, Springer, Heidelberg. [3] Krüger, W. (1999) Implementierung als Kernaufgabe des Wandlungsmanagements. In Hahn, D., Taylor, B. (Eds.) Strategische Unternehmensplanung, Strategische Unternehmensführung Stand und Entwicklungstendenzen. Physica Verlag, Heidelberg, [4] Heeks, R. (2006) Health information systems: Failure, success and improvisation. International Journal of Medical Informatics 75(2): [5] Ärztekammer für Wien. (2007) E-Health: Weniger Staat Mehr Privat. [Press release] Wien: Ärztekammer Wien; 2007 [cited ]; Pressekonferenz]. [6] Hoerbst, A., Schabetsberger, T., Ammenwerth, E. (2008) Die elektronische Gesundheitsakte in Österreich aus der Sicht der Bürger. In Zöllner, I., Klar, R., (Eds.) GMDS2008; Deutsche Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie e.v. (gdms), Stuttgart, [7] Glaser, B.G., Strauss, A.L. (2005) Grounded Theory Strategien Qualitativer Forschung. Verlag Hans Huber, Bern. [8] Witzel, A. (2000) Das Problemzentrierte Interview. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research [serial on the Internet]. (1(1)) [9] Lamnek, S. (1995) Qualitative Sozialforschung Band 2 Methoden und Techniken. Beltz, Psychologie Verlags Union, Weinheim. [10] Mayring, P. (2002) Einführung in die qualitative Sozialforschung: eine Anleitung zu qualitativem Denken. 5., überarbeitete und neu ausgestattete Auflage, Beltz, Weinheim. [11] Mayring, P. (2003) Qualitative Inhaltsanalyse. Grundlagen und Techniken. Beltz Verlag, Weinheim. [12] Atlas.ti GmbH. (2008) Atlas.ti The Knowledge Workbench. 5.2 edition, ATLAS.ti Scientific Software Development GmbH. [13] IBM Österreich GmbH im Auftrag der Bundesgesundheitsagentur. (2006) Machbarkeitsstudie betreffend Einführung der elektronischen Gesundheitsakte (ELGA) im österreichischen Gesundheitswesen. [Report] Wien: ARGE ELGA; 2006 [cited ]; Arge_Papers/Machbarkeitsstudie_ELGA_Endbericht_ pdf. [14] IBM Österreich GmbH. (2007) Ergebnisbericht ELGA Systemkomponenten und Masterplan. [Report] Wien: ARGE ELGA; Arge_Papers/Endbericht_Folgeauftrag.pdf. [15] Lorenzi, N.M., Kouroubali, A., Detmer, D.E., Bloomrosen, M. (2009) How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings. BMC Medical Informatics and Decision Making 9:15.

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