CC BY-NC-ND
0Available online at www.sciencedirect.com
SciVerse ScienceDirect
Procedía Technology 5 (2012) 706 - 715
HCIST 2012 - International Conference on Health and Social Care Information Systems and
Technologies
Adoption of Electronic Health Care Records: Physician Heuristics and Hesitancy
Jerald D. Hattona*, Thomas M. Schmidtb, Jonatan Jelenc
aUniversity of Phoenix, 3157 East Elwood Sreet, Phoenix, AZ 85034 bDean, Engineering and Information Sciences, DeVry College of New York, 180 Madison Avenue, New York, NY 10016 cParsons The New School for Design - School of Design Strategies, 2 West 13 th Street, New York, NY 10033, USA
Abstract
Political, economic, and safety concerns have militated for the adoption of Electronic Health Records by physicians in the United States, but current rates of adoption have failed to penetrate the 50% level. A qualitative phenomenological study of practicing physicians reveals stumbling blocks to adoption. Maintaining a physician's perceived sense of control of the process is key. Electronic Health Records (EHRs) are critical to the support of research, quality control, cost reduction, and implementation of new technologies and methods in healthcare. Progress in the USA towards adoption of standardized EHRs has been halting. We discuss the results of a phenomenological study of physicians and draw conclusions that will assist all stakeholders in building a more consistent, comprehensive, and cost-effective healthcare system. When attempting to persuade physicians to migrate to an EMR-based solution, a strong focus on the control that physicians will have should be emphasized. The transition to an EHR system is eased by clearly articulating early in the process the potential benefits and the degree of control physicians can have in the use of the applications.
© 2012 Published by Elsevier Ltd. Selection and/or peer review under responsibility of CENTERIS/SCIKA -Association for Promotion and Dissemination of Scientific Knowledge
Keywords: Electronic Health Records; Electronic Medical Records; Health Information Technology
* Corresponding author. E-mail address: Jerald@Hatton.com.
2212-0173 © 2012 Published by Elsevier Ltd. Selection and/or peer review under responsibility of CENTERIS/SCIKA - Association for Promotion and Dissemination of Scientific Knowledge doi: 10.1016/j.protcy.2012.09.078
1. Introduction
Technology adoption by informed health care consumers, increasingly responsible for the personal health care of children and dependent adults, has outpaced that of most physician practices. According to Police, Foster, and Wong [28] health information technology (HIT) can potentially improve clinical outcomes for patients, increase physician productivity, and decrease healthcare costs. Although most patient care is delivered in physician offices, the adoption and use of available technology continues to lag [p. 245]. The slow adoption rate of electronic medical record (EMR) applications by physician practices illustrates the issue [14]. While most patient health-related information remains formatted in paper charts located in physician offices (24), access to personal health history, medications, inoculations, and treatments becomes more important in the evolving mobile, technology-driven environment [1].
President Obama stated: "The biggest threat to our nation's balance sheet, by a wide margin, is the skyrocketing cost of health care" [29]. Health care accounts for $1 out of every $6 spent in the United States and those costs are increasing at twice the rate of inflation [29]. According to a United Nations report, the United States has the most expensive health care system in the world, yet 24 countries have longer life expectancies and 34 have lower infant mortality rates.
Despite the huge expenditures by individuals and corporations, health care quality in the United States compares poorly against many other first-world countries [20]. Healthcare has failed to keep up with other industries in the adoption of technology. One estimate is that health care technology in the United States is 20 years behind the rest of the nation's industries [16]. One medical provider stated, "This is a $2.4 trillion industry run on handwritten notes" [29].
2. Purpose of the Study
The purpose of our qualitative study was to investigate physician perceptions of increased technology adoption in physicians' medical practices. Understanding of the physician's view of EMR technology will eliminate barriers and accelerate the adoption of currently available technology that improves patient care and the accessibility of patient records. Sparse research exists concerning physician perceptions of the technology-enabled changing dynamics in health care [25]. We focus specifically on the slow rate of technology adoption into physician medical practice [37].
A qualitative phenomenological research design questioning a sampling of physicians located in south-central Indiana revealed information regarding participants' lived experiences, and helped clarify genuine human motivations and discover relationships involving economic or social phenomena [17]. The initial intent of this study was to interview at least 15 physicians; however, after 10 physician interviews, the study appeared to reach a saturation with no new information being provided.
3. Methodology
Little research is available on physician perceptions associated with the adoption of new technology in the practice of medicine. Stewart and Shamdasansi [33] noted that qualitative questioning could provide researchers with an opportunity to capture components of collective, yet seldom-discussed, opinions held by professionals. The insights and opinions provided through this method provided an opportunity to explore and understand the underlying issues associated with slow technology adoption rates.
The focus of our study was to identify physician perceptions of increased technology adoption in medical practices. Physicians were asked to provide perspective on why health care providers have been slow to incorporate technology into medical practices. Demographic questions were asked to gather data on the
participants, and open-ended questions were used to explore the reasons a majority of physicians have failed to adopt currently available technical innovations. Our qualitative phenomenological approach supports the gathering of personal perspectives that are not known or available. The study included a sampling of a homogeneous grouping of 10 physicians out of a larger pool of 15 candidates in south-central Indiana. Criteria for participants in the study included the following: (a) the provider had to be a currently active, practicing physician, (b) family practice physicians and adult internal medicine physicians were preferred because they are more often the primary care physicians for the patient community, and (c) physicians who employ EMR applications might be included in the population along with providers who are still using paper charts.
Vishnevsky and Beanlands [36] note that the qualitative researcher aims "to create a rich description of the phenomenon of interest" (p. 234). To accomplish this, qualitative phenomenological research designs analyze words, phrases, and constructs to describe the phenomenon studied. Qualitative research seeks to derive meaning rather than make generalized hypothesis statements [8]. After conducting interviews with 10 actively practicing physicians, a keyword prevalence analysis using the NVivo 9© software assisted in the determination that theoretical saturation had occurred: we reached a saturation point where no new information, insights, or coding categories were produced regardless of increasing the sampling population
Interviews occurred between November 15, 2011, and December 15, 2011 in the physician's office or in an office of an affiliated physician. In each case, the discussions were private and lasted between 40 and 75 minutes. Ten open-ended questions guided the conversations. A Zoom H2 portable digital stereo recorder captured the interviews allowing an accurate transcription of the participant responses. Those transcripts were used in conjunction with NVivo 9© software for coding the data and performing the thematic analysis.
Demographic information gathered included sex, years in practice, and medical specialization. The participants interviewed were eight male and two female family practice physicians. The physicians are members of a larger affiliation of medical practices involving 75 total practitioners in 16 separate practices. Beginning in 2005, the initial six practices in the affiliation chose to implement an EMR application. As additional practices joined the affiliation over the years, they had the option to implement the EMR application or remain with the existing paper-based system. As of this study, all but one of the practices has adopted the EMR. The affiliated physicians do all patient interactions and charting through the computerized system. The physicians serve patients from a five-county area with a total population of 350,000 people [5].
Physicians chosen for this study had to be in active practice for at least five years, to have previously employed traditional paper-based patient charting techniques, and to have migrated to using an electronic medical record (EMR) application in their medical practice. For our phenomenological study, it was important to involve physicians who had lived through the experience of using the traditional paper charting methods and utilized the capabilities of a computerized medical record application. The physicians in the study have been in practice for five to 35 years (see Table 1).
Table 1. Summary of Participant Years in Practice
5 - 10 Years
1 (10%) 2 (20%) 2 (20%) 2 (20%) 2 (20%)
10 - 15 Years
16 - 20 Years
21 - 25 Years
26 - 30 Years
31 or more Years 1 (10%)
Note: n = 10
4. Findings
The interviews produced discussions beyond the scope of the questions. Shown in Table 2 are the major and minor emergent themes of the research study. The themes fell into a categorization of either benefits or challenges to the physicians' practice of medicine. Participants referred to challenges more frequently (199 references or 64.6%) than to benefits (109 references or 34.4%). Relationships between these themes exist that link many of the observations together. As a result, none of the themes are mutually exclusive.
Table 2. Emergent Themes
Challenges Comments
Major Theme - Challenges
Loss of Control 68
Minor Themes - Challenges
Attitude of Providers 34
Financial Negatives 28
Continuity of Care 27
Total Challenges 199
Benefits
Major Themes - Benefits
Supporting Physician Decisions 29
Physician Access to Information 25
Financial Improvements 25
Minor Themes - Benefits
Time Improvements 18
Patient Access to Information 12
Total Benefits 109
4.1. Challenges Theme
4.1.1 Challenges major theme: Loss of control The references to loss of control were prominent in the conversations and included references to (1) procedural or workflow challenges, (2) the EMR causing them to work more slowly, (3) the pace of technology obsolescence, (4) too much information available to patients or that needed to be gathered from
patients, and (5) the cognitive distraction that occurs when the physician interacts with a computer in the examination room.
4.1.2 Challenges major theme: Attitude of providers
Moving from any established process to a different process can be difficult. Moving from a paper-based medical practice to an electronic medical record environment is especially challenging for physicians [32]. In many cases, the physician had created the paper-based system to match his or her individual interpretation of best practice.
Migration to an EMR from a paper-based system can be categorized as a second order change. Second-order changes, in the context of this study, would involve a fundamental shift in the way physicians perceive themselves and the world. This is different from a first order change, which could be comprised of minor changes to the way things are done. A second order change would transform an existing paradigm into something very different [27].
The success physicians experience adjusting to these changes can affect their attitude toward the new technology. The challenges noted by the participant physicians included 34 distinct references to the attitude of physicians toward the technology used in their practices. The areas noted included: 1) the sense that paper charts were easier to use than computerized record systems, 2) the technical ability, or lack of technical skills, of the physician, and 3) the age of the physician. Physicians who had long used paper charting in their practice appeared to have more ingrained habits that were difficult to change. As one physician noted, "Physicians are such creatures of habit. We write the same drugs all the time. We are comfortable and sometimes you have to get out of your comfort zone for this technology" (P3).
4.1.3 Challenges minor theme: Financial Negatives
Cost of the software, cost of the maintenance, and cost of the support personnel to ensure the application continues to run, the data is backed up, and the networks are secure were comments heard from each of the participants. In total, 29 comments from the physicians referred to the cost of obtaining and maintaining computerized medical record systems.
4.1.4 Challenges minor theme: Continuity of Care
Liss et al. [21] noted most physicians have neither the time nor the needed expertise to address all patient medical needs. Referrals to other physicians are a normal in the current healthcare environment. Because services are comingled among many providers, and no single model of care coordination is universally applicable across patient populations, ensuring that patient care is coordinated is a challenge (p. 323). Many physicians believed that electronic medical record applications would facilitate improved coordination of patient care across the practitioner community, but that has not happened as quickly or effectively as they had hoped.
4.2. Benefits Theme
The physicians interviewed for this study described a number of benefits. Analyzing transcripts of the interviews using the NVivo 9 software facilitated the discovery of major themes relating to the capability of technology to support physician decisions, provide physicians with improved access to information, and the financial improvements associated with the incorporation of technology into medical processes. Minor themes emerged related to time improvements that can be realized from using computerized medical record applications and the potential for improved patient access to his personal health information.
4.2.1 Benefits major theme: Supporting Physician Decisions
Much of the technology implemented in medical practices is designed to support the decisions made by physicians concerning the care they provide to patients. The EMR is particularly useful in noting drug allergies and drug-to-drug interactions [7].
4.2.2 Benefits major theme: Physician access to information
Physicians need access to timely and accurate information to make decisions about patient care. EMRs can provide that access in a structured, retrievable format. Then, it was a significant challenge to just locate the folder containing the patient's past care information. An electronic medical record integrates patient information systems so that demographic, financial, and medical information can be collected, accessed, transmitted, and stored in a readily available digital format [31]. In most cases, an EMR provides physicians with improved access to needed patient information supporting a prompt diagnosis and treatment plan [3]. Better information can translate to improved patient care and a healthier patient population.
4.2.3 Benefits major theme: Financial Improvements
Physicians have a sense that the EMR makes them more cost effective and more efficient. They cited anecdotal evidence that the EMR is helping them to code more accurately and more consistently capture charges for services rendered. Several practices have begun to mine patient data to search for patients who qualify for or require medical examinations or procedures. By being proactive in the interactions with patients, physicians are finding an increase in patient loads. The government of the United States is providing more than $20 billion in incentives to encourage physicians to implement electronic medical record applications by 2014 [13]. The incentive program provides a total financial incentive, "of $44,000 for each physician who adopts EMRs in 2011 or 2012, $39,000 for those who adopt in 2013, and $35,000 for those who adopt in 2014" (p. 44). Should physicians wait until later to implement an EMR, they will receive a 1% decrease in Medicare reimbursement with an accelerating decrease in years thereafter.
4.2.4 Benefits minor theme: Time Improvements
Physician participants in this study equated efficiency with time improvements. Noted improvements in this area include improved communication with staff through the EMR messaging capability. Instead of scribbling a note, as they might have done in the past, the EMR provides an internal system for sending and receiving information between all persons in the office.
4.2.5 Benefits minor theme: Patient access to information
Most of the physicians participating in this study recognized that patients could benefit from the increased incorporation of technology into the medical practice. Six of the physicians noted the "increased availability of information" would be a benefit for the patient population. Three of the physicians observed that better-informed patients can provide opportunities for improved care and healthier outcomes.
5. Interpretation of the Findings
Several studies of the health care system recognize how the dramatic changes affecting the industry, such as the introduction of more technology, are causing physicians to perceive a loss of control over how they practice medicine [18]. The systemic uncertainty occurring in the healthcare system today is particularly difficult for physicians [32]. Physicians may deal with this perception of loss of control in many ways:
• Positive Assertive - the physician focuses on changing themselves or the environment by becoming decisive, leading the effort, and communicating needs
• Negative Assertive - the physician becomes very involved trying to control and manipulate the change
• Positive yielding - the physician becomes more patient, trusting, accepting, and yields active control efforts
• Negative yielding - the physician becomes very passive, timid, indecisive, and gives in to feelings of helplessness [32]
Physicians in this study shared these sentiments. Possessing a sense of control is particularly relevant for physicians [32]. Medical training of physicians focuses on learning how to take control of problematic situations. With the realities of the current healthcare environment and the intrusion of new tools, techniques, and technologies often required by external agencies, physicians are recognizing that, "despite knowledge, skill, and expertise, there remains much in medicine and patient care that they are unable to control through active, instrumental efforts" (p. 16).
Overcoming this obstacle is critical to implementing EHRs and improving healthcare quality. Given the increased expenditure on health care in the United States, it is puzzling that the outcomes compare so poorly to other industrialized nations. Infant mortality can be an important indicator of national health. The stagnation of the United States infant mortality rate since 2000 concerns both researchers and policymakers [22]. The United States has both the highest infant mortality rate and the lowest life expectancy rate for those persons 60 and older [22; 30] in the comparison countries. Using 37 indicators of health quality, equity, access, and outcomes, the United States scored an average of 66 out of 100. As a percentage of gross domestic product, the United States spends more on health care than any other industrialized nation [12; 30].
Critics of the current health care system point to evidence of overuse, inappropriate care, duplication, waste, inefficient use of resources associated with poor access, regional variations in both quality and costs, and lack of information systems that foster efficiency [19]. At the heart of the issues highlighted by critics of the current system is the primary care physician. These doctors act as gatekeepers and repositories of patient health information. If the internal processes within these medical practices are paper-based, inefficient, or poorly organized, the other components in the continuum of care experienced by the patient will reflect those inefficiencies.
The health care industry has long recognized that physicians resist change. Understanding that even simple attempts at standardization, such as ordering common blood chemistry tests, can be challenging provides some perspective into the challenges associated with implementing an electronic medical record application. The use of an EMR can help to standardize many of these processes, but in the United States, less than 30% of physicians use an EMR compared to 60-90% in other industrialized nations [19]. This difference in technology utilization is important to consider when contrasting both the quality and cost of health care provided in differing world areas.
Although the attitude issues that emerged as a major challenge theme are comprised of several factors, it also contributes to the sense that physicians perceive they are being forced to practice medicine in ways different from what they were accustomed to doing when they were paper-based and could do as they pleased. The advent of electronic medical records and the expectation that the information is formatted in a standard way to be shared securely with other health care related entities changed the dynamics of the process. The themes that emerged from this study highlight the challenges associated with these dynamics.
One way to develop the needed attitudes toward the technology and need for control is to help physicians become more aware of their own control dynamics. Helping physicians understand the ways these factors can affect interactions with patients, colleagues, and staff may help to begin the process of developing a more
accepting attitude toward the technology. The loss of control that physicians experience should be addressed if the nation is to move forward with effectively implemented technology in medical practices.
Physicians are waiting for technology to adapt to their methods and processes rather than adapting to what others may determine to be optimum. If the physicians perceive they do not have control over the processes, or the associated costs, they will remain reluctant to adjust to a new system, regardless of the potential benefits to the larger community. The attitude professed by a majority of the physicians in the United States is preventing the adoption and use of technologies that can save patient lives, improve the quality of care provided, and lower the cost of healthcare to individuals, employers, and the nation.
The movement toward accountable care organizations (ACO) may provide the catalyst to begin the standardization of processes and information flow that would demonstrate the inherent value of electronic medical record keeping to physicians [6]. Most EMR functionality is isolated to the internal workflow of the practice and the personal preferences of the physician. As the circle of integration for the digitally shared data expands, the need to ensure that standardization improves across all members of the care organization will grow. As reimbursements become increasingly tied to the improved care received by the larger patient community, additional inducements to effectively use technology will come into play.
6. Future Research
A future study might contrast the perceptions of EMR technology of more recent medical school graduates who have less experience with paper-based systems and who may have learned to practice medicine using electronically integrated tools. This comparison may help to project when the true value of an integrated health care continuum might become the norm rather than the fragmented system that exists at present. Medical students who have a higher comfort level with computer systems may not perceive the same challenges as the more experienced physicians who had to migrate from paper-based to computer-based processes.
7. Conclusion
Physician perceptions and attitudes associated with their perceived sense of control over EMR technology significantly influence the decision to implement, and effectively use, an EMR. Knowing these factors play a critical role in the successful promotion of these applications can help focus the effort to define the advantages and potential uses of EMR technology. When attempting to persuade physicians to migrate to an EMR-based solution, a strong focus on the control that physicians will have should be emphasized. Those areas that would influence process flows or tasks required by the physician will need to be identified and accepted, as should any potential added costs that may be required in future years. Physicians do not like to be surprised by added complexities and added costs. If these elements are clearly articulated early in the process, it could ease the transition to the new system.
References
[1] Brown, B. (2007). The number of online personal health records is growing, but is the data in these records adequately protected? Several key issues that covered entities should consider when it comes to personal health information.(HIPAA). Journal of Health Care Compliance, 9(3), 35. Retrieved from http://www.compliance-institute.org/pastcis/2009/PDFs3page/PreAM/P8_handout1.pdf
[2] Centers for Medicare and Medicaid Services. (2008). National health expenditure data. Baltimore, MD.
[3] Chao. C . Jen, W., Chi. Y, and Lin, B. (2007). Improving patient safety with RFID and mobile technology. International Journal of
Electronic Healthcare, 3(2). 175-192. doi:10.1504/IJEH.2007.013099
[4] Cohen, L., Manion, L., & Morrison, K. (2003). Research methods in education (5th ed.). London; New York: RoutledgeFalmer.
[5] Columbus, Indiana. (2010). Retrieved from http://www.city-data.com/city/Columbus-Indiana.html
[6] Correia, E. W. (2011). Accountable Care Organizations: The Proposed Regulations and the Prospects for Success. American Journal of Managed Care, 17(8), 560-568.
[7] Crane, J. F. G. (2006). Preventing medication errors in hospitals through a systems approach and technological innovation: A prescription for 2010. Hospital Topics, 84(4), 3. doi:10.3200/HTPS.84.4.3-8
[8] Crouch, M. & McKenzie, H. (2006). The logic of small samples in interview based qualitative research. Social Science Information, 45(4), 483-499. doi:10.1177/0539018406069584
[9] Fortin, J., & Zywiak, W. (2010). Getting meaningful use getting meaning value from IT. HFM (Health care Financial Management), 64(2), 54.
[10] Fox, A. (2010). Intensive diabetes management: Negotiating evidence-based practice. Canadian Journal of Diabetic Practice and Research, 71(2), 62-70. doi:10.3148/71.2.2010.62
[11] From clipboards to keyboard. (2007, May 19). The Economist, pp. 68-69.
[12] Garber, A. M., & Skinner, J. (2008). Symposium: Health care: Is American health care uniquely inefficient? Journal of Economic Perspectives, 22(4), 27-50. doi:10.1257/jep.22.4.27
[13] Hasson, M. (2009). Federal stimulus includes more than $20 billion in incentives for EMR adoption. Ocular Surgery News, 27(9), 44-44.
[14] HIMSS Analytics. (2009). The EMR adoption model. Retrieved from http://www.himssanalytics.org/docs/4thEditionEssentialsEMRAdoptionModel.pdf
[15] Hsiao, C. J., Hing, E., Socey, T., & Cai, B. (2011). Electronic Health Record Systems and Intent to Apply for Meaningful Use Incentives Among Office-based Physician Practices: United States, 2001-2011. CDC National Center for Health Statistics - Health E-Stat. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db79.htm
[16] Ilie, V., Van Slyke, C., Parikh, M. A., & Courtney, J. F. (2009). Paper versus electronic medical records: The effects of access on physicians' decisions to use complex information technologies. Decision Sciences, 40, 213-241. doi: 10.1111/j. 1540-5915.2009.00227.x
[17] Jansen, H. (2010). The Logic of Qualitative Survey Research and its Position in the Field of Social Research Methods. FQS Forum: Qualitative Social Research, 11(2). Retrieved from http://www.qualitative-research.net/index.php/fqs/article/viewArticle/1450/2946
[18] Katerndahl, D., Parchman, M., & Wood, R. (2009). Perceived complexity of care, perceived autonomy, and career satisfaction among primary care physicians. Journal of the American Board of Family Medicine, 22, 24-33. doi:10.3122/jabfm.2009.01.080027
[19] Kumar, S., & Steinebach, M. (2008). Eliminating US hospital medical errors. International Journal of Health Care Quality Assurance, 21, 444-471. doi:10.1108/09526860810890431
[20] Lenert, L. (2010). Transforming health care through patient empowerment. Information Knowledge Systems Management, 8, 159175. doi:10.3233/iks-2009-0158
[21] Liss, D. T., Chubak, J., Anderson, M. L., Saunders, K. W., Tuzzio, L., & Reid, R. J. (2011). Patient-reported care coordination: associations with primary care continuity and specialty care use. Annals Of Family Medicine, 9(4), 323-329.
[22] MacDorman, M. F., & Mathews, T. J. (2010). Behind international rankings of infant mortality: how the United States compares with Europe. International Journal Of Health Services: Planning, Administration, Evaluation, 40(4), 577-588. doi:10.2190/HS.40.4.a
[23] Mathews, A. W. (2010). Fewer Practices Are Doctor-Owned. Wall Street Journal - Eastern Edition, 256(110), A6.
[24] Meinert, D. B. (2005). Resistance to electronic medical records (EMRs): A barrier to improved quality of care. Issues in Informing Science & Information Technology, 2, 493.
[25] Meinert, D. B., & Peterson, D. K. (2009). Anticipated use of EMR functions and physician characteristics. International Journal of Health care Information Systems and Informatics, 4(2), 1.
[26] Miller, J. (2008). Basic Facts. Managed Healthcare Executive, 18(3), 14-18.
[27] Paredes, D. W. (2011). Creating a meaningful learning environment for second-order change. T+D, 65(7), 44.
[28] Police, R. L., Foster, T., & Wong, K. S. (2010). Adoption and use of health information technology in physician practice organisations: systematic review. Informatics in Primary Care, 18(4), 245-258.
[29] Salter, C. (2009). The doctor of the future. Fast Company, 135, 64.
[30] Schoen, C., Davis, K. How, S. K. H., & Schoenbaum, S. (2006). U. S. health system performance: A national scorecard. Health Affairs, 25, w457-w475. doi:10.1377/hlthaff.25.w457
[31] Seeman, E., & Gibson, S. (2009). Predicting acceptance of electronic medical records: Is the technology acceptance model enough? SAM Advanced Management Journal, 74(4), 21-26.
[32] Shapiro, J., Astin, J., Shapiro, S. L., Robitshek, D., & Shapiro, D. H. (2011). Coping with loss of control in the practice of medicine. Families, Systems, & Health, 29(1), 15-28. doi: 10.1037/a0022921
[33] Stewart, D.W. & Shamdasani, P.N. (1990). Focus Groups: Theory and Practice. Newbury Park, London, New Delhi: SAGE Publications.
[34] Tavabie, A., Stanwick, S., Belling, R., & Lister, G. (2010). Closing the gap between expectations and practice in continuity of care: can we still teach continuity of care? Education for Primary Care, 21(2), 83-88.
[35] Venkatesh, V., & Bala, H. (2008). Technology Acceptance Model 3 and a research agenda on interventions. Decision Sciences, 39,
273-315. doi:10.1111/j.1540-5915.2008.00192.x
[36] Vishnevsky, T., & Beanlands, H. (2004). Qualitative research. Nephrology Nursing Journal, 31, 234-237.
[37] Witry, M. J., Doucette, W. R., Daly, J. M., Levy, B. T., & Chrischilles, E. A. (2010, Winter). Family physician perceptions of personal health records. Perspectives in Health Information Management, 1-12. Retrieved from http://healthit.ahrq.gov/portal/
