Jim Tufano

Promoting widespread availability and provider adoption of electronic medical records is a core component of current efforts to reform healthcare in the United States. Initiatives to redesign healthcare to achieve quality improvement, patient access, economic sustainability, and other reforms often seek to leverage the potential of electronic medical records and other information and communication technologies. However, the evidence pertaining to the effectiveness of these technologies in supporting and promoting these objectives is limited, and their adoption among healthcare providers remains low – particularly in primary care and other ambulatory care settings. Given both the questionable sustainability of primary care and its central role in current healthcare reform initiatives, there is a critical need to inform these endeavors with empirically - derived knowledge of how information and communication technologies affect healthcare providers and their efforts to redesign care to better meet the needs of their patients and communities. This dissertation explores provider perspectives on the roles, importance, and effects (both positive and negative) of healthcare information and communication technologies in the context of patient-centered healthcare redesign. Three qualitative observational studies were conducted at Group Health Cooperative, a large integrated healthcare delivery system serving patients throughout the Pacific Northwest. These studies were informed by Donabedian’s framework for evaluating healthcare quality, Rogers’ Diffusion of Innovations Theory, and the Tavistock Institute’s Sociotechnical Systems Theory.

Findings revealed provider and organizational perspectives on their experiences with implementing and using a commercial clinical information system (EpicCare Ambulatory EMR) with an integrated patient Web portal, patient-provider email, internal clinical messaging, an internally-developed online health risk assessment application, and other information and communication technologies. Participants expressed sharply contrasting perspectives on the same technologies viewed as components of two unique practice redesign initiatives – an organization-wide redesign of operations to implement Patient-Centered Access, and a single clinic redesign to implement the Patient-Centered Medical Home model. These findings suggested that contextual factors such as the care redesign methods and the care models used to guide care redesign are key determinants of the effects associated with the implementation and use of these technologies. This dissertation contributes to the literature on sociotechnical approaches to technology-enabled healthcare redesign and evaluation by describing how instances of these different care redesign models incorporated the various technologies, and by evaluating providers’ perspectives on their roles, importance, and effects.