1178611

research-article2023
HIM0010.1177/18333583231178611Health Information Management JournalGriesser and Bidmon

Research Article

Health Information Management Journal

A holistic view of facilitators and barriers 1­–10

© The Author(s) 2023

of electronic health records usage from Article reuse guidelines:

sagepub.com/journals-permissions
different perspectives: A qualitative DOI: 10.1177/18333583231178611
https://doi.org/10.1177/18333583231178611
journals.sagepub.com/home/himj
content analysis approach

Anna Griesser, MA
Sonja Bidmon, PhD

Abstract
Background: Electronic health records (EHR) are seen as a promising endeavour, in spite of policies, designs, user
rights and types of health data varying across countries. In many European countries, including Austria, EHR usage has
fallen short when compared to the deployment plans. Objective: By adopting a qualitative approach, this research
aimed to explore facilitators and barriers experienced by patients and physicians across the entire EHR usage process in
Austria. Method: Two studies were conducted: In Study 1, discussions were held with four homogeneously composed
groups of patients (N = 30). In Study 2, eight expert semi-structured interviews were conducted with physicians to gain
insights into potential facilitators and barriers Austrian physicians face when utilising personal EHR. Results: A wide
range of barriers and facilitators were identified along the entire EHR usage spectrum, emerging on three different
levels: the micro-level (individual level), the meso-level (level of the EHR system) and the macro-level (level of the health
system). EHR literacy was identified as a booster to support EHR adherence. Health providers were identified as crucial
gatekeepers with regard to EHR usage. Conclusion: The implications for mutual benefits arising out of EHR usage
among the triad of health policymakers, providers and patients for both theory and practice are discussed.

Keywords (MeSH)
electronic health records, patient perspective, physician perspective, barriers, facilitators, holistic view, health
digitalisation, Austria, qualitative content analysis, health information management

Introduction cross-border interoperability in the European Union,

pushed by a desire to improve medical and nursing quality,
The process of digitalisation in health has led to new promote medical research into health challenges and strive
approaches aimed at patient care and networking with and towards sustainability and efficiency of national health sys-
between health professionals (Meister et al., 2018), acceler- tem (NHS; George et al., 2013). For example, frontrunners
ated by, for example, challenges with regard to long-time care Denmark and Estonia, with approximately two million vis-
or changed demographics (Evans, 2016; Kreps and Neuhauser, its by patients per month, are well advanced in terms of
2010). Patient-related electronic health records (EHR) are EHR implementation (Rahbek Norgaard, 2013), while
viewed as a promising instrument, ranging from ‘stand-alone’ countries such as France (Burnel, 2018), the United
to connected and integrated approaches (Tenforde et al., 2011). Kingdom (Bonomi, 2016) and Austria (Hoerbst et al., 2010)
These health data rely on web-based applications, which can have experienced difficulties that have halted their plans.
be shared among the triad of health policymakers, health pro-
viders and patients (Essén et al., 2018; Tavares and Oliveira,
2016), and can support a transparent exchange of health data Alpen-Adria-Universitaet Klagenfurt, Austria
and improve quality of care (Menachemi and Collum, 2011).
The term ‘EHR’ should be differentiated from electronic med- Corresponding authors:
Anna Griesser, Department of Marketing and International
ical records (EMR), which contain the standard medical and Management, Alpen-Adria-Universitaet Klagenfurt, Universitaetsstrasse
clinical data gathered in one specific healthcare institution. 65-67, Klagenfurt am Woerthersee, 9020, Austria.
EHR extend beyond and include a more comprehensive Email: [email protected]
patient history than EMR (McMullen et al., 2014). Sonja Bidmon, Department of Marketing and International Management,
To date, European stakeholders have been motivated to Alpen-Adria-Universitaet Klagenfurt, Universitaetsstrasse 65-67,
advance the development of EHR systems for different rea- Klagenfurt am Woerthersee, 9020, Austria.
sons (Damschroder et al., 2007), including facilitation of Email: [email protected]
2 Health Information Management Journal 00(0)

The French EHR programme was relaunched in 2016, after conducted a systematic literature review on 650 UTAUT2-
the initial adoption of the nationwide framework had been based studies and concluded that adding new constructs
historically poor (Séroussi and Bouaud, 2018). In 2010, the and associations with higher-order moderation effects led
NHS in the United Kingdom faced numerous difficulties to low parsimony of the UTAUT2, which is a major draw-
linked to the rollout plan, including software problems and back when compared to the original TAM.
absence of deadlines (Bonomi, 2016). EHR have great The aim of the current study was to investigate possible
potential but interoperability has only been successful barriers and facilitators of EHR usage, exemplified by the
within and across various national health sectors, while not Austrian EHR system for the two major user groups:
yet possible in others (European Commission, 2021). patients and physicians (Halmdienst et al., 2022).
There has also been much debate about the choice to
‘opt-out’ or to explicitly ‘opt-in’ to maintain sharing of con- Theoretical background and research
fidential information on the national database (Powell
et al., 2006). ‘Opt-in’ is the process used when positive
questions
action is required to subscribe a patient to an EHR system. A considerable body of literature on EHR usage has been
‘Opt-out’, on the other hand, means that each patient published, from both patients’ and physicians’ perspectives
receives a login to the EHR system, and individuals have to (e.g. Ancker et al., 2015; Powell, 2017), with a broad range
take action on their own if they want to withdraw from the of facilitators highlighted, such as digital literacy (Alanazi
EHR system. Both systems differ with regard to the level of et al., 2020), and education and training as a primary facili-
informed consent. An ‘opt-in’ system makes it more likely tator (Mold et al., 2015). Furthermore, a high level of usabil-
that individuals have given their explicit consent to create ity of the system (Zarcadoolas et al., 2013) and compliance
an EHR (Pearce and Bainbridge, 2014 cited by Torrens and with security requirements, integration and sharing of EHR
Walker, 2017). The default setting of an ‘opt-out’ system is (Rezaeibagha et al., 2015) have been shown to foster usage
characterised by presumed consent, which can expose indi- for patients as well as for physicians. In contrast, several
viduals to greater risks of harm related to EHR use. In barriers for patients have also been found, including a lack
Australia, a country that switched from an ‘opt-in’ system of PU for the EHR system (Cowell, 2002), or a negative
to the present ‘opt-out’, patients have additional strength- attitude or simply no interest towards new technologies
ened privacy protections guaranteed (Torrens and Walker, (Honeyman et al., 2005). In particular, two studies among
2017). Austria is another example of an ‘opt-out’ system, as physicians conducted in 2016 and 2021 revealed that the
EHR is automatically created for each Austrian inhabitant. majority of physicians surveyed had already experienced a
However, the principals (Federal, state and local govern- fear of EHR-related administrative burden, increased work-
ments), who established the EHR system ‘ELGA’ (the load, as well as feeling uncomfortable with regard to a pos-
German term for ‘EHR’) in 2009, have faced resistance sible surveillance without benefiting from using EHR in
from patients, with fewer than 10,000 EHR system accesses their day-to-day practice (Jamoom et al., 2016; Rahal et al.,
counted per month (ELGA GmbH, 2021). 2021).
Historically, physicians have been the specific gatekeep- However, too little attention has been paid to taking a
ers in their role of facilitating access for patients to special- holistic view of the entire EHR usage process, which ini-
ised care (Brooks et al., 2013). Lauckner and Whitten tially begins with awareness raising, then proceeds to adop-
(2016) demonstrated that physicians were the most essen- tion, followed by usage, and the evaluation of the final
tial gatekeepers for telemedicine. Physician engagement consequences of EHR usage (Larsen, 2003). The core ele-
has also been identified as both the enabler to increase ment of a holistic approach is to understand all aspects of
innovation adoption and the greatest potential barrier to be patients’ and physicians’ needs: psychological, physical as
overcome to expand innovation services. In addition, a well as social (Crameri et al., 2022). In terms of EHR, a
broad literature base exists in other scientific domains (e.g. holistic understanding could help to encourage EHR usage
marketing), which have studied innovation adoption from on a broader scale (Smith et al., 2020; Strandberg et al.,
the patients’ perspective (i.e. Smith et al., 2020). 2007). For this study, the ‘adoption’ step has been replaced
With regard to the range of theoretical foundations with ‘willingness to use’, as we believe this term is a better
applied in EHR studies, the most widespread are ‘technol- match for this stage and more meaningful within the con-
ogy acceptance’ approaches (e.g. Cherif et al., 2021). Most text of EHR usage.
popular is the original ‘Technology Acceptance Model’ As the first step in our research, we undertook a system-
(TAM) developed by Davis (1985), which conceptualises atic literature review from the patients’ perspective
perceived ease of use and perceived usefulness (PU) as (Griesser and Bidmon, 2023). The current approach takes
central antecedents of technology acceptance (Davis, this a step further and aims to develop in-depth knowledge
2005). Since then, several extensions of the original TAM on barriers and facilitators of both patients’ and physicians’
have been developed, such as the Unified Theory of EHR usage. Furthermore, it is imperative to focus on the
Acceptance and Use of Technology (UTAUT) (Venkatesh physicians’ perspective to emphasise the relevance of a
et al., 2003). The more sophisticated version of the TAM, possible gatekeepers’ role in the acceptance of EHR usage.
UTAUT2 (Venkatesh et al., 2012) has led to a proposal for In this study, the following general research questions were
a multilevel framework of technology acceptance and use explored: (1) what facilitators do patients and physicians
(Venkatesh et al., 2016). However, Tamilmani et al. (2021) perceive regarding EHR in each step of EHR usage? and
Griesser and Bidmon 3

(2) what barriers do patients and physicians perceive After summarising and labelling key issues as codes across
regarding EHR in each step of EHR usage? all transcripts, the codes were sorted into main and subcat-
egories. The software ‘MAXQDA’ was used as a supporting
tool for data analysis. In addition, one transcript of the focus
Method
groups was reviewed independently by the first author and
Study 1 one bachelor’s degree student looked for discrepancies and
the level of agreement. Discrepancies were solved by dis-
In this study, a qualitative exploratory design using focus cussion between the two authors and the bachelor’s degree
group discussions was chosen. Four groups, homogeneous student.
with regard to user experience and age, were drawn from Thus, the current approach investigated in-depth knowl-
N = 30 participants: experienced users included seven par- edge on barriers and facilitators of patients’ and physicians’
ticipants ⩽45 years old and nine aged >45 years; and non- EHR usage along the entire usage process: from the first
users included seven participants ⩽45 years old and seven moment of awareness, to willingness to use and the existing
aged >45 years. Characteristics of the patient participants user experience. In addition, physicians could be identified
are shown in Table 1. A semi-structured, pilot-tested inter- as EHR gatekeepers that could set the process in motion:
view guideline was used. Focus groups were conducted in
September and October 2021, producing total 262 minutes
of comments, which were transcribed verbatim and ana- Step 0: Facilitators and barriers related to physicians as
lysed (average: 60 minutes). For those groups without user EHR gatekeepers
experience, a brief introduction to the Austrian version of Step 1: Facilitators and barriers of awareness of EHR
the EHR platform was given.
Step 2: Facilitators and barriers of willingness to use
EHR
Study 2
Step 3: Facilitators and barriers of usage experience
To investigate the barriers and facilitators faced by physicians with EHR
in Austria, another qualitative research setting was applied.
Eight physicians were recruited for this study, with partici- Ethics approval. Group discussions and expert interviews
pant characteristics shown in Table 2. Primary data were received prior approval from the authors’ university ethics
gathered through eight semi-structured interviews, producing committee (Institutional Review Board for Research Ethics
a total of 216 minutes. The interviews were performed from at the University of Klagenfurt (ER-AAU); ID: 2022-001
February to March 2022 and were held in German (i.e. the & ID: 2021-039). Informed written consent was obtained
native language of the target group of the respondents). from all individual participants included in the study.

Design of the study. Study 1 aimed to analyse the patient

perspective using focus group discussions, while Study 2 Results
examined the physician’s perspective. All participants Sample description (Studies 1 and 2)
were recruited using purposive sampling (see, e.g. Ninaus
et al., 2015). By taking a segmentation perspective, we For Study 1, we decided to differentiate between the two
differentiated between patients’ EHR usage experience, target groups of patients with or without EHR usage expe-
gender, age and educational background and physicians’ rience. Table 1 reveals the sample description separated
gender, age, medical specialty and setting. All collected according to the subgroups of EHR users. For Study 2,
data during the research process underwent a translation eight in-depth interviews with physicians were conducted.
process to ensure rigour in translation. The method Participant details are provided in Table 2. Barriers and
included transcribing verbatim in the original language in facilitators were identified on the macro-level of the
which data were collected, using an English native speaker healthcare system, the meso-level of the EHR system, and
who was linguistically competent and culturally sensitive the micro-level on the personal level. In all, 16 barriers
in both languages and moving back and forth between raw and facilitators were synthesised (see Figure 1). Findings
and translated data to guarantee consistency (Mohamad in Figure 1 from the patient’s perspective are marked in
et al., 2020). blue and the physician’s perspective are in orange. In the
case of a consistent view of patients’ and physicians’ per-
Data analysis. Following the procedure of qualitative con- spectives, the coloration is orange and blue.
tent analysis as proposed by Mayring and Fenzl (2014), the
first author read the transcripts several times. During the Step 0: Facilitators and barriers
analysis, the main topics were identified deductively related to physicians as EHR
(approaching the data with some preconceived themes based
on existing literature), as well as inductively (allowing the
gatekeepers
data to determine the categories), with subsumption of cat- Eight factors related to the role played by physicians with
egories or formulating new categories. After several feed- regard to EHR usage were identified. The physicians
back loops, a revision of categories was prepared, with a seemed to have a gatekeeping role and they determined
formative check of reliability and a final coding system. whether patients entered the process stages of EHR usage.
4 Health Information Management Journal 00(0)

Table 1. Description of patients participating in the focus groups according to subgroups: Discussion groups of EHR users
(Groups 1 and 2) versus non-users (Groups 3 and 4).

Group 1: EHR users aged up to 45 years Group 2: EHR users aged 46 years and above
ID Gender Age Highest level EHR usage ID Gender Age Highest level EHR usage
of education experience in years of education experience in years
U1 Female 29 University 2 (2019) U8 Male 52 High school 6 (2015)
U2 Male 30 University < 1 (2021) U9 Male 47 High school 1 (2020)
U3 Female 33 University 3 (2018) U10 Male 70 High school 7 (2014)
U4 Female 25 University 3 (2018) U11 Male 53 University 2 (2019)
U5 Female 26 University < 1 (2021) U12 Male 61 University 6 (2015)
U6 Female 29 High school 6 (2015) U13 Male 55 University < 1 (2021)
U7 Male 26 High school < 1 (2021) U14 Female 46 University 2 (2019)
U15 Female 57 High school 7 (2014)
U16 Male 47 University 6 (2015)

Group 3: EHR non-users aged up to 45 years Group 4: EHR non-users aged 46 years and above

ID Gender Age Highest level EHR usage ID Gender Age Highest level EHR usage
of education experience in years of education experience in years
N1 Male 35 University None N8 Male 55 University None
N2 Female 29 University None N9 Male 54 University None
N3 Female 23 University None N10 Male 68 University None
N4 Female 27 University None N11 Female 50 High school None
N5 Male 25 University None N12 Female 46 University None
N6 Male 21 High school None N13 Male 52 High school None
N7 Female 29 University None N14 Male 61 High school None

EHR: electronic health records.

Table 2. Description of physicians participating in the expert interviews.

ID Gender Age Medical specialty Setting

Doc1 Male 46 General medicine and orthopaedics Outpatient
Doc2 Male 37 General medicine Outpatient
Doc3 Female 54 General medicine Inpatient
Doc4 Female 36 Paediatrics Inpatient
Doc5 Female 36 General medicine Outpatient
Doc6 Male 56 Anaesthesiology and ELGA representative Inpatient
Doc7 Male 54 Psychiatry Inpatient and outpatient
Doc8 Female 30 Neurosurgical Inpatient

If physicians expressed a negative attitude towards EHR, relationship between the costs and benefits of the EHR
patients might not even enter Step 1 of EHR usage. system:

The benefits of products like ELGA can be immense (i.e.,

Patient perspective creating medical reports using text modules or automatic
Networking with and between physicians. High perceived value speech recognition), but you have to be able to fully exploit
for networking with and between physicians in a treatment pro- them . . . I have to honestly admit that our medical practice
cess emerged as a facilitating factor. However, the lack of inter- exploits 20–25% of what the product can do. (Doc1,
operability of systems presented as a substantial hurdle: ‘The male, 46)
inconsistency I see is that hospitals work with several systems,
which means there can never be a baseline’ (U11, male, 53). Differences compared to the time before EHR sys-
tems. Finally, from the physicians’ perspective, there had
Physician perspective been no noticeable differences since the introduction of the
EHR system. Minimal visible changes were nevertheless
Cost–benefit analysis of EHR. At the meso-level, from the noticeable: ‘Quite banal, there is simply less paper’ (Doc4,
physicians’ point of view, there was currently no balanced female, 36).
Griesser and Bidmon 5

Figure 1. Code system of deductively and inductively derived categories of facilitators and barriers (blue: patient perspective;
orange: physician perspective; and blue and orange: consistent view).

Patient and physician perspective: Consistent information base for patients: ‘Exactly, it’s the physicians
views in relation to EHR themselves. The patients trust them and if it works at the
grassroots level, it gets transported upwards. This is an
Previous contact points. Patients noted that previous contact opportunity that should be used!’ (U6, female, 29).
points for EHR were predominantly negative, since general The physicians’ view regarding the gatekeeper role here
physicians communicated negatively about EHR. They is somewhat different and calls for a clear boundary
also remembered flyers in the waiting rooms: ‘I can only between medical and technical educational work: ‘Yes, I
remember one visit to my physician, and there were posters am a person of trust and also a gatekeeper but in medical
et cetera “Get out of ELGA”)’ (N1, male, 35). terms in a treatment process’ (Doc1, male, 46). The experts
Physicians expressed that previous contact points with saw the technical introduction and explanation for the use
patients in relation to EHR were relatively neutral, since of the system as being the responsibility of a higher
most patients seemed to be unaware of the rollout plan and authority.
its steps or the ‘opt-out’ procedure of the EHR system in
Austria: ‘First of all, most patients don’t even know that Attitude towards EHR of patients and physicians. From the
they are registered in the system and have to actively opt- patients’ perspective, a negative attitude and behaviour of
out. For my practice, I can speak of 90–95% who have no physicians towards EHR was reasonable and attributed to
idea about the conditions of participation’ (Doc1, male, 46). perceived customer competition between physicians: ‘Per-
sonally, I could also think of it as “job security” because my
Physicians as EHR gatekeeper. The physicians’ role as gate- physician has the exact information on my health data and
keepers of EHR usage was classified as that of a facilitator therefore I am “bound” to him’ (N9, male, 54), and an
who motivated and influenced patients: ‘I see the general increased effort for financing of and training on systems.
practitioners as the best option to convince patients’ (U1, Attitudes towards the EHR system varied for both
female, 29), who could make patients more aware of EHR. younger and older colleagues. Digital affinity seemed to
In addition, the general physicians act as a low-threshold foster a positive attitude towards EHR usage:
6 Health Information Management Journal 00(0)

My partner in the group practice is 64 years old and both handling the opportunity to opt out of the system. For
motivated and digitally literate. He believes that the medical example, ‘I find it interesting that we are all automatically
practice needs a qualitative system (ELGA), but only because enrolled in the EHR system, and you have to go through the
he has familiarised himself with it (he does his own research registration process before you are allowed to opt out’ (N2,
and online training) and also because he is convinced of its
female, 29).
benefits. (Doc1, male, 46)
Challenging or motivating points of contact. Some patients
Privacy and security concerns of EHR. Bearing in mind the also perceived the previous contact points with EHR as
sensitivity of the exchanged data, patients found that pri- more challenging than motivating (i.e. requiring digital
vacy and security throughout the entire EHR usage process competencies, lacking assistance). Both users and non-
had to be comprehensively guaranteed: ‘You can’t afford to users referred to this experience as a challenge: ‘Exactly,
make mistakes at such a level where you work with sensi- that is the main problem. Nobody is digitally aware, but
tive data, so I trust the system’ (N11, female, 50). there’s no help available anywhere’ (U2, male, 30).
However, experts in the physicians’ segment viewed
patients’ privacy and security concerns rather critically, as,
in their view, data exchange and networking happen with- Patient and physician perspective: Consistent
out problems in many other realms of everyday life: views in relation to EHR
We should consider the things we do on a daily basis (points to Attitude towards EHR of patients and physicians. The attitude
the AppleWatch, social media). Payment via mBanking, towards EHR as an influencing factor for experts with low
shopping via AmazonPrime, sports via calorie tracking, et usage experience occurred mainly in a negative context: ‘I
cetera, but as soon as it comes to ELGA, they don’t want that. don’t see the EHR system as an advantage for the patient any-
(Doc5, female, 36) way, but rather for the healthcare system’ (Doc8, female, 30).

Furthermore, experts did not report increased competi- Information and EHR strategy. Finally, the most important
tion among colleagues through the existence of EHR sys- inhibitor of awareness to use EHR on the personal level
tems, as competition exists with and without the EHR was a lack of information strategies for both target groups.
system: ‘No, because it has nothing to do with ELGA, The information available on EHR was perceived as insuf-
whether you read and theoretically criticise the diagnosis in ficient, as was mentioned by users and non-users in the
digital or in physical form’ (Doc1, male, 46). patient segment as well as by physicians: ‘The biggest area
is undoubtedly the information gap that exists. Patients do
Data sharing of EHR. On the macro-level, one issue emerged: not know what an EHR system is, what advantages it brings
data sharing. Data can be accessed regardless of time and or what to do with it’ (N3, female, 23). Provision of infor-
place in critical medical situations, which was seen as posi- mation was viewed as insufficient from both the patients’
tive. Moreover, there was uncertainty about which physi- and the physicians’ perspectives.
cian actually accessed one’s data, when and how: ‘Does
everyone see everything about me, or do I actually know
Step 2: Facilitators and barriers of
who is allowed to read what?’ (U12, male, 61).
From the experts’ point of view, the procedures and willingness to use EHR
responsibilities for data sharing in an EHR system are not Patient and physician perspective: Consistent
clearly defined: ‘There is also no standardised procedure here
views in relation to EHR
as to what has to be recorded in ELGA? Is it enough to record
a diagnosis? Or should the medication be entered? Who Information and EHR strategy. In Step 2 (willingness to use
decides/regulates this? Currently, no one’ (Doc7, male, 54). EHR), the views of patients and physicians were similar, as
both felt poorly informed about EHR in general. One criti-
cal and omnipresent theme was the fear that EHR usage
Step 1: Facilitators and barriers of would be mandatory in the future for both patients and phy-
awareness of EHR sicians. However, physicians did not currently see them-
If the physician has successfully acted as a gatekeeper in selves as being able to utilise an EHR system fully: ‘How
Step 0, the patient might enter the first awareness stage of can I explain the EHR to a patient if I have no idea about
EHR. In this phase, in Studies 1 and 2, facilitators and bar- the concept myself?’ (Doc3, female, 54).
riers could be identified without exception at the personal
level (micro-level) from both perspectives. Step 3: Facilitators and barriers of
usage experience with EHR
Patient perspective In summary, three facilitators and inhibitors were identi-
Personal view of EHR. The personal view of EHR was iden- fied in the area of user experience on the micro-level. The
tified as the holistic collection of all personal health data in same three factors were mentioned on the meso-level of
electronic form. Patients without usage experience men- the EHR system: usability, technical necessity and addi-
tioned that EHR portals are troublesome when it comes to tional features.
Griesser and Bidmon 7

Patient perspective Additional features of EHR systems. Another reoccurring

theme was thinking about future possible additional fea-
Usability of EHR. The usability of collecting, saving and tures of the EHR system that would lead to a higher usage
administrating EHR was perceived as a considerable bar- rate. For example: ‘An example would be the constant
rier and challenging, as mentioned by users as well as non- communication of current information on diseases, with
users, who received initial training on the login process symptoms, and treatments, et cetera’ (N1, male, 35).
and use of the EHR system at the beginning of the focus
group discussions: ‘The login-procedure, with path and
various links and shortcuts, is much too complicated’ (N7, Discussion
female, 29). The contribution of the present study is three-fold. First,
from a public health perspective, it contributes to a better
Physician perspective understanding of the differing perspectives of patients and
physicians with regard to facilitators and barriers of EHR
(Non-)Usefulness of EHR. There was a broad range of opin- usage. Second, distinct facilitators and barriers could be
ion with regard to the usefulness of EHR. Some physicians identified in different stages of the entire EHR usage pro-
were not convinced of its usefulness: ‘Even in an emer- cess (from awareness raising, to willingness to use and the
gency, primary care must function without an EHR sys- existing user experience, underlined by the physicians’ role
tem’ (Doc8, female, 30), whereas in contrast, others found as EHR gatekeeper). Third, the themes emerged on three
EHR helpful in some respects: ‘For me, the medical aspect different levels: the micro-level (individual level), the
is in the foreground, avoiding unnecessary multiple treat- meso-level (level of the EHR system) and the macro-level
ments, such as medication or procedures (X-rays)’ (Doc4, (level of the health system). Most themes discussed focused
female, 36). on the micro-level. A lack of awareness, as well as a lack of
knowledge about EHR, was seen as the main barrier.
Patient and physician perspective: Consistent Greenhalgh (2008) explained that patients’ awareness
views in relation to EHR impacts on the way they perceive and process information
as well as on their behaviours. In addition, most patients in
EHR literacy. A new theme, termed ‘EHR literacy’ by the this study were unaware of the opt-out scheme in the
authors, emerged inductively. It refers to the specific com- Austrian EHR system, which allows patients to restrict
petency necessary to be able to manage and use EHR effec- their health information or fully opt out of the programme
tively. High perceived EHR literacy could be classified as a (ELGA GmbH, 2021). This discrepancy highlights the
facilitator of EHR usage. On the other hand, particularly in complexity of the EHR system and indicates the existence
relation to the population of older people, low EHR literacy of barriers that hinder patients from actively using EHR.
can impede effective EHR usage and negatively influence Interestingly, this fact was not detected in the previous
the treatment process with health providers: ‘It takes an literature.
immense amount of effort when a patient who is not digi- EHR literacy was identified as a necessary prerequisite
tally literate comes to see me at the clinic’ (Doc1, male, to handle the complex, though classified as secure, login
46). Without the support of others (e.g. family members, procedure and to be able to navigate its features. Torrens
friends, health professional (colleagues)), patients might be and Walker (2017) emphasised the importance of empow-
limited in their options to use the EHR system. ering patients of all ages to manage their EHR, ensuring
that special population groups, such as older people, are
Information and EHR strategy. Building on the previously consistently represented. These findings broadly support
mentioned obstacles with regard to limited knowledge of findings in previous studies, namely that digital competen-
EHR, one of the factors dealt with possible mediated infor- cies and applying the knowledge gained can help patients
mation strategies on a personal level: ‘Nowadays, it makes better understand medical conditions and treatment plans,
sense to use all the channels you have to achieve a broader make informed decisions and take proper action (Chen and
distribution’ (N11, female, 50). Decary, 2019). To realise these advantages, widespread
Physicians have provided some current examples to acceptance and use of EHR by healthcare actors are
achieve improved information strategies for EHR sys- required (Hanna et al., 2017).
tems. For instance, the open discussions on television The identified facilitators and barriers were assigned to
during the first peak of the COVID-19 pandemic in 2020 different phases of the EHR usage process. Strongly
in Austria were described as valuable: ‘access require- reported in the first phase of (1) awareness were facilita-
ments and privacy terms from the EHR system’ (Doc5, tors, such as sufficient and continuous information and
female, 36). training for all health actors in a treatment process (i.e.
patient, physicians). In line with previous findings about
Technical necessity for use of EHR. Similarly, the technical the importance of ensuring the handling with EHR,
necessity for secure access and a transparent EHR usage improved patients’ and physicians’ (Henry, 2006) aware-
process was perceived as indispensable: ‘Especially for ness of EHR is critical before an applied system is recom-
EHR systems, which handle sensitive data, a “strict” entry mended (Mossaed et al., 2015). With the help of measures
must be mandatory’ (U12, male, 61). through various communication channels, EHR can be
8 Health Information Management Journal 00(0)

made more appropriate (Riordan et al., 2015). Furthermore, Limitations and implications for future research
self-initiative and step-by-step self-learning from the sys-
tem are the basis for mastering EHR. However, negative This research had some limitations. Focus group participants
experiences with contact points during the first step were distributed disproportionally with regard to gender and
impeded further willingness to use EHR (Goel et al., 2011). educational background, which may have reduced the gener-
The lack of communication strategies targeted to health alisability of results. Nonetheless, the research has high-
actors (i.e. younger and older patients, patients and physi- lighted promising areas for further study, with this study
cians) seems to prevent people from engaging in EHR providing the first step towards a deeper understanding of
usage. The information situation of EHR relates not only to facilitators and barriers along the entire EHR usage contin-
the phase of (2) willingness to use, but also to (3) the usage uum. However, our results should be confirmed with a larger
experience prior to information strategies. This finding is and more representative sample reflecting the diversity of the
consistent with other studies, which emphasise that patients Austrian healthcare system. In countries with similar health-
feel uninformed about EHR (Riordan et al., 2015). A future care systems, our research could serve as an anchor for a simi-
factor ‘additional features’ (i.e. check-up reminder, news of lar holistic view. It could also be interesting to analyse our
current health information, side effects of medication) in coding system with subsections of the EHR system, such as
the EHR system, to maximise patients’ and physicians’ the Digital COVID Certificate, created by the government.
intention to use, could be identified to streamline manage-
ment of health information in this study. Murphy et al. Conclusion
(2019) and Guo et al. (2017) identified suboptimal design
features and workflows as reasons for not using EHR. This study has provided a holistic understanding of patients’
General physicians or other physicians were specified as and physicians’ views of the facilitators and barriers during the
a kind of gatekeepers for EHR usage from the patients’ per- entire EHR usage process. In particular, we have highlighted
spective. It is well known that general practitioners act as the critical function of physicians as gatekeepers who played a
‘gatekeepers’ in their role of offering patients access to spe- key role in the use of EHR by their patient base. Results
cialised care in direct-access systems (Whitten and showed that patients’ awareness and knowledge of the Austrian
Kuwahara, 2004; Yellowlees et al., 2018). The gatekeeper is EHR system mitigated their EHR usage due to a lack of effec-
defined as the ‘individual of first contact, who controls the tive communication at the interpersonal, interactive and mass
flow of information to others within the company’ (Lau media levels (i.e. login procedure, opt-out scheme).
et al., 2003, cited by Bierma and Waterstraat, 2008: 697). Furthermore, we confirmed that for physicians, perceived
Sripa et al. (2019) could demonstrate that gatekeeping was risks outweighed the benefits of EHR use. Qualitative evi-
on the one hand related to better quality of care, but on the dence from patients and physicians has underlined the impor-
other hand it resulted in fewer hospitalisations. We use the tance of involving all the health actors in the entire EHR usage
term ‘gatekeeper’ in relation to the information delivered on process. Awareness raising leads to willingness to use, which
a new technology similar to the approach taken by Lauckner is further facilitated by actual usage and the beneficial conse-
and Whitten (2016). A broad literature base exists in market- quences of EHR usage. Our study offers new insights that lead
ing referring to innovation adoption (i.e. Bierma and to a more critical elaboration of mediated health communica-
Waterstraat, 2008; Smith et al., 2020). tion, including improved patient and physician usage of EHR.
Physicians participating in our Study 2 do not feel
responsible for the dissemination of the EHR system and Declaration of conflicting interests
assigned the responsibility for the technical introduction of The author(s) declared no potential conflicts of interest with
the system to some kind of higher authority (i.e. the public respect to the research, authorship, and/or publication of this
sector) since basic knowledge is lacking among physicians. article.
Furthermore, from the patients’ perspective, physicians are
seen as responsible for creating comprehensive awareness Funding
(White and Danis, 2013). This facilitating factor regarding The author(s) received no financial support for the research,
EHR usage was not identified clearly earlier. Past studies authorship, and/or publication of this article.
have focused primarily on the medical aspects for the dura-
tion of the treatment period rather than on ‘IT technical’ ORCID iDs
support for patients. Anna Griesser, MA https://orcid.org/0000-0001-8622-0650
Nevertheless, the study findings report that the current Sonja Bidmon, PhD https://orcid.org/0000-0003-1615-2116
physicians’ attitude towards EHR is negative and inhibits
further actions in the usage process (Lakbala and Dindarloo,
Data availability
2014). Furthermore, a certain level of basic knowledge
must be present on the part of the physician to fully exploit The authors confirm that the data supporting the findings of this
the possibilities in dealing with EHR (Voran, 2017). study are available upon request.
To the best of our knowledge, this is the first study that
takes a holistic approach to receive in-depth knowledge on References
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