Electronic Health Records and Plan-Do-Study-Act

Research Literature Support

PICOT Question Restated

What was the experience and impression of hospital staff such as practitioners, and its effect on the promotion and implementation of best practices to improve health outcomes and improve end-user/staff satisfaction and care efficiency?

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Observation of Academic Sources

The first article under discussion is the study by Fleming et al. (2014), which aimed to estimate the impact of implementing commercially available ambulatory electronic health records on such aspects of clinical settings as the efficiency, workflow, and financial measures. The authors used an interrupted time-series approach to design their study (Fleming et al., 2014). Administrative, payroll and billing data were collected by the means of using the SQLserver database. The principal finding of the study by Fleming et al. (2014) is that staffing and practice expenses increase by 3% and 6% respectively in 12 months after the implementation of EHR.

At the same time, productivity and net income decrease after the initial implementation, but they recover by the end of the observation period (12 months) (Fleming et al., 2014). One of the study’s principal findings is that it profoundly analyzes the implementation of EHR from the perspective of staff efficacy and financial measures. The critical limitation that could be mentioned is that the authors analyzed the data from a single network, and thus the findings could hardly be generalized.

The second article under discussion, written by Cifuentes et al. (2015), has the purpose of EHR-related practical experiences of integrating behavioral health and primary care, as well as evidenced-based strategies, challenges, and solutions. The authors used the method of an observational, cross-case comparative study of 11 diverse practices, for which the data was collected through the use of practice information surveys. The principal finding of the study is that the integration of behavioral health and primary care is challenged by the current design of EHR systems, and thus they should be further designed to adapt to these new conditions. The article’s primary strength is that numerous evidence-based approaches to the implementation of EHR could be retrieved from it. However, the study is considerably limited by the small number of participating practices.

The article by Cross et al. (2015) is directly related to the identified PICOT question, as it aims to identify EHR capabilities and innovations that would improve primary care practices in a meaningful way. Mixed quantitative and qualitative methods were used to retrieve information through surveys, which were completed by 328 primary care practices (Cross et al., 2015). The finding of this article is considerably similar to the one by Cifuentes et al. (2015), as the authors argue that vendors and policymakers should collaborate to create more comprehensive and patient-centered EHR implementations. The evident strength of the research is that it uses a considerably large sample compared to the study by Cifuentes et al. (2015). There are no significant limitations to this study.

The purpose of the study by King, Patel, Jamoom, and Furukawa (2014) was to assess the perceptions of physicians on the impact of EHR implementation on improving clinical outcomes. Also, the physicians’ length of experience with any EHR was considered. The study employed a qualitative cross-sectional data design. Data was collected from two sources: the 2011 National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records mail survey, and the follow-up mail survey that intended to evaluate the experience of physicians. Between 30 and 46 percent of clinicians who adopted EHR reported that the clinical benefits were evident. The qualitative nature of the study is its strength as it allows retrieving meaningful information about physicians’ perception of EHR implementation. The study’s findings are limited by the fact that clinical quality and outcomes were not independently measured.

The qualitative study by McAlearney, Hefner, Sieck, and Huerta (2015) aims to investigate the perceptions and behavioral changes of physicians towards EHR systems’ implementation, similar to the previously discussed study. The data was collected through surveys. The study’s principal finding is that it is beneficial to employ the grief coping process as it reflects the process of eliminating an old system and adapting to the new one. The second important finding is that the use of the organizational management model such as Kotter’s framework is beneficial in the process of EHR implementation. The study’s strength is that it provides meaningful qualitative insights into physicians’ behavioral attitudes towards EHR systems. The research is limited by the small number of participants, which does not allow generalizing the findings.

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The study by Meißner and Schnepp (2014) is focused on nurses’ experience as they participate in the process of EHR implementation. The study is designed based on a qualitative meta-ethnographic approach. The data was collected by the means of search engines such as PubMed and CINAHL. One of the study’s primary findings is that nurse consider the use of EHR systems as beneficial regarding the lesser time spent on retrieving sufficient information about patients. Gathering diverse experiences of nurses implementing EHRs in their practice is the strength of the study. However, the research is limited by the fact that the findings could hardly be generalized, and also the perceptions of nurses might change over time.

The article by Shea et al. (2014) is an analysis of the implementation of an adaptable method for assessing organizational capacity for achieving meaningful use of EHR systems. An interactive qualitative data analysis process was used as the study design method. The data was collected using the developed structured survey tool. The main finding of the research is that the proficiency of clinical practitioners regarding the use of EHR improves clinical outcomes. The article’s primary strength is that it focuses on the organizational level of EHR implementation. The critical limitation of the study is that the developed structure assessment tool could not be used in other clinical settings if issues around capacity and barriers are institution-specific.

The article by Shea, Reiter, Weaver, and Albritton (2016) aims to identify the use of a specific approach that supports the successful implementation of the EHR Meaningful Use Stage 1 trial. A qualitative sampling method is used to design the study. The chosen data collection method is a qualitative sampling. The primary finding of the article is that it is necessary to have a quality improvement team to control the meaningful implementation of EHR. Additionally, it is found out that super-users in EHR Meaningful Use Stage 1 trial have a considerable impact on the successful implementation of EHR. The evident demonstration of the correlation between super-users and quality improvement teams is the study’s primary strength. The research is considerably limited by the inability of the authors to measure factors at the practice level (such as management) and provider-specific characteristics like age or level of experience influencing the EHR Meaningful Use Stage 1 trial.

The article by Unger, Aldrich, Hefner, and Rizer (2014) is of particular interest, as it represents the case report, which reflects the authors’ experience of the EHR implementation. The primary purpose of this study is to understand how meaningful use of electronic health records could be successfully reported to the Centers for Medicare and Medicaid Services. The authors used the method of a case study as they implemented the EHR program themselves. The data was collected based on EHR implementation in The Ohio State University Wexner Medical Center (OSUWMC).

The primary finding of this research is that the authors were able to identify three areas of focus to assist with EHR Meaningful Use Stage 1 implementation. These areas are leadership, administrative strategies, and technological strategies. The evident strength of the study is that the authors’ conclusions are evidence-based as they controlled the implementation. However, the research findings are limited by the fact that OSUWMC is a large academic medical center, and thus smaller hospitals would face additional challenges in the process of EHR practices implementation described in this case study.

In their article, Zadvinskis, Garvey, and Yen (2018) describe the nurses’ perceptions of EHR meaningful use as well as its implementation over time. The study is designed based on a qualitative longitudinal study approach. The phenomenological method was used to collect meaningful data from the participants, who were surveyed three, nine, and eighteen months beyond the implementation of EHR. The primary finding is that at different time points nurses reported issues with the EHR implementation process at personal and organizational levels. The most evident strength of this study is that, due to its longitudinal approach, it allows evaluating and observing changes in clinical staff’s experience of EHR system implementation. The limited generalizability of the research findings that is caused by the sampling size of participants, which was limited to one unit within an academic medical center is the principal flaw of the study.

The final article under consideration, written by Williams, Shah, Leider, and Gupta (2017), is dedicated to the discussion of the current benefits and barriers of the EHR use. The exploratory mixed-method approach is used to design the study. To collect meaningful qualitative and quantitative information, surveys were employed. The primary finding of the research is that it demonstrates the perceived and actual benefits of the implementation of EHR systems as well as their meaningful use in public health. Staff training and financial burdens were the most evident barriers to the successful implementation of EHR systems. The article’s evident strength is that the authors use both qualitative and quantitative methods to provide a deeper overview of the current state of EHR use. The significant limitation of this study includes unverified self-reported opinions that may have been biased as well as a small sample size.

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Research Approach and Design

It could be stated that the qualitative research approach is the most suitable for the identified PICOT question as it enables the research to analyze experiences and perceptions of diverse hospital staff, such as nurses, nursing leaders, and managers about the implementation of electronic health records systems. Particularly, a phenomenological qualitative approach will be employed. Qualitative research can be described as the investigation of lived experiences and human perceptions (Rutberg & Bouikidis, 2018). Also, as it is mentioned by Miner-Romanoff (2012), qualitative methods produce findings that reveal individuals’ genuine thoughts and reflections. Based on these assumptions, it is appropriate to formulate the rationale for the selection of the chosen design approach: it allows efficiently retrieving meaningful data about hospital staff’s evaluations of the EHR implementation’s effectiveness.

It is also evident that, in the context of the identified PICOT question, the selected design has numerous advantages. First of all, a properly developed survey can be an efficient means of collecting meaningful data from a considerable large number of participants. Secondly, as it is mentioned by Zadvinskis et al. (2018), the phenomenological approach is the most suitable method for gaining profound knowledge about the specific behaviors of the participants. As the phenomenology is largely based on the explanation of the individual’s experience, it would be possible to make appropriate conclusions as well as to predict future trends in the area of concern. However, the select study design has a considerable disadvantage, since the phenomenological approach is not largely preoccupied with the density of analysis, and the results could hardly be quantified. Also, as the study findings will be experience-specific, they might not apply to other clinical environments.


As the research focuses primarily on retrieving experiences about the implementation of EHR systems, it is appropriate to suggest that the targeted population is nurses, nursing leaders, as well as managers in hospital settings (Cross et al., 2015). The probability sampling method should be used to retrieve objective and unbiased information (Cross et al., 2015). The primary inclusion criterion is the nurse’s level of proficiency in the use of EHR. Another inclusion criterion is the participant’s ability to adapt to new EHR technologies. The primary exclusion criterion is the absence of the experience of working with EHR systems.

Thus, it could be suggested that the sample size might be significantly large, according to the identified criteria. It is argued that a sample size of 100 nurses would give sufficient information about the staff’s perception of the efficiency of the EHR systems’ use in a particular hospital setting. The most evident advantage of the chosen method is that it allows retrieving meaningful data from a diverse variety of participants, based on which it is possible to make profound conclusions (Miner-Romanoff, 2012). The method’s primary disadvantage is that the results of the study might be difficult to generalize. To protect the participants’ rights, they must sign written consent forms for the affirmation of their compliance with the conditions of the participation.

Proposed Implementation in the Context of the Change Model

The Plan-Do-Study-Act (PDSA) change model is a framework for synthesizing the knowledge, which is employed in various evidence-based practice (EBP) processes. This model is the most suitable for this project as it provides a comprehensive and holistic framework for solving clinical problems. This paper could be considered as part of the Plan stage, as it proposes the framework for the implementation of the Do stage. After the project is implemented, it is essential to continuously evaluate it during the Study phase, and later to make additional changes to the process on the Act stage. Evidence-based results from this project might be difficult to generalize, and it is possible to overcome this barrier by using a more diverse sample of participants. Nurses and other clinical staff who participate in the project can foster its implementation by implementing the Act stage in their practice by continuous improvement of their professional behavior.


Cifuentes, M., Davis, M., Fernald, D., Gunn, R., Dickinson, P., Cohen, D. J. (2015). Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care. J Am Board Fam Med. (Suppl 1): S63-S72. Web.

Cross, D. A., Cohen, G. R., Nong, P., Day, A.-V., Vibbert, D., Naraharisetti, R., & Adler-Milstein, J. (2015). Improving EHR capabilities to facilitate stage 3 meaningful use care coordination criteria. In AMIA Annual Symposium Proceedings, 2015, 448-455.

Fleming, N. S., Becker, E. R., Culler, S. D., Cheng, D., McCorkle, R., Graca, B. D., & Ballard, D. J. (2014). The impact of electronic health records on workflow and financial measures in primary care practices. Health Services Research, 49(1pt2), 405-420.

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King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: National findings. Health Services Research, 49(1pt2), 392-404. Web.

McAlearney, A. S., Hefner, J. L., Sieck, C. J., & Huerta, T. R. (2015). The Journey through grief: Insights from a qualitative study of electronic health record implementation. Health Services Research, 50(2), 462-488. Web.

Meißner A., & Schnepp, W. (2014). Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: A systematic review and synthesis of qualitative research. BMC Medical Informatics & Decision Making, 14(1), 1-28. Web.

Miner-Romanoff, K. (2012). Interpretive and critical phenomenological crime studies: A model design. The Qualitative Report, 17(27), 1-32. Web.

Rutberg, S. & Bouikidis, C.D. (2018). Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research. Nephrology Nursing Journal, 45(2), 209-212.

Shea, C. M., Malone, R., Weinberger, M., Reiter, K. L., Thornhill, J., Lord, J., … Weiner, B. J. (2014). Assessing organizational capacity for achieving meaningful use of electronic health records. Health Care Management Review, 39(2), 124–133. Web.

Shea, C. M., Reiter, K. L., Weaver, M. A., & Albritton, J. (2016). Quality improvement teams, super-users, and nurse champions: A recipe for meaningful use? Journal of the American Medical Informatics Association: JAMIA, 23(6), 1195-1198. Web.

Unger, M. D., Aldrich, A. M., Hefner, J. L., & Rizer, M. K. (2014). A journey through meaningful use at a large academic medical center: Lessons of leadership, administration, and technical implementation. Perspectives in Health Information Management, 11, 1f.

Williams, K. S., Shah, G. H., Leider, J., & Gupta, A. (2017). Overcoming barriers to experience benefits: A qualitative analysis of electronic health records and health information exchange implementation in local health departments. eGEMs, 5(1), 18. Web.

Zadvinskis, I. M., Garvey Smith, J., & Yen, P.-Y. (2018). Nurses’ experience with health information technology: Longitudinal qualitative study. JMIR Medical Informatics, 6(2), e38. Web.

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