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Examining the adoption of electronic health records system in patient care and students’ education using the GAP analysis approach

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Examining the adoption of electronic health records system in patient care and students’ education using the GAP analysis approach

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Content Running Head: EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 1

EXAMINING THE ADOPTION OF ELECTRONIC HEALTH RECORDS SYSTEM IN
PATIENT CARE AND STUDENTS’ EDUCATION USING THE GAP ANALYSIS
APPROACH

by

Nkemjika A. Ukeje

A Dissertation Presented to the
FACTULY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2018

Copyright 2018 Nkemjika A. Ukeje

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 2

Acknowledgements
First and foremost, I would like to thank my God, with whom all things are possible. I
thank Him for his grace, guidance, and protection through this process. I would also like to
thank:
My lovely daughter, Somkene Okwuego “DaQueen,” you are truly my queen. Your love
and support kept me going. Your patience with me as you constantly waited for my class to be
over, so we could go home, get fed, and so forth. Your understanding that we couldn’t do all we
used to do together because of my school . . . Thank you for your selfless love.
My parents, Dr. and late Barrister (Mrs.) Ukeje. Mommy, I know you are gone but you
still live in my heart. I will never forget the day you left us (01/10/2018). On that sick bed, you
approved the start of my doctorate degree journey. I wrote all the required essays at the
rehabilitation center where I kept you company. I love you mom and I sincerely miss you.
Daddy, your love and support through this program is held very dear to me. Every time I spoke
with you, you continually asked me how the program was getting along. Thank you for the
continuous follow-up.
My siblings, Dr. Chilo Obianwu (my sister and friend in crime) – thank you for always
offering your house to me and my daughter every Christmas break. Taking care of my daughter
made it possible for me to finish this program in time. You knew every step I took. Money is
not enough to pay you for your support and helpfulness. Because of your love, your husband,
Sir. Tony Obianwu and children, Akosa and Adaeze Obianwu gave all their support as well. I
remember Akosa always telling me that he is so proud of me. He doesn’t know it, but I
appreciated all those words. Dr. Dinobi Nwosu, Eloche Ukeje (Attorney at law), Dr. Malibe
Ukeje, and Engr. Kene Ukeje; I love you all immensely. Engr. Chidi Ugwueze, my elder
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 3

brother, thank you ever so much for your constant support; Somkene and I appreciate and love
you!
Aunty Jane, I love you dearly. Thank you for always calling to see how Somkene and I
were doing even when I didn’t return the calls, you still understood.
Dr. Yates, without you, there will be no graduation for me. You are the most patient
instructor I have ever met. I know I had asked you on multiple occasions how you do what you
do. You hand held me throughout the process even when I was about to give up, you made it
seem so easy that sometimes I wondered how those who didn’t have you survived.
Dr. Sundt, you are so detailed, and I appreciated that so much. You taught me to look
twice and re-read my sentences. Your guidance was impeccable.
Dr. Navazesh . . . I don’t even know where to begin. You’re my role model. The day
you said you would be a member of my dissertation group, said it all to me. Even with your
busy life, you kept on following up with me. I don’t know how to thank you enough. I am
extremely grateful.
Dean Sadan, your support saw me through. I remember you saying, “you have no excuse
not to finish,” your voice kept me going. I knew I had to finish. Thank you for always asking
how it was going.
My family members; those closer than friends, cousins, in-laws, nieces and nephews,
aunts and uncles, without you, this would not be possible. My support groups, friends, well-
wishers, colleagues, you all made this happen. I would have wanted to list all the names but if I
start, the list will go on forever. I appreciate all the calls, accepted all my excuses, lateness,
forgetfulness, and so forth. I love you all dearly!
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 4

Table of Contents
List of Tables 9
List of Figures 11
Abstract 12
Chapter One: Introduction 13
Introduction of the Problem of Practice 13
Organizational Context and Mission 14
Organizational Performance Status 16
Related Literature 16
Importance of Addressing the Problem 17
Organizational Performance Goal 18
Description of Stakeholder Groups 18
Stakeholder Group for the Study 20
Purpose of the Project and Questions 21
Conceptual and Methodological Framework 22
Definitions 22
Organization of the Proposal 23
Chapter Two: Review of the Literature 24
Introduction 24
Conceptual Framework 24
Stakeholder Knowledge, Motivation and Organizational Factors 25
Knowledge and Skills 25
Declarative Factual Knowledge Influences 25
Conceptual Knowledge Influences 27
Procedural Knowledge Influences 30
Metacognitive Knowledge 31
Motivation 34
Value 35
Self-efficacy 37
Mood 39
Attribution 40
Organization 43
Resources 44
Policies and Procedures 46
Cultural Setting 47
Cultural Models 48
Summary 53
Chapter Three: Methodology 54
Purpose of the Project and Questions 54
Conceptual and Methodological Framework 54
Assessment of Performance Influences 56
Knowledge Assessment 56
Motivation Assessment 63
Organization/Culture/Context Assessment 70
Participating Stakeholders and Sample Selection 78
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 5

Sample 78
Recruitment 79
Instrumentation 79
Survey 80
Knowledge and Skills 80
Motivation 80
Organization 81
Interview Protocol 81
Observation Protocol 82
Document Analysis Protocol 82
Data Collection 83
Surveys 83
Interviews 84
Observations 84
Document Analysis 84
Data Analysis 85
Surveys 85
Interviews 85
Observations 86
Documents 86
Trustworthiness of Data 87
Role of Investigation 87
Limitations 88
Chapter Four: Results and Findings 89
Participating Stakeholders 90
Data Validation 90
Criteria for Validation of the Data 91
Survey 91
Interviews 92
Observations 92
Document Review 92
Results and Findings for Knowledge Causes 93
Factual Knowledge 93
Assumed Knowledge Influence #1: Faculty
Members Need to Know What Electronic
Health Records Systems are 93
Assumed Knowledge Influence #2: Faculty
Members Need to Know where the
Whiteboard is Located 95
Assumed Knowledge Influence #3: Faculty
Members Need to Know the Goal of the
Electronic Health Records System
Implementation 97
Conceptual Knowledge 98
Assumed Knowledge Influence #4: Faculty
Members Need to Know the Purpose
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 6

of the Whiteboard 98
Assumed Knowledge Influence #5: Faculty
Members Need to Know the Purpose of
Electronic Health Records Systems 100
Assumed Knowledge Influence #6: Faculty
Members Need to Know the Relationship
between Electronic Health Records System
and the Whiteboard 102
Assumed Knowledge Influence #7: Faculty
Members Need to Know How Their Use
of EHRS Measures Up to the Goal of
the School 104
Procedural Knowledge 105
Assumed Knowledge Influence #8: Faculty
Members Need to Know How to Review
Students’ Documented Patient Treatment
Code Electronically 105
Assumed Knowledge Influence #9: Faculty
Members Need to Know How to Correctly
Enter Notes in the EHRS 108
Assumed Knowledge Influence #10: Faculty
Members Need to Know How to Approve
and Assign Grades to the Students’
Completed Work 109
Metacognitive Knowledge 111
Assumed Knowledge Influence #11: Faculty
Members Need to Know How to Reflect on
Their Utilization of the EHR System 111
Results and Findings for Motivation Causes 112
Value 112
Assumed Motivation Influence #1: Faculty Needs
to Value Their Use of the Electronic Health
Records System in Patient Care and Students’
Education 112
Self-efficacy 116
Assumed Motivation Influence #2: Faculty
Members Need to Have Confidence That
They Can Use the Electronic Health Record
System to Document Patient Care, in
Reviewing Student’s Documented Patient
Treatment Code and Notes Electronically
on the Computer, and in Following
the Steps in Using the EHR System 116
Mood 119

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 7

Assumed Motivation Influence #3: Faculty Need to
Feel Positive Using the Electronic Health
Records System in: Correctly Entering
Patient Data and Notes, Reviewing Students’
Documented Patient Treatment Code and
Notes Electronically on the Computer,
Following the Steps on Using the EHR
System, Using EHRS for Recommending
Next Steps in Patient Care to the students,
and Electronically Approving and Assigning
Grades to Students’ Completed Work 119
Attribution 122
Assumed Motivation Influence #4: Faculty
Members Need to Attribute the Success of
the Electronic Health Records System to
Their Efforts to Use it and They Need to
Believe that Using the EHRS is Important
for Patient Care and Students’ Education 122
Results and Findings for Organizational Barriers 124
Resources 124
Assumed Organizational Influence #1: Faculty
Members Need Resources to Successfully
Implement the Electronic Health Records
System, Such as Swipers, Signature Pads,
and So Forth 124
Policies and Procedures 127
Assumed Organization Influence #2: Faculty
Need to Have Policies That Align with Their
Goal to Use the Electronic Health Records
System All the Time 127
Culture 129
Assumed Organization Influence #3: Faculty Need
to be Part of a Culture That Aligns with the
Organizational Goal of 100% Use of the
Electronic Health Records System 129
Summary of Validated Influences 132
Knowledge and Skills 132
Motivation 134
Organization 134
Chapter Five: Recommendations and Evaluation 136
Purpose of the Project and Questions 136
Recommendations to Address Knowledge, Motivation, and
Organization Influences 136
Knowledge Recommendations 137
Introduction 137
Declarative Knowledge Solutions 139
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 8

Conceptual Knowledge Solutions 140
Procedural Knowledge Solutions 141
Metacognitive Knowledge Solutions 141
Motivation Recommendations 141
Introduction 141
Attribution Solutions 143
Organization Recommendations 144
Introduction 144
Resources Solutions 146
Culture Solutions 147
Policies and Procedures Solutions 149
Summary of Knowledge, Motivation and Organization
Recommendations 150
Integrated Implementation and Evaluation Plan 153
Organizational Purpose, Need, and Expectations 153
Implementation and Evaluation Framework 153
Level 4: Results and Leading Indicators 154
Level 3: Behavior 156
Critical Behaviors 156
Required Drivers 158
Organizational Support 159
Level 2: Learning 161
Learning Goals 161
Program 162
Evaluation of the Components of Learning 163
Level 1: Reaction 164
Evaluation Tools 165
Immediately Following the Program
Implementation 165
Delayed for a Period after the Program
Implementation 166
Data Analysis and Reporting 166
Summary of the Implementation and Evaluation 167
Limitations and Delimitations 169
Recommendations for Future Research 170
Conclusion 170
References 172
Appendix A: Demographics of Predoctoral Faculty Members 179
Appendix B: Immediate Survey after Program Implementation 182
Appendix C: Checklist During Faculty Workshop 183
Appendix D: Delayed Survey after Program Implementation 184
Appendix E: Informed Consent/Information Sheet 185
Appendix F: Recruitment Letter 187

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 9

List of Tables
Table 1: Summary of Stakeholders’ Performance Goals 19

Table 2: Summary of Assumed Knowledge Influences on Faculty’s Ability
to Achieve the Performance Goal 33

Table 3: Summary of Assumed Motivation Influences on Faculty’s Ability
to Achieve the Performance Goal 41

Table 4: Summary of Assumed Organization Influences on Faculty’s Ability
to Achieve the Performance Goal 51

Table 5: Summary of Knowledge Influences and Method of Assessment 57

Table 6: Summary of Motivation Influences and Method of Assessment 64

Table 7: Summary of Organization Influences and Method of Assessment 71

Table 8: Survey Results for Factual Knowledge of Electronic Health
Records System 93

Table 9: Survey Results for Factual Knowledge of Electronic Health
Records System 96

Table 10: Survey Results for Factual Knowledge of Electronic Health
Records System 98

Table 11: Survey Results for Conceptual Knowledge of Electronic Health
Records System 99

Table 12: Survey Results for Conceptual Knowledge of Electronic Health
Records System 101

Table 13: Survey Results for Conceptual Knowledge of Electronic Health
Records System 104

Table 14: Survey Results for Procedural Knowledge of Electronic Health
Records System 106

Table 15: Survey Results for Procedural Knowledge of Electronic Health
Records System 108

Table 16: Survey Results for Procedural Knowledge of Electronic Health
Records System 110

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 10

Table 17: Survey Results for Value Motivation of Electronic Health
Records System 113

Table 18: Survey Results for Self-efficacy Motivation of Electronic Health
Records System 117

Table 19: Survey Results for Mood Motivation of Electronic Health
Records System 121

Table 20: Survey Results for Attribution Motivation of Electronic Health
Records System 123

Table 21: Survey Results for Organizational Resources of Electronic
Health Records System 125

Table 22: Survey Results for Organizational Policies and Procedures of
Electronic Health Records System 128

Table 23: Survey Results for Organizational Policies and Procedures of
Electronic Health Records System 130

Table 24: Summary of Assumed Knowledge Causes Validation 133

Table 25: Summary of Assumed Motivation Causes Validation 134

Table 26: Summary of Assumed Organization Causes Validation 135

Table 27: Summary of Knowledge Influences and Recommendations 137

Table 28: Summary of Motivation Influences and Recommendations 142

Table 29: Summary of Organization Influences and Recommendations 145

Table 30: Summary of Knowledge Gaps Solution Recommendation 150

Table 31: Outcomes, Metrics, and Methods for External and Internal
Outcomes 155

Table 32: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 157

Table 33: Required Drivers to Support Critical Behaviors 158

Table 34: Evaluation of the Components of Learning for the Program 163

Table 35: Components to Measure Reactions to the Program 165
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 11

List of Figures
Figure A: The Sequence of Steps in the Gap Analysis Process 55
Figure B: Dashboard to Monitor the Goal for Fall, 2018 and
Spring, 2019 167

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 12

Abstract
This study examined faculty member’s adoption of electronic health records system in patient
care and in students’ education at ABZ Dental School using the gap analysis improvement model
(Clark & Estes, 2008). The gap analysis model was used as a guide to identify whether
knowledge, motivation, and organization barriers contribute to the faculty’s ability to implement
electronic health records system 100% of the time. The research questions governing this study
asked about the knowledge and skills, motivation, and organizational barriers that prevented the
faculty members of the predoctoral clinic of the ABZ Dental School from utilizing the electronic
health records system 100% of the time. It also examined the knowledge and skills, motivation,
and organizational solutions for faculty members of the predoctoral clinic of the School to use
the electronic health records system 100% of the time. The assumed knowledge, motivation, and
organizational influences that interfered with organizational goal achievement were generated
based on personal knowledge and related literature. These influences were assessed using a
survey, interviews, document analysis, and observations of volunteered predoctoral faculty
members. Forty nine out of 237 predoctoral faculty members participated in the survey, 10 were
interviewed, and eight were observed. Research-based solutions were recommended and
evaluated in a comprehensive manner as discussed in Chapter Five.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 13

CHAPTER ONE: INTRODUCTION
Introduction of the Problem of Practice
Historically, providers used paper records as a documentation tool in health care due to
its nature of simplicity, low implementation cost, and widespread acceptance (Bates, Ebell,
Gotlieb, Zapp, & Mullins, 2003). Research showed that paper records have significant
disadvantages such as availability to only one person at a time, frequent illegibility, and inability
to be accessed remotely or at the time and place where it is needed (Bates et al., 2003).
However, information technology is becoming a vital part of healthcare delivery including the
electronic health records systems (Perry et al., 2014). The electronic health records and the
electronic medical records systems are used interchangeably to refer to computerized medical
and/or health information systems that collect, store, and display patient information (Boonstra &
Broekhuis, 2010). These systems are used to create legible and organized recording as well as to
access clinical patient’s information (Boonstra & Broekhuis, 2010). The American Recovery
and Reinvestment Act of 2009, the Health Information Technology for Economic and Clinical
Health Act (HITECH, 2009) legislation was enacted to promote the adoption of electronic health
records systems and its meaningful use in the United States (HITECH, 2009).
Examining the adoption of electronic health records system in patient care and students’
education are needed as research has shown that learning about computers and applying
computer technology to education and clinical care are key steps in computer literacy for
physicians (Hilty et al., 2006). Faculty and providers widely use digital resources but are
uncomfortable with complete elimination of paper while medical students are shown to use
electronic health records at higher rates than physicians in practice (Hammoud et al., 2012; Latz,
Bolin, Quick, Jones, & Chapman, 2015). This results in recommendation of cautiousness on
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 14

limitation placed on students’ electronic health records documentation which can potentially
affect students training (Hammoud et al., 2012). Evidence demonstrated that partial adoption of
electronic health records system is a problem in the United States as only 14.3% of solo
practitioners and 15.9% of group practitioners use computers to manage all [emphasis added]
patient information (Schleyer et al., 2013). Partial adoption of electronic health records,
therefore, can be defined as not having or utilizing the key functionalities or several technologies
bundled together to realize the potentials of the electronic health records systems (Menachemi,
Ford, Beitsch, & Brooks, 2007).
Organizational Context and Mission
ABZ Dental, a pseudonym, is a year-round urban dental school located in a large urban
area, in the southwestern section of the United States. Since 1897, the ABZ Dental School has,
through challenging clinical education and expert faculty members, shaped talented students into
outstanding dentists and dental hygienists by providing the skills they need to be the best. They
do not only educate and produce excellent clinicians with long-lasting experiences but also
professionals who are dedicated to service and who earn their patients’ trust with solid
commitment to exemplary ethical standards. The ABZ Dental School graduates also earn the
respect of their colleagues by taking active leadership roles in the organized dental community
from local to international levels as they provide care to patients.
The mission of the ABZ Dental School is to offer outstanding dental education as well as
provide comprehensive and compassionate care to patients. The students, faculty, staff, and
alumni are committed to provide oral health services and education to thousands of people in
need internationally as well as locally and at every stage of life. They care for the less fortunate
by not only providing assistance to the vulnerable populations but also an avenue that provides
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 15

the students with valuable clinical experiences and inspires a lasting dedication to service. A
comprehensive lifespan methodology to patient care necessitates collaboration with and referral
to dental and medical specialists. Within the ABZ Dental School are multiple specialty clinics
who work together to provide outstanding care and education. The ABZ Dental School has
approximately 565 faculty members with many program clinics ranging from the predoctoral
clinic; Doctor of Dental Surgery (DDS) and (ASPID) programs, Dental Hygiene (DH) to
Advanced Specialty program clinics including combined Master’s degree programs.
In 2001, the predoctoral program clinic of the ABZ Dental School became one of the
dental school clinics in the nation to adopt a fully learner-centered pedagogy. As stated by
Stukalina (2010), learner-centered pedagogy is the ability of an institution to provide students an
efficient and attractive environment that motivates them to learn. The ABZ Dental School,
through its learner-centered environment, supports students as they work collaboratively in
groups to solve challenging, patient-based problems. The expert faculty members encourage
evidence-based, critical-thinking, and problem-solving strategies which helps students in the
acquisition of knowledge, skills, and values needed to excel in the delivery of comprehensive
oral health care. The predoctoral program enrolls approximately 176 students yearly who are
trained by 237 dental faculty members including full time, part time, and voluntary faculty
members. The predoctoral program clinic has approximately 10 disciplines in which the students
need to go through to be able to meet the required competencies for graduation from the school.
These disciplines range from diagnostics, preventive, restorative, through pediatrics and
orthodontics dentistry. The predoctoral clinic of the ABZ Dental School provides care to
approximately a quarter of a million patients yearly. Students go on rotation to disciplines for
their dental education and patients are referred through disciplines for their dental care. In the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 16

ABZ Dental predoctoral clinic, there are a clinical dean, program chair, clinical administrator,
nine group practice directors, nine group practice treatment coordinators, and schedulers to
mention some of the functionalities that take place for successful student education and effective
care for the patients.
Organizational Performance Status
The organizational performance problem at the root of this study is the lack of
consistency and uniformity with students, staff, and faculty in data entry and in accessing patient
records throughout the predoctoral clinic of the ABZ Dental School. This affects existing
processes and workflows resulting in delays in patients’ treatment and non-standard educational
training for the students. There are 10 disciplines in the predoctoral clinic of the School with two
disciplines fully electronic and eight using some aspects of the system as well as paper charts.
The 250,000 patients seen annually, mentioned above, generate upwards of 200,000 individual
records, the majority of which are not yet electronic. As a result, data flow is delayed especially
in predoctoral clinic disciplines that are not 100% electronic as charts are stored in individual
offices, paper chart rooms, staff drawers or anywhere students, staff, and faculty seem fit. The
lack of a standard place of storage such as the electronic health records system makes it difficult
to access those charts when needed especially during students’ rotational education as students
move from one discipline to another. The lack of a standard storage system also affects patient
care especially when patients are referred from discipline to discipline in the predoctoral clinic or
in an event of an emergency.
Related Literature
Since 2008, Electronic Health Records (EHR) systems has increased more than five-fold
with nearly 59% of practitioners having EHR systems, a 34% increase from 2012 to 2013
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 17

(Charles, Gabriel, & Furukawa, 2013). Higher levels of adoption were found among larger
urban teaching hospitals showing greater availability of financial resources necessary to acquire
EHR systems (Jha et al., 2009). Among hospitals that adopted electronic health records systems,
82% identified improved reimbursement results and 75% identified financial incentives as
factors positively influencing the likelihood of adoption (Jha et al., 2009). Promoting EHR
implementation increase without considering partial adoption scenarios could potentially
threaten the goal of improving clinical outcome, patient safety, and controlling costs which if
poorly implemented could pose challenges and disruption of existing workflow for office staff,
physicians, patients, and concerns regarding students’ education (Hammoud et al., 2012;
Menachemi, Ford, Beitsch, & Brooks, 2007)
Importance of Addressing the Problem
It is important to address this problem because the effect of not adopting electronic health
records system (EHRS) fully affects collaboration between clinics in accessing patient records
and in students’ education which can result in treatment errors and sub-standard students’
education. Survey of medical and surgical patients’ visits to hospitals reported hospitals with no
EHRS at 3.5%, partial EHRS at 55.2%, and full EHRS systems at 41.3% (Yanamadala,
Morrison, Curtin, McDonald, & Hernandez-Boussard, 2016). Additionally, it was noted that
patients at hospitals with full EHRS had the lowest rates of inpatient mortality, readmissions, and
patient safety indicators followed by patients at hospitals with partial EHRS, and then by patients
at the hospitals with no EHRS (Yanamadala et al, 2016). Research cited 78% of physicians with
EHRS reported that EHRS provided improved patient care overall, 81% of them noted that
EHRS helped them access patient’s chart remotely, 65% noted that EHRS alerted them to
potential medical errors, and 62% noted critical lab values (King, Patel, Jamoom, & Furukawa,
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 18

2014). Between 30% and 50% of physicians reported that EHRS use was associated with
clinical benefits that are related to providing recommended care, with ordering appropriate tests,
and with facilitating patient communication (King et al., 2014). To not solve the problem of
partial adoption of electronic health records raises red flags about the eventual widespread
realization of electronic health records’ benefits as the functionalities not being adopted are those
with the greatest potential to improve clinical outcomes, increase patient safety, control costs,
and have consequences on students’ education (Hammoud et al., 2012; Menachemi et al., 2007).
Organizational Performance Goal
By the end of February 2019, the ABZ Dental School will accomplish its goal of using
the electronic health records system 100% of the time in all the disciplines of the predoctoral
clinic of the School. The ABZ Dental School’s goal is derived from the mission of the school
which is to offer outstanding dental education as well as provide comprehensive and
compassionate care to the patients. This goal of 100% electronic has always been a subject of
discussion and proposed plan of implementation by the upper management of the predoctoral
clinic. The achievement of this goal will be measured by the usability of the electronic health
records system in the predoctoral clinic 100% of the time.
Description of Stakeholder Groups
At the ABZ Dental School, the stakeholders include dental faculty members, students,
patients, and administrators including staff members. The dental faculty members teach the
students while utilizing the electronic health records system either for continuation of care
through extracting data, or documenting all activities pertaining to the student education and
patient care. The students use the electronic health records system to document their day-to-day
activities with their patients for self-evaluation, faculty evaluation and approval, completion of
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 19

academic competencies, as well as for patients’ treatment and continuation of care.
Administrators including clinical staff utilize the electronic health records system for their day-
to-day functions which includes patients’ scheduling, billing such as in patients’ payment,
reporting of day’s outcome, work completed, work in progress, scanning patients’ documents
etc. The electronic health records system is used in simplifying the needs of all the stakeholders
as they perform their daily tasks. Table 1 shows the summary of the stakeholders’ performance
goals.
Table 1
Summary of Stakeholders’ Performance Goals
Stakeholders’ Performance Goals
ABZ Dental School Organizational Goal:
By the end of February 2019, ABZ Dental School’s goal is to be 100% electronic in
providing dental education and patient care 100% of the time

Faculty
Predoctoral
Students

Staff

Patients
By November 30,
2018, all faculty
members will review
all students’ entered
patient treatment data
electronically.
By November
30, 2018, all
predoctoral
students will
enter patient
treatment data
electronically.
By November
30, 2018, all staff
members will
verify all patient
treatment history
electronically.
By November 30, 2018,
all patients will complete
their patient treatment
history electronically and
sign the associated
documents electronically.
Critical Behaviors
(Expected faculty
behaviors in EHRS
use):

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 20

Table 1 (Cont’d.)

Faculty
Predoctoral
Students

Staff

Patients
1. Faculty checks
the whiteboard to
know when
needed by the
students.

2. Faculty goes to
student and
reviews student’s
documented
patient treatment
code and notes
electronically on
the computer.

3. Faculty
recommends next
steps in patient
care to student
such as to take X-
rays, fill out
forms, and so
forth.

4. Faculty
electronically
approves and
assigns grade to
student’s
completed work.

Stakeholder Group for the Study
While the joint efforts of all the stakeholders contribute to the achievement of the overall
organizational goal of 100% electronic in providing dental education to the students and
providing dental care to the patients 100% of the time, this study will concentrate on faculty
members being one of the stakeholders. The dental faculty members will be the stakeholder of
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 21

focus as they hold the uppermost role in the ABZ Dental School. The dental faculty members’
roles are not limited to educating students, but also treat patients, research on ways to improve
the dental practice, and manage the whole ABZ Dental School. The faculty members are looked
upon as role models as they drive the processes that occur in the ABZ Dental School. Students,
administrators, and patients depend on faculty decisions to be successful in their various
functions and outcomes. Faculty ability to use the electronic health records system effectively
and efficiently will directly and indirectly inspire all stakeholders to do the same.
The stakeholder goal is that 100% of faculty members will demonstrate hands-on
knowledge of the electronic health records system by reviewing all patient records electronically.
Currently, we assume that 50% or less of faculty members did not follow or supervise all the
steps required to review patient records in the electronic health records system 100% of the time.
More than 75% faculty members reviewing or supervising the transcription of data in the
electronic health records system will show significant improvement towards accomplishing the
desired goal of being 100% electronic in the electronic health records system use 100% of the
time.
Purpose of the Project and Questions
The purpose of this project was to conduct a gap analysis to examine the knowledge,
motivation, and organizational influences that interfere with ABZ Dental School’s goal to be
100% electronic in providing dental education and patient care 100% of the time. The analysis
will begin by generating a list of possible or assumed interfering influences that will be
examined systematically to focus on actual or validated interfering influences. While a complete
gap analysis would focus on all stakeholders, for practical purposes the stakeholder to be focused
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 22

on in this analysis are the predoctoral dental faculty members of ABZ Dental School (the
School).
Thus, the questions for this study are:
1. What are the knowledge and skills, motivation, and organizational barriers that prevent
the faculty members of the predoctoral clinic of the ABZ Dental School from utilizing the
electronic records system 100% of the time?
2. What are the knowledge and skills, motivation, and organizational solutions for faculty
members of the predoctoral clinic of the School to use the electronic health records
system 100% of the time?
Conceptual and Methodological Framework
Clark and Estes (2008) suggested that to close gaps and achieve organizational goals, one
has to first identify the cause of the gap and therefore determine the type of performance
improvement program required to close that gap. As such, a systematic, analytical method that
helps to clarify organizational goals and identify the gap between the actual performance level
and the preferred performance level within an organization will be implemented as the
conceptual framework (Clark and Estes, 2008). Assumed influences in knowledge, motivation,
and organization that interfere with organizational goal achievement will be generated based on
personal knowledge and related literature. These influences were assessed by using surveys,
document analysis, interviews, literature reviews, and observations. Research-based solutions
were recommended and evaluated in a comprehensive manner.
Definitions
• EHR: Electronic Health Records are used as an alternative to paper but recorded in an
electronic format for health-related information
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 23

• EMR: Electronic Medical Records are used as an alternative to paper in electronic format
for medical information
• EHR System: Electronic health records system is used in storing patient information
digitally
• Partial Adoption of EHR Systems: Implementing less than 100% aspects of EHR systems
• Predoctoral faculty: Faculty members who teach students studying to become dentists
Organization of the Proposal
Three chapters were used to organize this proposal. This chapter provided the
introduction and background of the study as well as key concepts and terminology commonly
found in a discussion about adoption of electronic health records system in patient care and
students’ education. The organization’s mission, goals and stakeholders, as well as the initial
concepts of gap analysis, were introduced. Chapter Two will include a review of current
literature surrounding the scope of the study. EHRS implementation will be addressed using
Clark and Estes’ (2008) gap analysis framework which are people’s knowledge, motivation, and
organizational factors. Chapter Three is a presentation of detailing the assumed interfering
knowledge, motivation, and organizational elements as well as methodology for the selection of
participants, data collection, and analysis.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 24

CHAPTER TWO: REVIEW OF THE LITERATURE
Introduction
The purpose of this chapter is to examine through research, the adoption of electronic
health records system in patient care and students’ education. Historically, and with the
enactment of Health Information Technology for Economic and Clinical Health Act (HITECH)
in 2009, research has shown that learning about computers and applying computer technology to
education and clinical care are fundamental elements of computer literacy for physicians (Hilty,
2006; HITECH, 2009). Research showed that medical students are using electronic health
records at higher rates than physicians in practice, which might result in consequences for their
education (Hammoud et al., 2012). The review of the literature showed outcomes from hospitals
and healthcare related industries regarding electronic health records systems experiences, the
challenges encountered, gaps that exist, and the lessons learned. This literature review examined
several topics pertaining to the adoption of electronic health records systems in patient care and
students’ education as they relate to faculty members. The expected critical behaviors of the
faculty members in the predoctoral clinic of the ABZ Dental School were used as a guide in this
literature review. The known influences were organized using Clark and Estes’ (2008)
knowledge, motivation, and organizational influences.
Conceptual Framework
“Though human performance is complex, research can help focus efforts on the factors
that have the biggest impact on work goals” (Clark & Estes, 2008, p. 42). It is critical, as noted
by Clark and Estes (2008), to collect data about the barriers individuals face in accomplishing
their goals. The more novel a goal is, the more extensive the performance support required for
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 25

people to achieve it. The type of support people need can be determined from analysis of what is
required to close the specific gap (Clark & Estes, 2008).
Clark and Estes (2008) continued by identifying the three critical factors that must be
examined when analyzing the performance of an organization. They identified knowledge,
motivation, and organizational factors as the drivers of performance. Successful goal attainment
depends on people having the knowledge and skills required to achieve their goal, the motivation
to do the required task to accomplish the goal, and the organization’s support such as in
resources, policies, and procedures required to accomplish the goal. This literature review
examined the three factors as outlined under each critical behavior starting with the ABZ Dental
School, predoctoral faculty members’ knowledge and skills, their motivation, and finally, the
organizational factors.
Stakeholder Knowledge, Motivation and Organizational Factors
Knowledge and Skills
As defined by Anderson et al. (2001), knowledge is organized and structured by the
learner. As knowledge is domain specific and conceptualized (Anderson et al., 2001), this
literature review examined the knowledge and skills needed for the successful adoption of
electronic health records system for patient care and students’ education. Anderson et al. (2001)
suggested that the knowledge dimension consists of four different types of knowledge. These
four types of knowledge are factual knowledge, conceptual knowledge, procedural knowledge,
and metacognitive knowledge. The ABZ Dental School faculty members’ critical behaviors
were analyzed using factual, conceptual, procedural, and metacognitive knowledge.
Declarative factual knowledge influences. Declarative factual knowledge is the
knowing of the basic elements that the experts use when communicating in their field of practice,
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 26

understanding it, and organizing it systematically (Anderson et al., 2001). Anderson et al. (2001)
categorized factual knowledge to include types of knowledge such as the knowledge of
terminologies, knowledge of specific details, and knowledge of elements. Faculty members need
to know the basic terminologies and elements that align with their current process of using the
electronic health records system in the predoctoral clinic of the ABZ Dental School. Faculty
inability to recognize and identify elements such as what an electronic health records system is,
what the whiteboard is, and so forth, can be defined as factual knowledge problems and would
show knowledge gaps that need to be closed (Anderson & Krathwohl, 2002; Clark & Estes,
2008).
Faculty members need to know what electronic health record systems (EHRS) are.
Faculty need to know where the whiteboard is located, the goal of the whiteboard and the goal
of the EHRS implementation which is to use the system all the time and to eliminate paper
charts. Studies have found that electronic health record systems (EHRS) are defined in diverse
ways by different users (Boonstra & Broekhuis, 2010; Blumenthal, 2007; Häyrinen, Saranto, &
Nykänen, 2008; Hsiao et al., 2013; Peled, Sagher, Morrow, & Dobbie, 2009). According to
literature, the meaning of electronic health records system is not standard (Häyrinen et al., 2008).
Research found that in 52 different journals reviewed, which were published between 1982 and
2004, EHRS is depicted as a repository of patient data in digital form, stored, and exchanged
securely, and accessible by multiple authorized users (Häyrinen et al., 2008). Boonstra and
Broekhuis (2010) defined EHRS as a computerized medical information system that collects,
stores, and displays patient information. They defined EHRS as tools for creating legible and
organized recording of data as well as tools for accessing clinical information about patients
(Boonstra & Broekhuis, 2010). Blumenthal (2007) defined EHRS as enormous diverse set of
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 27

technologies with computerized storage and reporting of laboratory results. Blumenthal went on
to define EHRS as a communication medium for sharing patient information between institutions
and geographical boundaries through granted access.
Also noted by Blumenthal (2007), in his definition, is that EHRS is for use by consumers,
providers, payers, insurers, and all other groups with interest in health and health care. Hsiao et
al. (2013) defined EHRS from a different perspective by stating that EHRS is any system that
indicates a physician’s decision to move from paper based to electronic based while Peled et al.
(2009) described EHRS as not a health care delivery method, meaning, it cannot enhance care
but as a medium through which imperfect human providers deliver health care. In summary,
from all the definitions, EHRS can be defined as a health care tool. As such, it is essential for
faculty members to know what electronic health record systems are, so they can identify them for
meaningful use.
For usability, it is important for faculty members to know where the tools they need are
physically located such as the white boards which are located at the predoctoral clinic. Knowing
what an EHR system is prompts the question of whether faculty know the purpose.
Understanding the purpose of the EHRS will enhance its usage.
Conceptual knowledge influences. Conceptual knowledge as defined by Anderson et
al. (2001) included knowledge of categories, classifications, and the relationships between them.
It is the interrelationships among the basic elements described in the factual knowledge such as
the relationship between the whiteboard and the electronic health records system. Faculty
members need to know the purpose of using the electronic health records system in patient care
as well as in students’ education. If faculty members do not know the purpose of electronic
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 28

health records system, it means there is a conceptual knowledge gap which needs to be
addressed.
Faculty members need to know the purpose of electronic health records systems, how
they work, the relationship with the whiteboard, and how their use of EHRS measures up to
the goal of the school. Research showed that EHRS users use EHRS in different ways for
different purposes including (1) accessibility through EHRS use, (2) consistency of data, (3)
accuracy of data, and (4) standard of care, as illustrated in the literature (Bell & Thornton, 2011;
Blumenthal, 2007; Lorenzi, Kouroubali, Detmer, & Bloomrosen, 2009; Schleyer et al., 2013).
(1) Accessibility through EHRS use. Studies showed that in United States, 73.8% of solo
practitioners and 78.7% of group practitioners use computers to manage some patient
information while 14.3% of the solo practitioners and 15.9% of the group practitioners managed
all patient information on the computer (Schleyer et al., 2013). Research showed that some of
the purposes of EHRS were to save staff time which would have been used in searching for
physical charts, to reduce staff overtime charges such as in elimination of paperwork, to increase
more personal time because of seeing same number of patients in less time, to simplify
inventory, to enter charges manually, and to post charges, thereby improving office efficiency
and productivity (Bell & Thornton, 2011; Lorenzi et al., 2009). Blumenthal (2007) affirmed that
EHRS are used for transmitting and managing of patient information and for granting access to
clinicians to share patient information while Bell and Thornton (2011) asserted that EHRS
provide easier access to clinical information across the continuum of care to support providers’
decision making and to provide better preventive care through improved communications
between physician and their patients.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 29

(2) Consistency of data. Research has shown that EHRS are used for data consistency
such as improving the availability of data for real-time clinical decisions through prompts and
alerts to physicians (Bell & Thornton, 2011). Bell and Thornton (2011) continued by stating that
these alerts to physicians lead to better patient care and ultimately reduce medical errors.
Lorenzi et al. (2009) concurred with Bell and Thornton (2011) in EHRS use for data consistency
meaning that the data are kept in the same format and can be accessed immediately while on call
and from home remotely.
(3) Accuracy of data. As a result of EHRS adoption, studies have shown reduced
medical errors, increased medication safety, and fewer adverse drug events (Bell & Thornton,
2011; Menachemi & Collum, 2011). Also shown by research was that EHRS adoption has
resulted in error reduction which would normally occur with handwriting or transcription from
providers as well as increased error checking for duplicate or incorrect prescription doses and
tests (Bell & Thornton, 2011).
(4) Standard of care. Studies showed that EHRS adoption has the potential to
standardize care which will improve patient outcomes, improve quality of care, improve
appropriateness of care, and strengthen patients’ quality of care (Bell & Thornton, 2011; Lorenzi
et al., 2009; Menachemi & Collum, 2011). Baron et al. (2005 as cited in Lorenzi et al., 2009)
noted that after implementing an electronic health record system, the Greenhouse Internists, four
internists from community-based practice of general internal medicine located in Pennsylvania,
communicated more quickly and clearly with patients on the telephone and by letter. Koppel and
Lehmann (2014) confirmed that EHRS improved standardization of care across facilities due to
exchange of data with other EHR systems and through tools that promote innovation by allowing
real-time clinical decision support.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 30

In sum, faculty members need to know the purpose of electronic health records system to
be able to consistently use it in accomplishing their goals. Faculty members, knowing the
purpose of the EHR system, will make navigation through the system easy, less stressful, and
helpful with patient care and students’ education. Knowing the purpose of EHRS will enhance
faculty curiosity to use the system. But not knowing how to use the system will deter faculty
members from using it.
Procedural knowledge influences. Procedural knowledge as defined by Anderson et al.
(2001) is the “knowledge of how.” It refers to the process of knowing how to do something
(Anderson et al., 2001; Rueda, 2011), the methods of inquiry, and the criteria for using the skills
and techniques (Anderson et al., 2001). Collectively, procedural knowledge includes knowledge
of the steps in accomplishing a specific goal. The assumed lack of faculty members knowing the
steps in accomplishing the goal of using the electronic health records system all the time in
patient care and students’ education will denote a gap in procedural knowledge.
Faculty members need to know how to review student’s documented patient treatment
code and notes electronically on the computer. They need to know how to correctly enter
patient data and notes as well as be able to follow the steps in using the EHRS. They need to
know how to recommend next steps in patient care to the students and be able to approve and
assign grades to the students completed work. Research noted suitable provider training in the
use of EHR systems as a factor in EHR system adoption (Boonstra & Broekhuis, 2010; Morton
& Wiedenbeck, 2010; Peled et al., 2009). Boonstra and Broekhuis’ (2010) study showed that the
introduction of EHRS leads to additional time required for selecting, implementing, and learning
how to use the EHRS. Although some researchers (Boonstra & Broekhuis, 2010) noted that the
process to enter data into the EHRS might result in an increase in workload and decrease in
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 31

productivity, Holden (2010) asserted that initial training and technical support on electronic
medical records (EMR) use promotes physicians’ frequent use of EMR.
Studies show that lack of suitable provider training and lack of formal computer training
will not only affect the quality of EHRS use but will also slow down the adoption (Peled et al.,
2009). Peled et al. (2009) added that when providers receive suboptimal training on EHRS use,
it affects proper utilization including fewer incentives for students to critically think about
processes involved in what they do such as in imaging or drawing blood work. They further
noted that lack of skills in which attending physicians largely depended upon trainees for data
about patients affects proper utilization of EHRS but with proper EHRS training, medical
students learned quickly to clarify facts and then present them in a relevant and effective manner
(Peled et al., 2009). It is important to have suitable provider training in the use of EHRS for
effective adoption of EHR systems. Providers will not use EHRS if they don’t know how to use
it. Provider training should consist of essential skills providers need for proper utilization and
education of the students. Effective training on EHRS will increase the drive for faculty
members to use the system as well as, give them the opportunity to reflect on their use of EHRS.
Metacognitive knowledge. Anderson et al. (2001) defined metacognitive knowledge as
the knowledge about cognition which includes the awareness of and knowledge of one’s own
cognition. Using this definition, it is assumed that faculty members who are not aware of and
responsible for their own knowledge might affect accomplishing the goal of using the system all
the time.
Faculty members need to know how to reflect on their utilization of the EHR system.
Studies found that faculty members who reflect on their utilization of EHR system to increase
productivity use it (Cheriff, Kapur, Qiu, & Cole, 2010; Denomme, Terry, Brown, Thind, &
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 32

Stewart, 2011; King et al., 2014). Denomme et al. (2011) noted that physicians who reflected on
the desire to get on the same page as fellow team members with their EMR usage to accelerate
task, most likely will use EMR. As stated by Cheriff et al. (2010), providers who think that the
system will compromise productivity do not use it. King et al. (2014) noted that faculty
reflecting on the overall use of EHRS leads to increase in clinical benefits such as those seen in
enhanced patient care.
Faculty members need to self-reflect on how to teach students patient care using the
EHRS. Research showed that faculty members who self-reflect on their EHRS experiences
utilize it for improvement in care delivery (Denomme et al., 2011; Holden, 2010; King et al.,
2014). Studies show that EHRS users recognized that consistently entering of data in EHRS
increases productivity and eases workflow (Denomme et al., 2011). And experiences in EHRS
lead to improvement in care delivery and quality of care (King et al., 2014). Holden (2010)
emphasized that physicians’ reflection on constant use of electronic medical records, same as
electronic health records, improves their ease of performance with the system. He continued by
stating that physicians’ experience with on-call technical support made the physicians
comfortable in the system’s use (Holden, 2010). For a successful adoption of EHRS, faculty
members’ reflection on their EHRS use and experience is crucial and need to be taken into
consideration. The more faculty members have positive reflections about EHRS experience, the
more they will use the system. Faculty members’ positive reflection on EHRS use will promote
their use of EHRS. To continue using the EHRS, faculty members need to feel motivated in
using the system.
The summary of assumed knowledge influences from expected faculty members’ critical
behavior when using the electronic health records system are demonstrated in Table 2. Table 2
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 33

shows assumed declarative factual knowledge, conceptual knowledge, procedural knowledge,
and metacognitive knowledge.
Table 2
Summary of Assumed Knowledge Influences on Faculty’s Ability to Achieve the Performance
Goal

Assumed Knowledge Influences Research Literature
Declarative Factual (terms, facts,
concepts)

Faculty needs to know what electronic
health records systems are
Boonstra & Broekhuis, 2010; Blumenthal,
2007; Häyrinen, Saranto, & Nykänen, 2008;
Hsiao et al., 2013; Peled, Sagher, Morrow, &
Dobbie, 2009
Faculty needs to know where the
whiteboard is located and the goal
Boonstra & Broekhuis, 2010; Blumenthal,
2007; Häyrinen et al., 2008; Hsiao et al., 2013;
Peled et al., 2009
Faculty needs to know the goal of EHRS
implementation
Boonstra & Broekhuis, 2010; Blumenthal,
2007; Häyrinen et al., 2008; Hsiao et al., 2013;
Peled et al., 2009
Declarative Conceptual (categories,
process models, principles, relationships)

Faculty needs to know the purpose of
electronic health records systems
Bell & Thornton, 2011; Blumenthal, 2007;
Lorenzi, Kouroubali, Detmer, & Bloomrosen,
2009; Schleyer et al., 2013
Faculty needs to know how the electronic
health record system works
Bell & Thornton, 2011; Blumenthal, 2007;
Lorenzi et al., 2009; Schleyer et al., 2013
Faculty needs to know the relationship
between the whiteboard and the electronic
health record system
Bell & Thornton, 2011; Blumenthal, 2007;
Lorenzi et al., 2009; Schleyer et al., 2013

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 34

Table 2 (Cont’d.)
Assumed Knowledge Influences Research Literature
Faculty needs to know how their use of
EHRS measures up to the goal of EHRS
Bell & Thornton, 2011; Blumenthal, 2007;
Lorenzi et al., 2009; Schleyer et al., 2013
Procedural
Faculty needs to know how to review
students documented patient treatment code
and notes electronically on the computer
Boonstra & Broekhuis, 2010; Morton &
Wiedenbeck, 2010; Peled et al, 2009
Faculty needs to know how to correctly
enter patient data and notes
Boonstra & Broekhuis, 2010; Morton &
Wiedenbeck, 2010; Peled et al., 2009
Faculty needs to be able to follow the steps
in using the EHR system
Boonstra & Broekhuis, 2010; Morton &
Wiedenbeck, 2010; Peled et al., 2009
Faculty needs to know how to use the
EHRS in recommending next steps in
patient care to the students
Boonstra & Broekhuis, 2010; Morton &
Wiedenbeck, 2010; Peled et al., 2009
Faculty needs to know how to
electronically approve and assign grades to
students’ completed work
Boonstra & Broekhuis, 2010; Morton &
Wiedenbeck, 2010; Peled et al., 2009
Metacognitive
Faculty needs to know how to reflect on
their utilization of the EHR system
Cheriff, Kapur, Qiu, & Cole, 2010; Denomme,
Terry, Brown, Thind, & Stewart, 2011; King,
Patel, Jamoom, & Furukawa, 2014
Faculty needs to self-reflect on how to
teach students patient care using the EHRS
Denomme et al., 2011; Holden, 2010; King et
al., 2014

Motivation
As defined by Clark and Estes (2008), motivation is the product of interaction between
people and their work environment. Schunk, Meece, & Pintrich (2012) described motivation as
the process whereby goal directed activities is instigated and sustained. To improve motivation,
the goal is to influence people’s understanding of the impressions they create in others, about
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 35

their own abilities to do a job, and their beliefs about the personal or group benefits of the work
accomplished (Clark & Estes, 2008). According to Clark and Estes, motivation can be observed
through three indicators – active choice, persistence, and mental effort. Active choice refers to
the intention of an individual to pursue a goal which is then replaced by an action (Clark &
Estes, 2008). Persistence is the ability of an individual to continue in that action even in the face
of distraction to accomplish the goal which is accompanied by adequate mental effort invested in
the goal (Clark & Estes, 2008).
The electronic health records system of the ABZ Dental School was implemented in 2003
and has been in use by the predoctoral faculty members since then. Active choice and
persistence are two facets of motivated performance that can be assumed to exist with the
predoctoral faculty members. The predoctoral faculty members’ inability to persist at
accomplishing the goal of using the electronic health records system all the time is an indicator
of assumed motivational problem. Faculty members need to be able to make active choices to
use the electronic health records system. Faculty members, choosing not to use the electronic
health records system all the time by using physical paper charts defeat the goal of the school to
use the system all the time. According to Clark and Estes (2008), value, self-efficacy, mood, and
attribution are some of the assumed causes that affect motivation. The ABZ Dental School
faculty members’ expected behaviors will be analyzed using these four types of motivation to
understand what’s known through research as well as in categorizing the faculty behaviors into
motivational types as shown in Table 3.
Value. Value as described by Clark and Estes (2008) can be viewed as preferences that
guide individuals to adopt a course of action and persist even when there are distractions.
Research showed that value answers the question “Do I want to do this task and why?” which
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 36

indicates that value refers to individuals’ beliefs as to the reasons they might engage in a task
(Schunk, Meece, & Pintrich, 2012, p. 47). Individuals value what they believe will help them
and they reject what they believe to be obstacles (Clark & Estes, 2008). Faculty members might
have a variety of reasons as to why or why not to use the electronic health records system such as
them being interested in the system, liking the system, thinking it’s essential, not wanting to use
it, not liking the system and so forth.
Faculty needs to value their use of electronic health record system in patient care and
students’ education. They need to value reviewing students documented patient treatment
code and notes electronically on the computer. Their need to value knowing how to correctly
enter patient treatment codes and notes in the EHRS, value recommending next steps in
patient care to the students, and value the process of electronically approving and assigning
grade to students’ completed work will increase their use of EHRS. Studies showed that
faculty members who value EHRS tend to use it more often (Denomme et al., 2011; Holden,
2010; King et al., 2014). Research by Denomme et al. (2011) supported that physicians value of
EHRS made them keen to continue to learn and use the system. The demonstrated potential
benefits and expediency in everyday work with the use of EHRS increases users value of the
EHR system (Denomme et al., 2011) as physicians who value EHR systems, positively use them
(Holden, 2010). Studies show that recognition of EHRS value foster a feeling of possibilities
and enthusiasm within physicians and their EHR use as their value from initial training, number
of years using the system, and technical support on EHR use promotes comfort in use (Denomme
et al., 2011; Holden, 2010; King et al., 2014). The more faculty members value the EHR system,
the more they will use it. Faculty members are eager to use the EHR system when they know the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 37

worth of the system. The more faculty members value the EHR system’s use, the more they can
grow their confidence in using it.
Self-efficacy. Self-efficacy as defined by Bandura (1997 is the individual's judgment of
their capabilities to organize and execute courses of action required to attain designated types of
performance. An individual who holds low self-efficacy for accomplishing a task will most
likely avoid the task while a high self-efficacy to accomplish the same task will follow through
and participate (Schunk, et al., 2012). Self-efficacy goes hand-in-hand with confidence. As
shown in Schunk et al. (2012), researchers often use confidence to assess individual’s self-
efficacy. High confidence denotes the individual has high self-efficacy and is willing to engage
in tasks that foster the development of their skills and capabilities while low confidence in
fulfilling a task shows low self-efficacy which leads to inability of the individual to not engage in
tasks that might help them learn (Bandura, 2006; Schunk et al., 2012).
Faculty members need to have confidence that they can use the electronic health
records system to document patient care, in reviewing student’s documented patient treatment
code and notes electronically on the computer, and in following the steps in using the EHR
system. Faculty need to have confidence using electronic health record system to recommend
next steps in patient care to the students, in electronically approving and assigning grades to
students’ completed work, and in using the whiteboard to know when the students need them.
Studies show faculty members’ self-efficacy increases when they have confidence in the EHR
system (Denomme et al., 2011; Holden, 2010; Jha et al., 2009). Denomme et al. (2011) in their
study showed that consistent data entry elevates self-efficacy as users feel confident using
EHRS. Researchers such as Holden (2010) believed that constant use of EMR improved
physicians’ ease of personal performance as individual experiences of gains from its usage
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 38

increases self-efficacy (Denomme et al., 2011). While Holden (2010) noted that physicians
believe that their initial training and technical support on EMR system use facilitated comfort in
the use, Jha (2006) demonstrated that physicians’ skepticism in EHRS such as in privacy and
security concerns will affect their confidence to use EHRS. The more faculty members have
contact with the EHR system, the more confident they become in their ability to use it effectively
and that increases their self-efficacy. Faculty members’ confidence in EHRS will promote their
use of the system but fear that it might not meet their need will reduce its usage.
Faculty members fear that EHRS might not meet their need. Research shows faculty
members’ fear of EHR system not meeting their need affects self-efficacy (Devine, Patel, Dixon,
& Sullivan, 2010; Randeree, 2007; Rao et al., 2011; Vishwanath & Scamurra, 2007). Rao et al.
(2011) asserted that when unique barriers that cause fear in the use of EHRS is faced, self-
efficacy is increased. To add on to this study, Randeree (2007) through his exploration of the
physician adoption of EMRS noted that trust in EMRS vendors reduced fear in EMRS use. On
the other hand, Vishwanath and Scamurra (2007) noted that fear over the adoption of new
technology and fear of lack of control with EHRS adoption are some of the barriers to EHRS
adoption while Devine et al. (2010) cited prior computer use such as at home, increases self-
efficacy and removes fear of EHRS use. They went on to note that self-assessment of EHRS
computer knowledge reduces apprehension and increases confidence in the system use (Devine
et al., 2010). Faculty members fear of EHRS capabilities will diminish their use of it, but the
less fear and more confident faculty members feel in using EHRS the more they will successfully
use the system. The more confident faculty members feel about the EHRS, the more positive
their mood will be in using it to accomplish their goals.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 39

Mood. Mood is a more diffuse general feeling that has no specific prior cause as
individuals can be in a good or bad mood without really knowing why they feel the way they feel
(Schunk et al., 2012). When one is in a good mood which can be inferred to as being in a
positive mood, the individual tends to find enjoyment, hope, relief, gratitude, admiration, and so
forth but when an individual is in a bad mood, the outcome can be boredom, anxiety,
disappointment, anger, and so forth (Schunk et al., 2012).
Faculty need to feel positive about using the electronic health records system in:
correctly entering patient data and notes, reviewing students’ documented patient treatment
code and notes electronically on the computer, following the steps on using the EHR system,
using EHRS for recommending next steps in patient care to the students, and electronically
approving and assigning grades to students’ completed work. Studies show faculty members
exhibit a positive mood when they are able to accomplish their goals with the use of EHR
systems (King et al., 2014; Morton, & Wiedenbeck, 2010). The study by Morton and
Wiedenbeck (2010) show that physicians exhibited positive moods when they depended less on
staff personnel for patients’ charts (Morton & Wiedenbeck, 2010). Morton and Wiedenbeck
stated that physicians show a positive mood using the EHRS due to immediate access of
information compared to when they used paper chart. Physicians exhibit positive moods using
the EHRS due to number of years of positive experience such as seen in clinical benefits of
EHRS use as well as partly due to the ability to retrieve legible and easily understood
information from the system as in collating and sorting data (King et al., 2014; Morton, &
Wiedenbeck, 2010). Faculty members will exhibit a positive mood in using the EHRS when
they realize the clinical benefits associated with it such as in less dependent on staff, easy access
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 40

to data, and legible retrievable information. Faculty members’ positive mood in using the EHRS
will lead them towards attributing the success of the system to their efforts to use it.
Attribution. Attribution is the perceived causes of outcomes which are important
influences on the achievement behaviors and expectancies (Schunk et al., 2012). It is important
to understand what the success or failure of an outcome is attributed to as that will help in
closing that gap. The attribution theory examines individual’s beliefs as to why certain events
occur and correlates those beliefs to subsequent motivation (Anderman & Anderman, 2006). It
also proposes that individuals’ attributions will have significant consequences as to the expected
outcome (Schunk, et al., 2012). By better understanding the behaviors of faculty members, the
organization can help formulate achievement beliefs which will enhance motivation and
hopefully reduce attribution biases (Schunk, et al., 2012).
Faculty members need to attribute the success of electronic health records system to
their efforts to use it. Studies show faculty members attribute the success or failure of EHRS to
different factor levels such as the Micro, Meso, or Macro (Denomme et al., 2011; Holden, 2010;
King et al., 2014; Lau et al., 2012). At the micro-level, physicians attributed the success or
failure of EHRS to the technical design, performance, and support in its usage and user
satisfaction in the office (Lau et al., 2012). Physicians also attributed initial training and
technical support on EHRS to comfort in the use as well as attributed on-call tech support
personnel to making them comfortable in the use of EHRS use (Holden, 2010). At the meso-
level, the success of the EHRS was attributed to the implementation process and resulting
workflow which impacted on the office's ability to improve productivity and coordination (Lau
et al., 2012). Physicians’ attribute demonstrated potential benefits and expediency in daily use of
EHRS to increase in user’s value of the system (Denomme et al., 2011). Finally, at the macro-
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 41

level, incentives such as pay for performance were seen as attributes and as an important driver
for EHRS adoption since they increased the return on investment made (Lau et al., 2012).
Physicians attribute their positive attitude in using the EHRS to observe clinical benefits due to
its use (King et al., 2014) and attribute timely orientation on EHRS to the increase in
appreciation of the utility of EHRS (Denomme et al., 2011). Faculty members attributing the
success or failure of EHRS to their efforts in using it will increase their accountability in the
potential benefits or setbacks of EHRS which will increase their value in the system.
The summary of assumed motivational influences from expected faculty members’
critical behavior when using the electronic health records system are demonstrated in Table 3.
Table 3 shows value, self-efficacy, mood, and attribution as some of the assumed causes that
affect motivation.
Table 3
Summary of Assumed Motivation Influences on Faculty’s Ability to Achieve the Performance
Goal

Assumed Motivation Influences
Research Literature
Author, Year; Author, Year.
Value

Faculty needs to value their use of
electronic health record system in patient
care and students’ education

Denomme et al., 2011; Holden, 2010; King et al.,
2014
Faculty needs to value reviewing students’
documented patient treatment code and
notes electronically on the computer
Denomme et al., 2011; Holden, 2010; King et al.,
2014
Faculty needs to value knowing how to
correctly enter patient treatment codes and
notes in the EHRS
Denomme et al., 2011; Holden, 2010; King et al.,
2014
Faculty needs to value recommending
next steps in patient care to the students
Denomme et al., 2011; Holden, 2010; King et al.,
2014
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 42

Table 3 (Cont’d.)
Assumed Motivation Influences Research Literature
Author, Year; Author, Year.
Faculty needs to value the process of
electronically approving and assigning
grades to students’ completed work
Denomme et al., 2011; Holden, 2010; King et al.,
2014
Self-Efficacy
Faculty needs to have confidence that they
can use the electronic health record system
to document patient care
Denomme et al., 2011; Devine, Patel, Dixon, &
Sullivan, 2010; Holden, 2010; Jha et al., 2006;
Randeree, 2007; Rao et al., 2011; Vishwanath
and Scamurra, 2007
Faculty needs to have confidence in
reviewing students’ documented patient
treatment code and notes electronically on
the computer.
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath and Scamurra,
2007
Faculty needs to have confidence that the
system is accurate and secure when they
use it
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath and Scamurra,
2007
Faculty needs to have confidence in
following the steps in using the EHR
system
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath & Scamurra, 2007
Faculty needs to have confidence using
electronic health record system to
recommend next steps in patient care to
the students
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath and Scamurra,
2007
Faculty needs to have confidence in
electronically approving and assigning
grades to students’ completed work
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath and Scamurra,
2007
Faculty needs to have confidence using
the whiteboard to know when students
need them
Denomme et al., 2011; Devine et al., 2010;
Holden, 2010; Jha et al., 2006; Randeree, 2007;
Rao et al., 2011; Vishwanath and Scamurra,
2007

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 43

Table 3 (Cont’d.)
Assumed Motivation Influences Research Literature
Author, Year; Author, Year.
Mood
Faculty needs to feel positive about using
the electronic health record system in
correctly entering patient data and notes
Morton and Wiedenbeck, 2010; King et al., 2014
Faculty needs to feel positive about
reviewing students’ documented patient
treatment code and notes electronically on
the computer.
Morton and Wiedenbeck, 2010; King et al., 2014
Faculty needs to feel positive following
the steps in using the EHR system
Morton and Wiedenbeck, 2010; King et al., 2014
Faculty needs to feel positive using EHRS
in recommending next steps in patient care
to the students
Morton and Wiedenbeck, 2010; King et al., 2014
Faculty needs to feel positive in
electronically approving and assigning
grades to students’ completed work
Morton and Wiedenbeck, 2010; King et al., 2014
Attribution
Faculty needs to attribute the success of
electronic health records system to their
efforts to use it.

Denomme et al., 2011; Holden, 2010; King et al.,
2014; Lau et al., 2012
Faculty needs to believe that using the
EHRS is important for patient care
Denomme et al., 2011; Holden, 2010; King et al.,
2014; Lau et al., 2012

Organization
Organizational goals are best achieved by the interaction of processes (work and material
resources) that require specialized knowledge, skills, and motivation to operate successfully
(Clark & Estes, 2008). The lack of efficient and effective organizational work processes and
material resources can contribute to causes of performance gap even for people with top
motivational and exceptional knowledge and skills (Clark & Estes, 2008). Clark and Estes
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 44

(2008) described organizational barriers to include lack of necessary resources, inadequate work
processes, and so forth as critical factors to be examined during gap analysis. These work
processes specify how people, equipment, and materials must link and interact to produce
desired outcome.
Resources. Organizations need tangible supplies and equipment to be able to achieve
goals (Clark & Estes, 2008). As noted by Clark and Estes (2008), the design and availability of
tools and material supplies for work has been an issue for many hundreds of years, so the
temptation is to overlook it as a cause of performance gaps (p. 104). However, they, Clark and
Estes (2008), recommended that it should not be overlooked. It is assumed that the ABZ Dental
School might not provide its faculty members with all the needed necessary resources to
accomplish their goal. If this is the case, the faculty might not be able to utilize the electronic
health records system all the time in providing patient care and in educating the students.
Faculty members need resources to successfully implement electronic health records
system, such as swipers, signature pads, and so forth. They need effective training on EHRS
for their first-time use, ongoing professional development to meaningfully continue using
EHRS, and technological support to effectively use EHRS. Faculty members need to have
confidence that the system won’t break down when they use it as well as need the time to be
able to use EHRS effectively and efficiently. Studies demonstrate that resources such as finance
and time are needed for successful implementation and benefits of EHRS (Jha et al., 2006;
Menachemi & Collum, 2011; Morton & Wiedenbeck, 2010; Terry et al. 2008). Menachemi and
Collum (2011) noted that EHRS use resulted in reduced operational cost. With obvious return
on investment, Jha et al. (2006) cited that EHRS utilization grows while unclear return on
investment has been seen to be the reason behind 32% of hospitals not implementing EHRS. In
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 45

a study conducted by Terry et al. (2008), the enormous time commitment needed to implement
EHRS was noted as a challenge due to not enough time available in a work day. An example as
stated by Terry et al. (2008) is that it took four to five months for the billing clerk to be trained to
be able to use the computerized billing system. As a result, researchers noted time as a crucial
component in the implementation process of an EHRS and should not be underestimated in the
planning phase (Terry et al., 2008). Morton and Wiedenbeck (2010) concurred with Terry et al.
(2008) by stating that lack of flexibility in the timing and structure of EHRS training program
affects the adoption of EHRS.
Research noted time to utilize EHRS as a factor in the EHRS use (Jha et al., 2006;
Menachemi & Collum, 2011; Peled et al., 2009). Research cited lack of time to acquire the
system’s knowledge and learn how to use it including additional time for data entry as factors
affecting its usage (Jha et al., 2006; Menachemi & Collum, 2011). Peled et al. (2009) cited
instances when time was a constraint in utilizing the electronic health record system. Such
instances include (a) during presentation of cases, the time to electronically sign orders placed at
the instructor’s computer, (b) time to complete the process involved at a given work as this
results in a habit of clicking through the EHRS while conducting training which affects effective
training, and finally, and (c) the attending physicians end up answering their own questions using
the system rather than posing questions to the students to improve their knowledge base.
In all, return on investment is of importance as to whether faculty will fully utilize the
EHRS; increase in return on investment will increase EHRS use and a decrease in return on
investment will decrease faculty members’ use of EHRS. Time to utilize EHR is of essence and
should be considered when planning to adopt EHR system. Resources such as time and money
to buy required equipment will help to accomplish the organizational goal of 100% electronic in
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 46

the predoctoral clinic while having set policies and procedures to guide the faculty members in
their EHRS use will ease the process of using EHRS in accomplishing the goal.
Policies and procedures. Policies are principles, rules, and guidelines put together by an
organization to accomplish its long-term goal (BusinessDictionary.com, 2017). Procedures are
specific methods of accomplishing the set policies (BusinessDictionary.com, 2017). Together,
policies and procedures are set guidelines by the governing body of an organization which
ensures that a point of view or goal of the organization is translated into steps that result in an
outcome that aligns with that point of view or aligns with the organizational goal
(BusinessDictionary.com, 2017). Assumed influence of the ABZ Dental School not having
guidelines on how to accomplish the desired goal of using the electronic health records all the
time will cause a performance gap in the organization.
Faculty need to have policies that align with their goal to use electronic health records
system all the time. They need procedures on how to use the EHRS in recommending next
steps in patient care to the students. The organization needs to have a policy and procedure
on electronically approving students completed work 100% of the time as well as on
electronically assigning grades to students completed work 100% of the time. Studies revealed
that an organization’s policies and procedures guide faculty members in their use of electronic
health records system (Bowman, 2013; Sittig & Classen, 2010; Sittig & Singh, 2009). Through
research by Sittig and Classen (2010), they acknowledged that organizations should perform and
document extensive reviews of their EHRS yearly and as agreed by Sittig and Singh (2009),
“regulations to safeguard patient privacy are clearly important but may also have the greatest
unintended consequence on national EHRS implementation if not monitored” (p. 4). Bowman
(2013) emphasized that a combination of federal government oversight and industry action is
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 47

needed to avoid unintended outcomes from the use of EHRS. He suggested that leadership in the
form of regulation, legislation, and oversight helps to reduce serious EHRS related errors and
better EHRS implementation and adoption (Bowman, 2013).
Healthcare providers’ implementation of policies and procedures which address proper
EHRS training and use to avoid errors related to EHR system use helps to identify errors in the
system before patient care is affected (Bowman, 2013). Documentation on governing principles
of the organization’s expectation through policies and procedures are very important. These
documentations on the expectation and the process to get the tasks accomplished will guide
faculty members with clarity as to the organization’s goals. Faculty members will find it easier
to adhere to the organization’s policies and procedures if they belong in a cultural setting that
abides to those same policies and procedures.
Cultural setting. In a work environment, culture can be defined as the core values,
goals, beliefs, emotions, and processes learned as individuals develop and grow over time at their
work environment (Clark & Estes, 2008). To influence performance, it is recommended to
examine both the organizational environment and the knowledge, skills, and motivational
approaches of the individuals who work in them (Clark & Estes, 2008). Cultural setting as
defined in Rueda (2011) can be seen as who, what, when, where, why, and how of the routines
that constitute one’s everyday life. A change in one of these mentioned defining features affects
the cultural setting (Rueda, 2011). Gallimore and Goldenberg (2001) summarized cultural
settings definition as that which occurs whenever two or more people come together, over time,
to accomplish a goal. Rueda (2011) recommended that it is highly crucial to understand the
assumed influences and characteristics of the cultural setting that make up the work environment
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 48

especially as cultural setting is not static in nature. The ABZ Dental School will need to assess
its cultural setting for assumed causes that might lead to performance gaps.
Faculty need to be part of a culture that aligns with the organizational goal of 100%
use of electronic health records system. Faculty need to be part of the implementation team
for successful implementation. Studies noted cultural setting in EHR implementation as a
crucial factor to be considered for effective EHR adoption (Jha et al., 2006; Morton &
Wiedenbeck, 2010; Terry et al., 2008). Learning to use EHRS and trying to care for patients at
the same time is challenging and if not planned appropriately, will become obstacles for
physicians in taking care of the patients and in finding time to use the EHRS (Terry et al., 2008).
Jha et al. (2006) in their findings noted that only 30%of the staff had adequate expertise in
information technology to help physicians. A culture where there is a lack of formal computer
training prior to attending medical school and lack of flexibility in the timing and structure of
training programs are several factors that can affect adoption of EHRS (Morton & Wiedenbeck,
2010). The culture in which EHRS training is offered to physicians such as in-house versus
remote training as cited by Terry et al. (2008) will also affect physicians’ adoption of EHRS. In
essence, the cultural setting of a faculty member affects the faculty member’s use of EHRS. A
cultural setting that promotes 100% use of EHRS will positively influence faculty members to
use EHRS 100% of the time and a cultural setting that is viewed to not use the EHRS 100% of
the time will negatively influence faculty members’ use of the system. A good cultural setting
will positively influence faculty members’ use of EHRS and will ultimately produce expert role
models.
Cultural models. Gallimore and Goldenberg (2001) introduced the notion of cultural
models. They introduced cultural models as individuals at the cultural setting who are generally
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 49

known but often invisible and not noticed by those who hold them. Gallimore and Goldenberg
(2001) went further to define cultural models as those who define for individuals the way things
are and should be. As noted by Rueda (2011), cultural models are dynamic and help shape the
ways an organization is structured, including the values, policies, practices, reward structures,
and so forth. Expert cultural models are good to have in organizations such as in the ABZ
Dental School as they serve as an incentive because they have shared ways of thinking,
perceiving, and storing possible responses needed for adapting to challenges and changing
conditions (Rueda, 2011).
The organization needs to have expert role models who exhibit best practices to faculty
members. Research showed that having an expert role model, someone to trust and look up to or
a go-to person promotes the use of EHR systems (Jha et al., 2006; Morton & Wiedenbeck, 2010;
Peled, 2009; Terry, 2008). Organizations understanding the needs and attitudes of physicians
will help facilitate a smooth EHRS adoption (Morton & Wiedenbeck, 2010). Role models are
needed in organizations as with them, there is reduction in physicians’ resistance to adopt and
implement EHRS (Jha et al., 2006). Jha et al. (2006) cited 36% of physicians’ resistance to
adoption and 30% on lack of availability of staff with adequate expertise in information
technology among barriers in hospitals without EHR systems. The lack of learning to conduct
patient care from an expert model with the use of EHRS is a complex process that should begin
in medical school which affects effective implementation when that education is lacking (Peled
et al., 2009). Terry et al. (2008) concurred by stating that the type of training provided, and, who
is giving the training in an organization affects the adoption of EHRS. They noted that the
presence of an IT champion leader is important for successful EHRS implementation. Expert
role models are essential for effective use of EHRS as it reduces resistance on the part of faculty
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 50

members in utilizing the EHR systems. Faculty members look up to expert models to learn how
to use EHRS. Having expert role models on its own is an incentive for faculty members to use
the EHRS as they are seen to be a go-to resource when the need arises.
Faculty members need to have incentives to use electronic health records system, they
need to feel recognized on their effort in using EHRS for student education, and for patient
care. Research shows that faculty members will use EHRS if they have the incentives to use it
as well as if they feel recognized in their effort using the EHRS (Milano, Hardman, Plesiu,
Rdesinski, & Biagioli, 2014; Sittig & Singh, 2009; Spotts, 1999). As cited by Sittig and Singh
(2009), “The American Recovery and Reinvestment Act stipulates that clinicians and healthcare
organizations can receive incentive payments for ‘meaningful use’ of EHR system” (p. 4).
Depending on the definition and timeline of meaningful use, the legislation could result in a rush
by organizations to implement systems which might be suboptimal (Sittig & Singh, 2009). An
example as noted by Milano et al. (2014), the Medicare and Medicaid electronic health records
incentive programs which provide financial incentives to providers who demonstrate
‘meaningful use’ by using certified electronic health records technology. Research conducted by
Spotts (1999) concluded that recognition for work using instructional technologies is essential.
In his interviews, he noted that it was evident technology to be used must be perceived as a
benefit or value to the physicians or instructors. Recognition of effort which should lead to
promotion and tenure considerations is highly important which without, EHRS is of little use to
the faculty especially in terms of job security (Spotts, 1999). Many faculty according to Spotts
(1999) interview implied that they could spend their time better in pursuing things the university
deems necessary for promotion. Faculty members will use EHRS when they feel there are
associated incentives and that their efforts will be recognized such as in a job promotion.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 51

The summary of assumed organizational influences from expected faculty members’
critical behavior when using the electronic health records system are demonstrated in Table 4.
Table 4, the summary of assumed organizational influences, details the assumed organizational
influences at the ABZ Dental School which are not limited to resources, cultural setting, cultural
model, policies, processes, and procedures.
Table 4
Summary of Assumed Organization Influences on Faculty’s Ability to Achieve the Performance
Goal

Assumed Organization Influences Research Literature
Resources (time; finances; people)
Faculty needs resources to successfully
implement electronic health records system, such
as swipers, signature pads, and so forth
Jha et al., 2006; Menachemi and Collum,
2011; Morton and Wiedenbeck, 2010;
Terry et al. 2008
Faculty needs effective training on EHRS use for
the first time
Jha et al., 2006; Menachemi and Collum,
2011; Morton and Wiedenbeck, 2010;
Terry et al. 2008
Faculty needs ongoing professional development
to meaningfully continue using EHRS
Jha et al., 2006; Menachemi and Collum,
2011; Morton and Wiedenbeck, 2010;
Terry et al. 2008
Faculty needs technological support to
effectively use EHRS
Jha et al., 2006; Menachemi and Collum,
2011; Morton and Wiedenbeck, 2010;
Terry et al. 2008
Faculty needs time to use EHRS efficiently Jha et al., 2006; Menachemi and Collum,
2011; Peled et al., 2009
Policies, Processes, and Procedures
Faculty needs to have policies that align with
their goal to use electronic health records system
all the time

Bowman, 2013; Sittig and Classen, 2010;
Sittig and Singh, 2009;
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 52

Table 4 (Cont’d.)
Assumed Organization Influences Research Literature
Faculty needs to feel that the organizational
policy aligns with their goal of 100% use of
EHRS
Boman, 2013; Sittig and Classen, 2010;
Sittig and Singh, 2009
Faculty needs to have procedures on how to use
the EHRS in recommending next steps in patient
care to the students
Boman, 2013; Sittig and Classen, 2010;
Sittig and Singh, 2009
The organization needs to have processes on
using the EHR system
Boman, 2013; Sittig and Classen, 2010;
Sittig and Singh, 2009
The organization needs to have policy and
procedures on electronically approving and
assigning grades to students’ completed work
100% of the time
Boman, 2013; Sittig and Classen, 2010;
Sittig and Singh, 2009
Cultural Setting
Faculty needs to be part of a culture that aligns
with the organizational goal of 100% use of
electronic health system
Jha et al., 2006; Morton and Wiedenbeck,
2010; Terry et al., 2008
Faculty needs to be part of the implementation
team for successful implementation
Jha et al., 2006; Morton and Wiedenbeck,
2010; Terry et al., 2008
Cultural Models
Organization needs to have expert role models
exhibiting best practices to faculty
Jha et al., 2006; Morton and Wiedenbeck,
2010; Peled et al., 2009; Terry et al., 2008
Incentives; rewards; recognition, etc.
Faculty needs to have incentives to use
electronic health records system all the time
Milano, Hardman, Plesiu, Rdesinski &
Biagioli, 2014; Sittig and Singh, 2009;
Spotts, 1999
Faculty needs to feel recognized on their effort
in using EHRS for student education and patient
care
Milano et al., 2014; Sittig and Singh,
2009; Spotts, 1999

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 53

Summary
The goal of this literature review was to identify the strategies used through known
research in examining the adoption of electronic health records system in healthcare
organizations. The review was organized using Clark and Estes’ (2008) “Big Three” causes of
performance gap. The factors examined in the process were:
● Faculty knowledge and skills;
● Their motivation to achieve the desired goal; and
● Organizational factors.
The assumed influences were identified in Table 2, Table 3, and Table 4. While this chapter
provided a discussion of the known peer reviewed research on what impacts the study and the
assumed influences, Chapter Three will include a detailed description of the methodology for the
project which is the process of collecting and validating data on the assumed influences
identified in this chapter.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 54

CHAPTER THREE: METHODOLOGY
Purpose of the Project and Questions
The purpose of this project was to conduct a gap analysis through examining the
knowledge, motivation, and organizational influences that interfere with ABZ Dental School’s
goal to be 100% electronic in providing patient care and dental education to the students 100% of
the time.
The questions that guided this gap analysis were the following:
1. What are the knowledge and skills, motivation, and organizational barriers that prevent
the faculty members of the predoctoral clinic of the ABZ Dental School from utilizing the
electronic health records system 100% of the time?
2. What are the knowledge and skills, motivation, and organizational solutions for faculty
members of the predoctoral clinic of the School to use the electronic health records
system 100% of the time?
Conceptual and Methodological Framework
The framework for the methodology in this study was the Gap Analysis problem solving
approach (GAP or Gap Analysis) (Clark & Estes, 2008; Rueda, 2011). Clark and Estes’ (2008)
gap analysis process helped to survey people, examine records, and observe work processes to
determine what was necessary in achieving goals. As cited by Clark and Estes (2008), different
people can have very different insights about problems and on how to accomplish goals
(solutions). They stated that it’s very important to take note of people’s perceptions about the
barriers they face in attempting to close gaps and in achieving desired goals (Clark & Estes,
2008). The Gap Analysis as stated by Clark and Estes (2008) must also capture important
documentation and other data about the goal and the links between relevant work systems
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 55

including adequate analysis of why goals are not met. As a result, Clark and Estes (2008)
recommend the Gap analysis process model which is made up of seven steps. Figure A
illustrates the steps as shown in Clark and Estes’ (2008) GAP model:
● Step 1: Goals: Identify measurable performance goals;
● Step 2: Current performance status: Quantify the current achievement at each level;
● Step 3: Gaps: Determine gaps between goals and current performance;
● Step 4: Causes: Hypothesize and validate how each of the three known causes of gap;
knowledge and skills, motivation, and organization, impact the gap.
The additional steps in the Clark and Estes’ (2008) gap analysis process are not included in this
chapter but are discussed in Chapters Four and Five of this study as illustrated:
● Step 5: Solutions: Recommended proposed solutions to close the gap;
● Step 6: Implementation: Plan for implementing proposed solutions;
● Step 7: Evaluate and modify for continual improvement.

Source: Adapted from (Clark and Estes, 2008)
Figure A: The Sequence of Steps in the Gap Analysis Process
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 56

Assessment of Performance Influences
In examining the adoption of electronic health records system in patient care and
students’ education, the “Big Three” causes of performance gaps as cited by Clark and Estes
(2008) were used. These “Big Three” assumed causes as discussed in Chapter Two were
people’s knowledge and skills (K), their motivation to achieve the goal (M), and the
organizational barriers (O) (Clark & Estes, 2008). The purpose of this KMO gap analysis, as
explained by Clark and Estes (2008), was to identify whether all faculty members have adequate
knowledge, motivation, and support from the organization to be able to accomplish the work
goals. The KMO table as referenced in Tables Five, Six, and Seven show the assumed causes of
the gap and the methods of assessments such as in surveys, interviews, observations, and through
reviewing documents.
Knowledge Assessment
It is important to determine if faculty members know how, when, what, why, where, and
who to achieve their performance goals (Clark & Estes, 2008). The assumed knowledge
influences were drawn from Chapter Two’s Assumed Knowledge Influence Table 2. Anderson
et al. (2001) Taxonomy for learning, teaching, and assessing were used in the assessment. They
categorized knowledge into four domains (a) the factual knowledge; (b) the conceptual
knowledge; (c) the procedural knowledge; and (d) the metacognitive knowledge (Anderson et al.,
2001) as illustrated in Table 5. The declarative factual, conceptual, procedural, and
metacognitive knowledge types were assessed using multiple choice questions for the survey
items created from using Anderson et al. (2001) knowledge assessment table. Faculty members
were interviewed as shown in the interview item as well as observed for further clarity on work
processes. In addition, document review was used in the procedural knowledge assessment
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 57

through extracting data to verify current processes such as how many completed students’ work
was recorded and graded electronically in one month, February 2017.
Table 5
Summary of Knowledge Influences and Method of Assessment

Assumed
Knowledge
Influences

Survey Item
Interview Item
P = Primary
questions
FU = Follow up
questions

Observation

Document
Review
Declarative
Factual (terms,
facts, concepts)
Faculty needs
to know what
electronic
health records
systems
(EHRS) are

Multiple
choice. An
electronic
health records
system stores
patient
information:
a. Partly on the
computer and
on paper
b. Fully on
computer(s)
c. On paper
d. Nowhere
P. Tell me about the
electronic records
system.

FU. What is the
name of the
electronic health
record system you
use?

Faculty needs
to know where
the whiteboard
is located
Multiple
choice. In the
predoctoral
clinic, the
whiteboard is…
a. not located
there
b. located by
the windows
c. located only
in sections A
and B of the
clinic
d. located in
the four
sections of
the clinic
P. Tell me about the
whiteboards in the
clinic?

FU. Where are they
located?
Do faculty
members go to
the whiteboard?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 58

Table 5 (Cont’d.)

Assumed
Knowledge
Influences

Survey Item
Interview Item
P = Primary
questions
FU = Follow up
questions

Observation

Document
Review
Faculty needs to
know the goal of
EHRS
implementation
Multiple choice.
The
implementation
goal of the
electronic health
records system is to
document patient
information
electronically:
a. 50% of the
time
b. 10% of the time
c. 100% of the
time
d. 75% of the time
FU. What is the
goal of the
electronic health
records system
implementation?

Declarative
Conceptual
(categories,
process models,
principles,
relationships)

Faculty needs to
know the
purpose of the
whiteboard
Multiple choice.
The whiteboard in
the predoctoral
clinic is for…
1. Clinic
decoration
2. Requesting
maintenance on
the clinic floor
3. Requesting
supervisor’s
attention by
students
4. I don’t know
FU. What is the
purpose of the
whiteboard?
What do faculty
members do
with the
whiteboard?

Faculty needs to
know the
purpose of the
electronic health
records systems
The purpose of the
EHRS is to:
a. streamline
record keeping
for
FU. What do
you use the
electronic health
record system
for?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 59

Table 5 (Cont’d.)

Assumed
Knowledge
Influences

Survey Item
Interview
Item
P = Primary
questions
FU = Follow
up questions

Observation

Document
Review
billing
purposes
b. aggregate all
patient information
into one place
c. reduce the use of
paper and conserve
resources
d. none of the above
e. All of the above

Faculty needs to
know how the
electronic health
records system
works
At what stage in the
EHRS does the
faculty provide input
to the student about
patient care (please
select all that apply)?
FU. Please
explain how
the electronic
health records
system
works?

a. Before a patient is
checked in
b. When the patient is
seated.
c. Throughout the
patient cared. At
the end of the
treatment

Faculty needs to
know the
relationship
between the
whiteboard and
the electronic
health record
system
FU. Please
explain the
relationship
between the
whiteboard
and the
electronic
health records
system?
How does the
faculty show the
relationship
between the
whiteboard and
the electronic
health records
system?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 60

Table 5 (Cont’d.)

Assumed
Knowledge
Influences

Survey Item
Interview Item
P = Primary
questions
FU = Follow
up questions

Observation

Document
Review
Faculty needs to
know how their
use of EHRS
measures up to
the goal of the
school
Multiple choice.
How does your use
of EHRS measure
up to the goal of the
school?
a. 100% of the
School's goal
b. 75% of the
School’s goal
c. As a result of my
50% use of the
EHRS
d. Does not
measure up to the
goal of the school
FU. How does
your use of
EHRS
measure up to
the goal of the
school?

Procedural
Faculty need to
know how to
review student’s
documented
patient treatment
code
electronically
Multiple choice.
How should one
review a student’s
documented patient
treatment code
electronically?
a. By listening to
the student
b. By making sure
the correct
treatment code is
entered on the
computer
c. By making sure
the correct code is
noted on paper
d. I do not review
treatment codes
on the computer
P. Please
explain how
you review
students’
documented
patient
treatment code
electronically?
Observe how
faculty reviews
students’
documented
treatment code
electronically

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 61

Table 5 (Cont’d.)

Assumed
Knowledge
Influences

Survey Item
Interview Item
P = Primary
questions
FU = Follow
up questions

Observation

Document Review
Faculty needs to
know how to
review students’
documented
treatment notes
electronically
Multiple choice.
How do you review a
students’ documented
notes electronically?
1, By listening to the
student
2. By making sure
accurate notes are
entered
electronically
3. By making sure
there is paper
documentation
4. I do not review
notes
FU. Please
explain how
you review a
students’
documented
notes
electronically?
Observe how
faculty reviews
students’
documented
notes
electronically

Faculty needs to
know how to
correctly enter
patient data
electronically
FU. Please
explain the
steps you take
to enter patient
data
electronically?
Reports from the
system to see how
many procedure
codes were
entered within a
month
Faculty needs to
know how to
correctly enter
notes
electronically
FU. Please
explain the
steps you take
to enter notes
electronically?

Faculty needs to
be able to follow
the steps in using
the EHRS
FU. Please
explain the
steps you take
in using the
EHR system?
Observe faculty
members’ steps
in using the
EHR system

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 62

Table 5 (Cont’d.)

Assumed
Knowledge
Influences

Survey Item
Interview Item
P = Primary
questions
FU = Follow up
questions

Observation

Document
Review
Faculty needs to
know how to
electronically
approve and
assign grade to
students’
completed work.
Multiple
choice. How
do you
approve
students’
completed
work?
1. On paper
2. Electronica
lly through
swiping my
card
3. I tell
someone,
and they
enter it into
the
computer
for me.
4. Verbally
5. I do not
approve
students’
completed
work
FU. Please explain
how you approve
students
completed work?
Observe the
faculty to see
how they approve
students
completed work
Report of
completed
procedure
codes within
one month
Report of
completed
procedure
codes but not
approved
within one
month
Metacognitive
Faculty needs to
know how to
reflect on their
utilization of the
EHR system
P. Please explain
how you reflect on
your EHR system
utilization?

FU. How does your
choice to use or not
use the EHR system
impact others?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 63

Faculty needs to
self-reflect on
how to teach
students patient
care using the
EHRS
FU. Please explain
how you teach
students patient care
using the EHR
system?

Motivation Assessment
According to Schunk et al. (2012), motivation is the process whereby goal-directed
activity is instigated and sustained. Motivation as discussed by Clark and Estes (2008)
influenced three very critical aspects of accomplishing a goal. They noted the first to be for the
stakeholder to choose to work towards a goal; the second is for them to persist at the work until
the goal is accomplished; and the third is how much mental effort is invested to get the job done.
Chapter Two of this study demonstrated the assumed motivation influences which are shown
below along with the assumed validation process through survey questions, interviews, and
observations. Using Qualtrics sliding scale, the survey items for value were created for the
assumed motivation influences. Value discussed how individuals adopted a course of action
which they either persisted in even when distracted or avoided (Clark & Estes, 2008). The
assessment for value was established with the intent for the faculty members to rate how they
valued their work processes, as itemized in Table 6. Self-efficacy as defined by Bandura (2006)
is the individual’s judgement of their capabilities which basically mean individual’s confidence
in fulfilling their tasks. Self-efficacy was assessed using Bandura’s rating scale of how confident
one was, as at the time they were completing the survey, in accomplishing their work (Bandura,
2006). Mood denotes how positive or negative one feels which has no specific prior cause
(Schunk, et al., 2012). Mood will be assessed using Qualtrics sliding scale on how positive
faculty members felt about doing their work as itemized in Table 6. Attribution is another
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 64

motivational influence, which is the perceived cause of an outcome (Schunk, et al., 2012).
Attribution was assessed using Kirkpatrick and Kirkpatrick’s (2016) rating scale by asking
faculty members to denote what they attributed the success of implementing electronic health
records system to. The faculty members had the ability to select all that apply including “none of
the above” if none of the options applied to the faculty member. Interview questions asked are
shown in Table 6.
Table 6
Summary of Motivation Influences and Method of Assessment
Assumed Motivation
Influences

Survey Item

Interview Item

Value Please rate the extent
to which you value
the following using
the scale below:
0 Do not value at all
1
2
3
4
5 Moderately value
6
7
8
9
10 Highly value

Faculty needs to value their
use of electronic health
record system in patient care
and students’ education
Using the EHRS for
patient care
P. How do you value
your use of EHR system
in patient care and
students’ education?

Using the EHRS for
student education
FU. How do you value
your use of EHRS in your
student's education?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 65

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

Faculty needs to value
reviewing students
documented patient
treatment codes and notes
electronically on the
computer.
Student’s
documented patient
treatment codes
electronically
FU. How do you value
reviewing student’s
documented patient
treatment codes
electronically?

Reviewing student’s
documented notes
electronically
FU. How do you value
reviewing student’s
documented notes
electronically?

Faculty needs to value
knowing how to correctly
enter patient treatment codes
and notes in the EHRS
Knowing how to
correctly enter
patient treatment
codes in the EHR
system

Knowing how to
correctly enter notes
in the EHR system

Faculty needs to value
recommending next steps in
patient care to the students
using EHRs
Recommending next
steps in patient care
to your students:

Faculty needs to value the
process of electronically
approving and assigning
grade to students’ completed
work
The process of
electronically
approving your
student’s completed
work

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 66

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

The process of
electronically
assigning grades to
your student’s
completed work

Self-Efficacy Using the scale
below, please rate
how confident you
are that you can do
the following right
now:
0 Not confident at
all
1
2
3
4
5 Moderately
confident
6
7
8
9
10 Highly confident

Faculty needs to have
confidence that they can use
the electronic health records
system to document patient
care
Using the electronic
health records
system to document
patient care
electronically
P. Please comment on how
confident you feel using
the electronic health
records system to
document patient care?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 67

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

Faculty needs to have
confidence in reviewing
student’s documented
patient treatment codes and
notes electronically on the
computer.
Reviewing students’
documented patient
treatment codes
electronically

Reviewing students’
notes electronically

Faculty needs to have
confidence following the
steps in using the EHR
system
Following the steps
involved in using
EHR system

Faculty needs to have
confidence using electronic
health record system to
recommend next steps in
patient care to the students
Using EHR system
to recommend next
steps in patient care
to the students

Faculty needs to have
confidence in electronically
approving and assigning
grade to students’ completed
work.
Using EHR system
in approving
students’ completed
work

Using EHR system
in assigning grades
to students’
completed work

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 68

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

Faculty needs to have
confidence using the
whiteboard to know when
students need them
Using the
whiteboard to know
when the students
need my assistance

Mood Using the scale
below, please rate
how positive you
feel about doing the
following:
0 Not positive at all
1
2
3
4
5 Moderately
positive
6
7
8
9
10 Highly positive

Faculty needs to feel
positive about using the
electronic health record
system in correctly entering
patient data and treatment
notes
Using the electronic
health record system
in correctly entering
patient data
P. Please tell me how you
feel using the electronic
health records system in
correctly entering patient
data?

Using the electronic
health record system
in correctly entering
treatment notes
FU. Please tell me how
you feel using the
electronic health records
system in correctly
entering treatment notes?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 69

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

Faculty needs to feel
positive about reviewing
student’s documented
patient treatment code and
notes electronically on the
computer.
Reviewing students
documented patient
treatment code
electronically
FU. How do you feel
reviewing students
documented patient
treatment code on the
computer?

Reviewing students
documented notes
electronically
FU. How do you feel
reviewing students
documented notes on the
computer?

Faculty needs to feel
positive following the steps
in using the EHR system
Following the steps
in using the EHR
system
FU. How do you feel
following the steps in using
the EHR system?

Faculty needs to feel
positive using EHRS in
recommending next steps in
patient care to the students
Using EHRS in
recommending next
steps in patient care
to the students
FU. How do you feel
using EHRS in
recommending next steps
in patient care to the
students?

Faculty needs to feel
positive in electronically
approving and assigning
grades to students
completed work
Electronically
approving students
completed work
FU. How do you feel in
electronically approving
students completed work?

Electronically
assigning grades to
students completed
work
FU. How do you feel in
electronically assigning
grades to students
completed work?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 70

Table 6 (Cont’d.)
Assumed Motivation
Influences

Survey Item

Interview Item

Attribution
Faculty needs to attribute
the success of electronic
health records system on
their efforts to use it.
Successful
implementation of
EHR system is due
to?
Please check all that
apply.
a. Incentives
b. Leadership
c. Dentists helping
each other
d. The requirement
to use it
e. The training
f. My efforts to use
the system
g. The effectiveness
of the system
h. None of the above
P. To what do you
attribute the success of the
EHR system use?

Organization/Culture/Context Assessment
Clark and Estes (2008) explained that organizational barriers are usually the source when
knowledge and motivation can be ruled out as the cause of the gap. The assumed organizational
barriers were identified in Chapter Two of this. The method of assessments per influence are
shown in Table 7 using instruments for surveys, interviews, and observations for the resources,
policies, processes, and procedures as well as culture. Resources are tangible supplies and
equipment that are needed to be able to accomplish goals (Clark & Estes, 2008). Resources were
assessed using a Likert scale to determine the extent at which faculty members agree or disagree
with statements regarding the resources they have for accomplishing the goal of using the
electronic health records system all the time for patient care and students’ education. Policies,
processes, and procedures were set guidelines by the governing body of the organization which
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 71

ensured that the goal of the organization was translated into steps for accomplishing the
organizational goal (BusinessDictionary.com, 2017). Using a Likert scale as in resources,
faculty members were assessed to know the extent at which they agreed or disagreed with
statements regarding policies, processes, and procedures. Culture as defined by Clark and Estes
(2008) are the core values, beliefs, goals, emotions, and processes learned as individuals develop
and grow over time at their work environment. Culture, incentives, and rewards were assessed
using the Likert scale to rate the extent at which faculty members agreed or disagreed with
statements regarding those type of influences in the organization. Interview questions regarding
the organizational influences were asked and documents were reviewed as shown in Table 7.
Table 7
Summary of Organization Influences and Method of Assessment

Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
Resources
(time; finances;
people)
Using the scale
below, rate the
extent to which you
agree or disagree
with the following
statements regarding
the resources you
have for using the
EHRS:
1 Strongly Disagree
2. Moderately
Disagree
3. Neither Agree or
Disagree

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 72

Table 7 Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
4. Moderately
Agree
5. Strongly Agree

Faculty need
resources such
as swipers,
signature pads,
etc. to
successfully
implement the
electronic health
records system
The school provides
resources such as
swipers for
approving students’
completed notes
electronically?
P. What
resources will
you need to
successfully
implement EHR
system?
Are there
resources
such as
swipers,
signature
pads, etc. in
the clinic for
faculty use?

The school provides
Computers for
electronically
documenting patient
information?

The school provides
Signature Pads for
patients’ consent?

The school provides
Scanners for storing
patients’ records
electronically?

Faculty need
time to use the
EHRS
I have enough time
to use the EHRS in
educating the
students.
FU. How much
time do you
have for the
EHRS use?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 73

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
Faculty need to
have confidence
that the system
is accurate and
secure (and
won’t break
down) when
they use it
I am confident that
the data stored in the
EHR system is
accurate.
FU. Please
explain your
confidence that
the data on the
EHR system is
accurate?

FU. Please
explain your
confidence that
the system is
secure?

FU. Please
explain your
confidence that
the EHRS will
not break down
while using it?

FU. On the
survey X% of
faculty said
they had a mild
degree of
confidence or
little to no
confidence in
the system.
Why do you
think that is?

I’m confident that
EHRS is a reliable
system.

I am confident that
EHRS data is
secured.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 74

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
Faculty need
effective
training on their
first EHRS use
I received training to
use EHRS
successfully.
FU. Please
explain the kind
of training you
received at the
first time you
used the EHR
system?

Faculty need
ongoing
professional
development to
meaningfully
continue using
EHRS
I have additional
training
opportunities to
ensure that I can use
the EHRS
successfully.
FU. Please
explain how
you improve
your use of
EHR system?

Faculty need
technological
support to
effectively use
EHRS
I receive technical
support on the
EHRS use when the
need arises.
FU. Please
explain the
availability of
technological
support when
you need it for
EHRS use?

Policies,
Processes, &
Procedures
Using the scale
below, rate the
extent to which you
agree or disagree
with the following
statements regarding
the school’s Policies
and Procedures for
EHRS
implementation:
1 Strongly Disagree
2. Moderately
Disagree
3. Neither Agree or
Disagree
P. Please
explain the
policies and
procedures that
align with your
use of the
EHRS?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 75

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
4. Moderately Agree
5. Strongly Agree

Faculty need to
have policies
that align with
their goal to use
electronic health
records system
all the time
Our policies align
with our goal of
using EHR system.

There are
procedures on
how to use the
EHRS in
recommending
next steps in
patient care to
the students
We have a standard
procedure on how to
use the EHR system
for recommending
next steps in patient
care to our students.

The
organization
needs to have
policy and
procedures on
electronically
approving
students’
completed work
100% of the
time
The school has a
policy governing
electronically
approving students’
completed work.
Verify if
document
exists and
review
documents if
it/they exist

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 76

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
The
organization
needs to have
policy and
procedures on
electronically
assigning grades
to students’
completed work
100% of the
time
The school has a
policy governing
electronically
assigning grades to
students’ completed
work.
Verify if
document
exists and
review
document if
it exists
The school has a
procedure on how to
electronically assign
grades to students
completed work.

Culture Using the scale
below, rate the
extent to which you
agree or disagree
with the following
statements regarding
the culture of the
school in the EHRS
implementation:
1 Strongly Disagree
2. Moderately
Disagree
3. Neither Agree or
Disagree
4. Moderately
Agree
5. Strongly Agree

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 77

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
Faculty need to
be part of a
culture that
aligns with the
organizational
goal of 100%
use of the
electronic health
records system
The culture of the
school supports
100% use of the
EHRS.
P. To what
extent does the
culture of the
org. support
your using the
EHR system
100% of the
time

Faculty need to
be part of the
implementation
team for
successful
implementation
We help each other
use the EHRS
effectively.
FU. Please
explain how
you help each
other to use the
EHRS
effectively?

Organization
needs to have
expert role
models
exhibiting best
practices to
faculty
I learn more about
using the EHRS
effectively from
seeing others use it.

Incentives;
rewards;
recognition, etc.

Faculty needs to
have incentives
to use electronic
health records
system
The school provides
incentives to use the
EHRS.
P. What kind
of incentives do
you receive for
using the
electronic
health records
system?

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 78

Table 7 (Cont’d.)
Assumed
Organization
Influences

Survey Item

Interview Item

Observation

Document
Review
Faculty needs to
feel recognized
on their effort in
using EHRS for
student
education
My efforts to use the
EHR system for
student education
are recognized.
FU. How are
your efforts in
using the EHR
system for
student
education?

Faculty needs to
feel recognized
on their effort in
using EHRS for
patient care
My efforts to use
EHRS for patient
care are recognized.
FU. How
important to the
organization is
it for you to use
EHRS in patient
care and student
education?

Participating Stakeholders and Sample Selection
The stakeholder group of focus for this paper on examining the adoption of electronic
health records system in the predoctoral clinic of the ABZ Dental School was the ABZ Dental
School, predoctoral, faculty members. At the ABZ Dental School, there were approximately 565
faculty members including the full-time, part-time, and volunteer faculty members. All 237
predoctoral faculty members were solicited to participate in the survey. Those who participated
in the survey were asked to volunteer to participate in the follow up interview. Those who
participated in the interview were asked to volunteer to participate in a follow up observation.
Sample
To identify the participants in the survey, this study used typical purposeful sampling as
described by Merriam and Tisdell (2015) in which representativeness of individuals in the setting
of interest were identified. This sample method was used by selecting only those faculty
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 79

members who worked in the predoctoral clinic. There were approximately 237 predoctoral
faculty members. All of them were selected for a survey because they were the primary users of
the electronic health records system in the predoctoral clinic.
For the interview, a sample was drawn from those faculty who participated in the survey
as they volunteered to be interviewed. At the end of the survey, after submitting their
anonymous responses, the participants were asked if they would be willing to participate in a
follow-up interview. Those who participated in the follow up interview were asked to volunteer
to participate in the observation. The purpose of the observation was to further triangulate the
data collected in the survey and the interview.
Recruitment
For the purpose of this study, the recruitment strategy was to solicit all faculty members
who worked in the predoctoral clinic of the ABZ Dental School through the listserv. With the
permission of the school, the Executive Associate Dean for Academic, Faculty, and Student
Affairs, the predoctoral faculty members were sent a survey link through the school’s listserv
email address. A recruitment email that aligned with the Institutional Review Board (IRB)
guidelines was sent for faculty participation in a survey. The survey was anonymous. In the
anonymous survey, participants were asked to provide their name and email address, if they
would like to participate in a follow-up interview. At the follow up interview, participation for
observations were solicited.
Instrumentation
The data collection instruments used for this study included a survey, a semi-structured
interview protocol, an observation protocol, and a document analysis protocol.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 80

Survey
Survey items were constructed to measure whether there was a gap in assumed causes by
using Clark and Estes’ (2008) Knowledge and Skills (K), Motivation (M), and Organizational
(O) framework regarding the predoctoral faculty members of the ABZ Dental School. For each
assumed cause using the critical behavior of the faculty members, survey items were developed.
The survey contained 60 survey items; 10 items in relation to faculty knowledge; 26 items in
relation to motivation, and 24 items in relation to organizational factors. The survey shown in
Table 5, Table 6, and Table 7 was derived from the Chapter Two literature review. The survey
was built using Qualtrics application and distributed to all the predoctoral faculty members using
the email listserv.
Knowledge and Skills. To find out if there was a gap with the predoctoral faculty
members’ knowledge in the use of electronic health records system, the survey items for
assumed knowledge influences were created using Anderson et al. (2001) knowledge assessment
table as shown in Table 5. The survey items were categorized using factual, conceptual,
procedural, and metacognitive knowledge. The knowledge and skills survey items consisted of
general questions about the electronic health records system knowledge including the basic
information, the purpose of the system, the steps in using the system, and the metacognitive
strategies. An example of a conceptual knowledge survey question was using multiple choice (a
through e), the purpose of EHRS is to (a) streamline the record keeping for billing purposes; (b)
aggregate all patient information into one place; (c) reduce the use of paper and conserve
resources; (d) none of the above; (e) all the above.
Motivation. To find out if there was a motivational gap with the predoctoral faculty
members’ use of the electronic health records system, survey items were constructed. Studies on
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motivation show that self-efficacy plays a role in motivation (Bandura, 2006; Schunk, et al.,
2012). When faculty members believe and have confidence that they can accomplish a task, they
are motivated to perform that task while if they believe they cannot successfully accomplish the
task, the motivation to accomplish the task decreases. Qualtrics sliding scale (from 0 = “Do not
value at all” to 10 = “Highly value”) were used for assessing value. Qualtrics sliding scale (from
0 = “Not positive at all” to 10 = “Highly positive”) were used for mood assumed influences as
shown in Table 6. Bandura’s (2006) self-efficacy scale (from 0 = “Not confident at all” to 10 =
“Highly confident”) were used for self-efficacy assumed influences with a confident question of
“How confident are you as of now in using the electronic health records system in students’
education?” Kirkpatrick and Kirkpatrick’s (2016) rating scale items which included “please
check all that apply” option amongst other options were used in the attribution survey items as
shown in Table 6. The survey attribution items included questions such as “Who do faculty
members attribute the success of electronic health records system to?” The motivation survey
questions are shown in Table 6.
Organization. To investigate if the organization is one of the causes of the gap in the
predoctoral faculty members use of electronic health records system, survey items were
constructed. The survey items included questions such as, “Does the culture of the school
supports 100% use of the electronic health records system?” A 5-point Likert scale (from 1 =
“Strongly disagree” to 5 = “Strongly agree”) was utilized in the creation of the survey items for
resources, culture, policies, processes, and procedures as shown in Table 7.
Interview Protocol
To triangulate the data collected in the survey, open-ended interviews were conducted
using a subset of the predoctoral faculty members who volunteered at the end of the survey. The
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questions asked are shown in Table 5 for knowledge, Table 6 for motivation, and Table 7 for
organizational factors. The interview consisted of 47 interview questions with 12 primary
interview questions and 35 follow up questions. An example of a conceptual knowledge
interview question that was asked is “Please explain the relationship between the whiteboard and
the electronic health records system?” An example of a motivation follow-up interview question
was “Please comment on how confident you feel using the electronic health records system to
document patient care?” And an example of an organizational follow up interview question was
“Please explain your confidence that the EHRS will not break down while using it?” The
interview didn't last more than 20 minutes per participant.
Observation Protocol
Faculty members who participated in the interviews were asked to volunteer to be
observed. Observations took place in the predoctoral clinic where faculty provide patient care
and students’ education. The list of items observed were itemized in the Knowledge and
Organizational assumed influences table (Table 5 and Table 7) which include observational
items such as if the predoctoral faculty members’ use of the electronic health records all the time
in patient care and in students’ education or did they use paper charts as well. An example of a
procedural knowledge observation was on how faculty members review students’ documented
notes electronically. Organizationally, resources were observed. An example was whether
faculty had the resources they needed such as swipers to successfully approve students’
completed work electronically.
Document Analysis Protocol
To further triangulate data, reports generated from the electronic health records system
were analyzed. De-identified data were generated from the electronic health records database on
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the total number of students completed dental procedures and the total number of approvals of
students’ completed work by faculty in the month of February 2017. A comparison of the
student data and the faculty data showed if all student procedure codes entered in the system
were approved electronically by the faculty to further triangulate faculty use of the system.
Furthermore, the ABZ Dental School was asked to provide documentation on the existing
policies and procedures governing the school’s use of the electronic records system as shown in
Table 7. As faculty members were expected to use the electronic health records system all the
time, this provided a verification for the existence of policy and procedures guiding and outlining
the faculty’s use of the system. On the other hand, if the policy and procedures did not exist,
then, faculty members may not know how to access the resources necessary in the use of the
system.
Data Collection
Following University of Southern California Institutional Review Board (IRB) approval,
participants were solicited by email listserv. A request was approved for an email with the
survey link to be sent through the email listserv by the Executive Associate Dean of Academics,
Students, Faculty Affairs to all the predoctoral faculty members of ABZ School of Dentistry.
Surveys
Data was collected through a survey. The email sent through the email listserv had a link
which when clicked on opened the survey. An information sheet was attached in the survey
body notifying the participants that their completing the survey denotes their willingness to
participate. The first email reminder was sent to the faculty members on the sixth day, the
second email reminder on the 12th day, an announcement was made at the dental faculty meeting
about the survey on the 17th day, and the survey closed on the 21st day.
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Interviews
The interviews were scheduled ahead of time (at least two days before interview date),
and the interviewees chose the location that was conducive for them, in the interviewees’ space.
The interviews were recorded and then transcribed. The interviews did not last more than 20
minutes. Sixteen participants volunteered to participate in the interview. Ten of the 16
volunteered participated in the interview and interviews were stopped when saturation was
reached (Merriam & Tisdell, 2015); that is, when it became noticeable that the responses were
duplicative.
Observations
The predoctoral faculty members who were interviewed were asked to be observed in the
predoctoral clinic of the ABZ Dental School. All predoctoral faculty members who volunteered
to participate in the observation were observed at least once until saturation (Merriam & Tisdell,
2015) of the findings was reached. Observer as participant (Merriam & Tisdell, 2015) was the
role of the observer in this study. The observer’s activities were made obvious to the individuals
in the clinic where the observation was scheduled to take place. The observation was scheduled
ahead of time (at least 7 days before the observation date) and did not last longer than 30 minutes
per faculty member. Eight volunteered faculty members were observed.
Document Analysis
The documents analyzed included the policies and procedures governing the practice of
the predoctoral clinic as in Table 7. As faculty members were expected to use the electronic
health records system all the time, a verification for the existence of policy and procedures
guiding and showing the steps in the use of the system were collected.
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De-identified data were pulled from the electronic health records system database. The
data pulled were on the total number of students’ completed procedure and the total number of
approved completed procedure by faculty members in February 2017. If gap was found between
the two records, it would have prompted the question of why faculty were not approving all
students completed work electronically. Access to the data and documentation were requested
from the Clinical Dean of the predoctoral program. After access was approved, the policies and
procedures were gathered through the ABZ Dental School’s intranet. The data were generated
from the electronic health records system database.
Data Analysis
Surveys
The data gathered from the survey were analyzed using descriptive statistics which
included the mean and standard deviation scores. Frequencies among the knowledge,
motivation, and organization were analyzed. When analyzing for knowledge and skills, the types
of knowledge were categorized into factual, conceptual, procedural, and metacognitive
knowledge types. To examine motivation, the data were identified and grouped into value, self-
efficacy, mood, and attribution. To examine the organization, the data were categorized into
resources, culture, policies, processes, and procedure.
Interviews
The recorded interviews were first transcribed with the addition of collected memos
during each interview. The transcribed documents were reviewed and coded as shown in Tables
5, 6, and 7 and based on Clark and Estes’ (2008) knowledge, motivation, and organization
framework using frequencies and common themes. The frequencies and common themes in
knowledge were categorized into factual, conceptual, procedural, and metacognitive knowledge
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types. From the interviews, the variables associated with motivation were identified and grouped
into value, self-efficacy, mood, and attribution. Finally, the variables associated with the
organization were categorized into resources, culture, policies, processes, and procedure.
Any findings not included in one of these categories would have been analyzed using
grounded theory to identify emerging themes (Corbin & Strauss, 2008).
Observations
As suggested by Merriam and Tisdell (2015), the data analysis began at the same time as
the data collection. Field notes, observer comments, and artifacts were collected during the
observations as recommended by Merriam and Tisdell. The predoctoral faculty members’
process of using the electronic health records system in patient care and students’ education were
observed. The documented observational transcripts were coded using a coding scheme based
on Tables 5, 6, and 7.
Documents
As suggested by Clark and Estes’ (2008) framework, documents on policies, processes,
and procedures were reviewed and identified to show whether the policies existed or not. It was
noted that the policies and procedures existed. The documents were analyzed using a coding
scheme to identify the alignment of specific policy provisions with the knowledge influences on
Table 5.
De-identified data were pulled from the electronic health records system. The data were
on the total number of predoctoral students’ completed procedures and the total number of
approved completed procedures by the predoctoral faculty members in February 2017. The data
were extracted and analyzed in an excel spreadsheet. The number of student-completed dental
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procedure records were totaled, and the faculty approval records totaled. A comparison of the
totals was made to determine the number and percentage of missing faculty approvals.
Trustworthiness of Data
Triangulation strategy was used for credibility and trustworthiness check. As described
by Merriam and Tisdell (2015), triangulation is the using of multiple investigators, sources of
data or data collection methods to confirm evolving findings. Thus, this study triangulated the
findings and results of the survey, interviews, observations, and documents to enhance the
trustworthiness of the data.
Role of Investigator
The role of the investigator was to explain the purpose of the study to the individuals
involved in the study (Merriam & Tisdell, 2015). The author of this project was the subject
matter expert; the supervisor of the electronic health records system at the ABZ Dental School.
The author was also the Chair of the Electronic Health Records subcommittee. The role of the
author at the school included implementing solutions for best practices in the use of the system.
The predoctoral faculty members functioned in a different department from the author but used
the electronic health records system to provide care to the patients and to educate the students. It
was assumed that the faculty members would share information with the author as the
expectation was the author would be able to help improve and implement solutions if applicable.
The author was aware of the role and impact on relationships with the predoctoral faculty as
people rather than as subjects for this study. The author considered ahead of time, the protection
of the participants, discussed their right to privacy, confidentiality, and was transparent with
them in the submission to the institution’s Internal Review Board.

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Limitations
This project was a study on a clinic of a dental school. The findings were only applicable
to the predoctoral clinic of the ABZ Dental School. As a result, the recommendations were fully
functional in that clinic only. The gaps that were identified and the solutions that were
recommended were not generalized to other health care schools due to the study being from a
specific clinic in a dental school. The author of the project worked at the ABZ Dental School.
This could have brought bias to the study especially if the author interpreted the data to validate
their own beliefs in the cause of the gap.

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CHAPTER FOUR: RESULTS AND FINDINGS

This project was designed to assist the ABZ Dental School in examining the adoption of
electronic health records system in patient care and students’ education. The framework used in
this project was the Clark and Estes’ (2008) GAP Analysis Process Model. This model was used
to examine the assumed knowledge and skills, motivation, and organizational causes that could
be preventing ABZ Dental School from accomplishing its goal to be 100% electronic in
providing patient care and dental education to the students 100% of the time. The knowledge
types used in assessing the predoctoral faculty members of the ABZ Dental School were factual,
conceptual, procedural, and metacognitive knowledge types. For motivation assessment, value,
self-efficacy, mood, and attribution were used. For assessing the organizational factors,
resources, policies, processes, and procedures, and culture were used in checking for
organizational influences.
As discussed in Chapter Three, this study utilized a qualitative and quantitative mixed-
method approach. A survey was used to gather the quantitative data while interviews,
observations, and document reviews were used for qualitative data. The mixed method was used
to answer the project’s question about identifying the potential gaps in faculty knowledge and
skills, motivation, and organizational barriers in using the electronic health records system 100%
of the time in students’ education and patients’ care. In the next section, the results of the
survey, interviews, observations, and document reviews are organized using assumed influences
in the knowledge and skills, motivation, and organizational factors.

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Participating Stakeholders
The predoctoral faculty members of the ABZ Dental School were the stakeholder of
study. To protect anonymity, an email with a survey link was sent through the faculty listserv to
all dental faculty members with the goal of recruiting all 237 predoctoral faculty members (61
full-time, 79 part-time, and 97 volunteers); 49 predoctoral faculty members (21%) responded to
the survey. Of the 49 respondents, 33 were full-time, 13 were part-time, and three were
volunteer predoctoral faculty members. Twenty-five participants were female (51%) and 24
were male (49%). For a complete breakdown of the demographic data, see Appendix A.
Data Validation
Triangulation strategy was used for credibility and trustworthiness check (Merriam &
Tisdell, 2015). Findings on the assumed causes of the predoctoral faculty, not using EHRS
100% of the time, were verified with the use of an anonymous, 60-survey items to all predoctoral
dental faculty members. To clarify the survey findings as well as to learn more about the
predoctoral dental faculty members’ process, 10 predoctoral faculty members, who volunteered,
were interviewed. Interview questions, including 12 primary questions and follow up questions,
were used as in the survey to assess the predoctoral faculty members’ assumed knowledge,
motivation, and organizational causes for not using the electronic health record 100% of the time
in providing patients’ care and students’ education.
For further triangulation, eight of the interviewed predoctoral faculty members were
observed at their place of work, the predoctoral clinic. Observations were conducted for a
clearer view of the findings from the survey and the interview. Finally, for a more in depth
understanding, documents were collected to verify information gathered from the survey,
interviews, and observations. The document analysis focused on the number of approved
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completed procedure codes for the month of February 2017 and the existence of policies and
procedures documents that guided the activities of the predoctoral faculty members.
Criteria for Validation of the Data
The survey, interviews, observations, and reviewed documents were validated as further
discussed.
Survey. Data from the survey were reported using descriptive statistics which included
the mean and standard deviation scores. The validation criteria varied based on the kind of
questions and expected responses. The results were reported differently per knowledge,
motivation, and organizational category.
Knowledge category. In the knowledge category, three types of knowledge were
examined in the survey. They were the factual, conceptual, and the procedural knowledge types.
The assumption, as described in the previous chapters, was that there was a knowledge gap with
the predoctoral faculty members’ use of the electronic health records system. Therefore, a high
response rate on the expected correct answer does not validate the assumed knowledge gap while
a knowledge type question with a low response rate on the expected correct answer validates the
assumed knowledge gap. For example, a 75% and above correct response rate on a knowledge
question shows a 25% knowledge gap.
Motivation category. In the motivation category, value, self-efficacy, mood, and
attribution were the motivation types considered. The survey data were collected using Qualtrics
sliding scales which ranged from 0 (Do not) to 10 (Highly). An example of the Qualtrics sliding
scale used for value ranged from 0 (Do not value) to 10 (Highly value). The mean scores of the
results were calculated. Predoctoral faculty members high meant scores for motivation to use the
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EHRS for patient care and students’ education did not validate the assumed gap while low mean
motivation scores validated the assumed gap.
Organizational category. In the Organizational factors category, a five-point Likert scale
was developed with responses ranging from “Strongly Disagree,” “Moderately Disagree,”
“Neither Agree nor Disagree,” “Moderately Agree,” to “Strongly Agree.” The scores represent
the predoctoral faculty members’ perception on the organizational influence. The organizational
factors considered included resources, policies and procedures, and culture. Validation of this
category differed in each category, so they are reported based on aggregate number of response
answer narrative. For example, a 50% and above strongly disagree response denoted a 50%
organizational influence gap.
Interviews. The data from the semi-structured interview of the predoctoral faculty
members provided deeper and richer insight into the knowledge, motivation, and organizational
assumed influences. Validation of the assumed influences was based on common responses
from the participants.
Observations. Data from observations of the predoctoral faculty members in the clinic
were validated based on the number of observed practices the faculty had in common. Practices
observed included the steps predoctoral faculty members took to accomplish their goal of using
the EHRS 100% of the time in patients care and students’ education.
Document review. The data from reviewed documents and database were used to verify
and answer underlining questions regarding predoctoral faculty members’ use of the EHRS.
Data pulled from the documents included the policies and procedures guiding the use of EHRS,
how many procedure codes were completed in February 2017, and how many of the completed
procedure codes were approved.
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Results and Findings for Knowledge Causes
The results and findings of the knowledge causes were reported using the knowledge
categories and assumed knowledge influences for each category. In the knowledge category,
four types of knowledge were examined. They are the factual, the conceptual, the procedural,
and the metacognitive knowledge types as shown in the Tables below. There is no table for
metacognitive knowledge type as the influence was not surveyed
Factual Knowledge

Assumed knowledge influence #1: Faculty members need to know what electronic
health records systems are. The assumption is that faculty did not know what electronic health
records systems are.
Survey results. As shown in Table 8, 85% of faculty knew what an electronic health
records system is. As the threshold for validation of the survey results for knowledge was 75%,
this gap was not validated. However, this also showed that an improvement can be made for
users to understand the meaning of EHRS as 15% noted that it’s stored partly on the computer
and partly on paper. As the assumed influence is that the predoctoral faculty members did not
know what electronic health records systems are, this gap was not validated in the survey.
Table 8
Survey Results for Factual Knowledge of Electronic Health Records System
# Factual Knowledge Item % Count

An electronic health records system stores patient
information.

1 Partly on the computer and on paper 15 7
2 Fully on computer(s)* 85 41

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Table 8 (Cont’d.)
# Factual Knowledge Item % Count
3 In hard copy patient files --** --**
Total 100 48
*Correct response; **Not reported
Interview findings. There was clear agreement between the 10 interviewed participants
on knowing what an EHRS is. Participant 8 noted that,
My take about EHRS is it’s a useful tool to record therapy notes and to keep track of the
students’ procedures and to review x-rays and I also use it to communicate to different
faculty if I have to make notes because of the information in EHRS, its useful in that
sense.
Participant 10 agreed by stating that,
It’s an electronic health records system, it’s where we document about patient care,
activities, enter patient information; you can access the x-rays from there. I kind of look
at it as when I was in private practice. I used practice management system. So that’s the
way I use it because I just use it in clinics, I just use it functionally, you know, student
treat patients and document what they did in there, you could look up medical record, I
mean medical history, pull up x-rays, that’s the way I use it."
In summary, the interviewed predoctoral faculty members demonstrated factual
knowledge of knowing what electronic health records system is, and therefore this influence was
not validated by the interviews.
Observations. In the observation of eight predoctoral faculty members, they
demonstrated knowing what an electronic health records system was as they used it in their
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students’ education and patients’ care. For example, Participant 9 was observed as he walked
into a cubicle, looked at the computer screen, and then approved a student’s work.
Document analysis. Data were pulled from the electronic health records system which
demonstrated usage of the system by the predoctoral faculty members. Data pulled included the
number of approved completed procedures in the month of February 2017.
Summary. The results showed that the majority of the predoctoral faculty members know
what an electronic health records system is. As less than 100% of surveyed participants agreed
to knowing what an electronic health records system is, it was assumed that the discrepancy
(15%) might have to do with predoctoral faculty members using the system but not fully
understanding what the system is. Thus, the assumed knowledge of faculty not knowing what
EHRS is was not validated.
Assumed knowledge influence #2: Faculty members need to know where the
whiteboard is located. The assumption is that faculty did not know the location of the
whiteboards.
Survey results. As shown in Table 9, the gap was validated in the survey. The
assumption was that the predoctoral faculty members did not know the location of the
whiteboard that guides them to the students who need their assistance. As the threshold for
validation of the survey results for knowledge is 75%, this gap was validated in the survey as
only 71% of faculty knew the location of the whiteboard.

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Table 9
Survey Results for Factual Knowledge of Electronic Health Records System
# Factual Knowledge Item % Count

In the predoctoral clinic, the whiteboard is located

1 Not located there 16 7
2 Located by the windows 9 4
3 Located only in sections A and B of the clinic 4 2
4 Located in the four sections of the clinic* 71 32
Total 100 45
*Correct response
Interview findings. Nine out of 10 interviewed participants said they knew where the
whiteboards are located. Participant 4 noted
the whiteboard in each clinic, basically students just write their numbers so as a faculty,
we follow the order to where we are supposed to go, first is for SIP check, then if they
have any questions, they can hand write what they need.
Participant 6 agreed by stating
Our whiteboards are specifically for the students, we don’t have an open bay clinic, it’s
wrapped in a C shape, so we cannot see someone who needs us so someone who needs
us, the faculty or an assistant to take an X-ray, will go and write it on the whiteboard. We
regularly check, if I see room 1, 6, 7, I will go to room 1, come back to the board, go to
room 6, cross that off, go to room 7.”
On the other hand, one of the participants stated, “I do not use the whiteboard and I don’t
know about the whiteboard.” The interview findings did not validate this gap as the majority of
the interviewed participants knew the location of the whiteboard.
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Observations. During the observations, it was noted that one of the eight participants did
not use the whiteboard but met students in the cubicles to address their needs. For example,
Participant 9 walked up to a student and asked, “do you need help?” He then walked with the
student to the cubicle where the patient was waiting in the chair. Both the student and the
predoctoral faculty member discussed data from the computer by looking at the computer screen.
This showed the predoctoral faculty members did not always use the whiteboard to address the
students’ need in their use of electronic health records system.
Document analysis. This influence was not addressed.
Summary. This gap was validated, as the assumption was that the predoctoral faculty
members did not know the location of the whiteboard. The survey, interviews, and observations
demonstrated that not all faculty members used the whiteboard. It is essential to have a standard
process that will align with the expectation of the predoctoral faculty members when using the
electronic health records system in providing patients’ care and students’ education.
Assumed knowledge influence #3: Faculty members need to know the goal of the
electronic health records system implementation. The assumption was that faculty did not
know the goal of implementing electronic health records system.
Survey results. As shown in Table 10, 94% of faculty knew the goal of electronic health
records system implementation. This gap was not validated by the survey as the threshold for
validation of knowledge survey results is 75%.

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Table 10
Survey Results for Factual Knowledge of Electronic Health Records System
# Factual Knowledge Item % Count

The implementation goal of the electronic health records
system is to document patient information electronically

1 50% of the time 2 1
2 10% of the time --** --**
3 100% of the time* 94 45
4 75% of the time 4 2
Total 100 48
*Correct response; **Not reported
Interview findings. This influence was not addressed in the conducted interviews.
Observations. This influence was not observed.
Documents analysis. This influence was not addressed.
Summary. As noted in the survey, the majority of the participants, knew the
implementation goal of electronic health records system. As a result, the gap was not validated.
Conceptual Knowledge
Assumed knowledge influence #4: Faculty members need to know the purpose of the
whiteboard. The assumption for this influence is that the faculty did not know the purpose of
the whiteboard.
Survey results. As shown in Table 11, data from the survey showed that only 65% of
faculty participants knew the purpose of the whiteboard; however, the validation threshold
established for the survey is 75%. Thus, this indicated a conceptual knowledge gap. The noted
faculty critical behavior was that whiteboards are used in guiding the predoctoral faculty
members to know when their students need them. The survey results demonstrated the
predoctoral faculty members did not know the purpose of the whiteboard. If the predoctoral
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faculty members did not know the purpose of the whiteboard, it is assumed they will most likely
not use it.
Table 11
Survey Results for Conceptual Knowledge of Electronic Health Records System
# Conceptual Knowledge Item % Count

The whiteboard in the predoctoral clinic is for

1 Keeping track of patient files 6 3
2 Requesting maintenance on the clinic floor --** --**
3 Requesting supervisor’s attention by students* 65 31
4 I don't know 29 14
Total 100 48
*Correct response; **Not reported
Interview findings. Nine out of ten predoctoral faculty participants who were
interviewed knew the purpose of the white board. Participant 3 stated that “The students write
their names or their cubicle number on the board, so I can follow an order.” Likewise, Participant
5 said
Ok, so the dry erase board is where the students go to sign up with the faculty member
they are working with. They need assistance from, the students will go up, sign on the
board and then the faculty member will come up to the cubicle where they have the
interaction and treatment is going on and hang out in that area.
Participant 1 agreed with the rest of the participants by stating that “The purpose is to get
the students on board for the faculty to come over and check the student.” The interview
findings clarified the result of the survey as only the faculty members who use the whiteboard
understood the purpose while those who do not use are assumed to not know the purpose. Nine
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of the 10 interviewed faculty knew the purpose of the whiteboard, so the gap was not validated
by the interviews.
Observations. During the observations, seven out of eight participants observed were
able to demonstrate that they knew the purpose of the whiteboard as they went to the whiteboard
and either crossed out the student’s number or erased it and then walked to assist the student in
the cubicle after which they documented something in the EHRS. For example, Participant 5
walked up to the whiteboard and crossed out “Q5” which was written by the student and then
walked to cubicle Q5 to assist the student.
Document analysis. This influence was not addressed.
Summary. Comparing data from the interviews and from the observations, it seemed the
predoctoral faculty members who used the whiteboard knew the purpose. On the other hand, the
predoctoral faculty members who did not use the whiteboard could be assumed to not know the
purpose. To improve the use of the whiteboard, all predoctoral faculty members need to know
the purpose of the whiteboard. This influence was validated as actionable gaps were found in the
survey results.
Assumed knowledge influence #5: Faculty members need to know the purpose of
electronic health records systems. The assumption was that faculty did not know the purpose
of the electronic health records system.
Survey results. As shown in Table 12, 92% of faculty knew the purpose of the electronic
health records system. As the threshold for validation of survey results was 75%, this gap was
not validated by the survey. Ninety two percent of faculty participants were able to identify the
purpose of the electronic health records system. Although 8% were not able to identify all, they
were able to identify some. These survey results showed no conceptual knowledge gap as to
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what electronic health records system is used for. As a result of the survey, this gap was not
validated.
Table 12
Survey Results for Conceptual Knowledge of Electronic Health Records System
# Conceptual Knowledge Item % Count

The purpose of electronic health records system is to

1 Streamline record keeping for billing purposes --** --**
2 Aggregate all patient information into one place 6 3
3 Reduce the use of paper and conserve resources 2 1
4 None of the above --** --**
5 All of the above* 92 44
Total 100 48
*Correct response; **Not reported
Interview findings. All 10 participants who volunteered to be interviewed, were able to
discuss the purpose of EHRS. Participant 4 noted
I’m using EHRS all the time. I’m using it basically from checking in the patient to
treatment plan and when students do the procedure, it’s in process or finished, I swipe it
and I always use it to review the contact note and if there is any referral or problem, the
messaging system is good because we are connected to different departments, so it is a
good way to basically be in the web and everybody is connected. And if everybody fully
uses it properly and they know how to use it, it is pretty good.
Participant 2 concurred with Participant 4 by saying that
I like it, I basically use EHRS to go to imaging and since I teach radiology, we review the
images, there’s a bridge from EHRS to the X-ray software, we look at the images and we
will interpret them, and we swipe their work after they complete their treatment. I swipe
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 102

it in EHRS, sometimes I go to EHRS to check the patient’s pending treatment and
sometimes I go to diagnostics note to see the history of the treatment that has been done
on the patient.
The interview findings were in line with the survey results demonstrating that the gap in
knowledge was not validated.
Observations. All eight observed participants demonstrated knowing the purpose of
EHRS as they were observed educating the students while looking at the EHRS. The predoctoral
faculty members used it while discussing with the students, the patient’s data found in the EHRS.
Participant 4 spoke to a student while looking at the computer. The assumption is that the
student and the faculty member were discussing data from the computer which is evidence that
the faculty knew the purpose EHRS.
Document analysis. This influence was not addressed.
Summary. No conceptual knowledge gap was noted for this influence as the predoctoral
faculty members knew the purpose of the electronic health records system.
Assumed knowledge influence #6: Faculty members need to know the relationship
between electronic health records system and the whiteboard. The assumption is that faculty
members did not know the relationship between the electronic health records system and the
whiteboard, and thus there is a conceptual knowledge gap.
Survey results. This influence was not addressed in the survey.
Interview findings. During the interview, all 10 of the participants demonstrated no
knowledge of the relationship between the whiteboard and the EHRS. Participant 3 stated
I don’t see a direct relationship with EHRS, I see a direct relationship with the students
but when they need swipes, they do write their number on the board and ask for swipe,
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 103

that’s how I know they need me. The relationship, I just hope, we are talking about the
same whiteboard. Yes, it is like I don’t see a direct relationship, because the board is
more for me to know where to go next to see the patient, the students with the patients,
but they do have to write their numbers on the board if they want to get a swipe from me.
Participant 6 concurred with Participant 3 by stating
I don’t know that the whiteboard has anything to do with EHRS. The only relationship
between the whiteboard, the whiteboard is an organizational tool. The students are
served in the correct order in the clinic, but you could also use the whiteboard as their
verification of X-ray needs. In other words, if there’re six orders of X-rays, if they are
recorded correctly in the EHRS. I don’t know if the assistants use that but there is a
protocol that has to be in EHRS before they take X-rays.
From the interview statements, it’s assumed that faculty participants automatically
perform functions without truly understanding what they were doing. From their statements,
they mentioned they did not see the relationships but the description of what they did denoted a
relationship. The interview findings show gap in knowledge.
Observations. During the observations, it was observed that predoctoral faculty members
walked to the white board and then proceeded to the electronic health records system to review,
discuss, and/or approve students’ work. As observed, Participant 10 walked to the white board,
crossed out F2, and then walked to the cubicle. Participant 10 pointed to the screen while
discussing information seen on the computer with the student. The observation showed a
relationship with the faculty using the whiteboard and the computer.
Document analysis. This influence was not addressed.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 104

Summary. By not knowing the relationship between the whiteboard and the electronic
health records system, predoctoral faculty indicated a gap in conceptual knowledge. The
predoctoral faculty members need to understand why they use the tool available to them. As a
result of the findings, this influence was validated as the results show conceptual knowledge gap.
Assumed knowledge influence #7: Faculty members need to know how their use of
EHRS measures up to the goal of the school. The assumption is that faculty did not know how
their use of EHRS measure up to the goal of the school.
Survey results. As shown in Table 13, the gap was validated in the survey as the
validation threshold for knowledge survey is 75%. Forty four percent of the predoctoral faculty
participants not knowing the goal of the school exhibits a conceptual knowledge gap that needs
to be addressed. Thirty three percent demonstrated that the use of EHRS measured up to the goal
of the school while 15% did not believe so. Knowing the goal of the school as well as the goal
of using EHRS is essential in its use. Therefore, the gap was validated in the survey.
Table 13
Survey Results for Conceptual Knowledge of Electronic Health Records System
# Conceptual Knowledge Item % Count

How does your use of EHRS measure up to the goal of
the school

1 100% of the school's goal* 33 16
2 Does not measure up to the goal of the school 15 7

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 105

Table 13 (Cont’d.)
# Conceptual Knowledge Item % Count
3 I don't know the goal of the school 44 21
4 Not applicable 8 4
Total 100 48
*Correct response
Interview findings. This influence was not addressed in the conducted interviews.
Observations. This influence was not observed.
Document analysis. This influence was not addressed in the reviewed documents.
Summary. Faculty members need to know how their use of EHRS measure up to the goal
of the school for effective use of the EHRS. The conceptual knowledge gap was validated.
Procedural Knowledge
Assumed knowledge influence #8: Faculty members need to know how to review
students documented patient treatment code electronically. The assumption was that faculty
did not know how to review students documented patient treatment code electronically.
Survey results. As shown in Table 14, this influence was not validated in the survey.
Ninety four percent of participated faculty members demonstrated knowledge of how to
electronically review students documented patient treatment codes. Six percent of the
respondents, which are three people, did not respond correctly on how they review student’s
documented patient code electronically. One of the incorrect responses showed the predoctoral
faculty member might not have understood the question as the emphasis was on reviewing
treatment codes electronically. The other two responses noted not reviewing treatment codes
electronically. This means, maybe, the two anonymous respondents used paper charts. As the
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threshold for validation of survey results for knowledge was 75%, thus, the gap was not
validated in the survey.
Table 14
Survey Results for Procedural Knowledge of Electronic Health Records System
# Procedural Knowledge Item % Count

How should one review a student’s documented patient
treatment code electronically

1 By listening to the student 2 1
2
By making sure the correct treatment code is entered on
the computer*
94 45
3
By making sure the correct code is noted in the hard
copy file
--** --**
4 I do not review treatment codes electronically 4 2
Total 100 48
*Correct response; **Not reported
Interview findings. Ten interviewed participants clearly explained how they used the
electronic health records system in reviewing students’ documented procedure codes. Participant
2 explained his process by stating
Basically, I, when I enter the patients EHRS number and it opens up the patient chart,
there is a highlighted number at the bottom of the screen that I can go there to approve
their completion. I click on that highlighted number which is the patient’s chart number,
and it takes me to the treatment that is completed. Sometimes, when students have
completed it already and I see that there is a code for the treatment and I click it and
approve it, sometimes I see that the students forget to complete the treatment, so I
actually go back to EHRS and to the chart record and then I will go and find the planned
pending treatment and on the planned pending treatment, I double click and make sure I
enter the student number who completed it so I basically do the completion over there
and then I go back and now I see the completed treatment and approve it.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 107

The interviewed participants also noted they recommend next actions for patients’ next
visit to the students as well as document “NV,” meaning “Next Visit,” in the EHRS as a guide
when the patients return for follow-up visits. The interview findings concurred with the survey
results in that this influence showed no procedural knowledge gap.
Observations. During observations, the eight volunteered participants were observed
looking at the EHRS while discussing with the students. They swiped the students’ completed
procedure code in the electronic health records system and recommended next steps to the
students. Participant 10 was seen pointing at the computer, reading line to line with the student
and clarified what was written. The observations as well as the interviews and survey results did
not validate the gap.
Document analysis (collected data). The data pulled from the EHRS showed 3122
patients visited the predoctoral clinic in the month of February 2017. It also showed that 5577
procedure codes were documented in the EHRS within that month. Out of the 5577 procedure
codes entered, only one procedure code was not approved.
Summary. The gap was not validated as it showed the predoctoral faculty members knew
how to enter procedure codes electronically as well as knew the steps in reviewing students’
entered procedure codes. Data collected from the EHRS triangulated this assumption by
showing only one procedure code as unapproved in the EHRS for the month of February 2017.
The collected data, surveyed, interviewed, and observed participants demonstrated knowledge on
their process in the use of EHRS. In sum, this influence was not validated as there was no
procedural knowledge gap.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 108

Assumed knowledge influence #9: Faculty members need to know how to correctly
enter notes in the EHRS. The assumption was that faculty did not know how to correctly enter
notes in the EHRS.
Survey results. As shown in Table 15, the gap was not validated in the survey. Ninety
eight percent of participants knew how to review student’s documented notes electronically. As
the threshold for validation of the survey results for knowledge was 75%, no procedural
knowledge gap was found. Thus, this gap was not validated.
Table 15
Survey Results for Procedural Knowledge of Electronic Health Records System
# Procedural Knowledge Item % Count

How do you review a student’s documented notes
electronically

1 By listening to the student --** --**
2
By making sure accurate notes are entered
electronically*
98 47
3 By making sure there is hard copy documentation 2 1
4 I do not review notes electronically --** --**
Total 100 48
*Correct response; **Not reported
Interview findings. All 10 interviewed participants demonstrated knowledge on how to
review students’ documented notes electronically. Participant 1 described the process by saying
The student usually has a template note or some form of note that is in EHRS. It is
written up, they are completed, faculty comes over, we read the note, we make
recommendations, to change or modify, we usually stand there with the student and they
make the change, if there are any.
Participant 8’s response added clarification to the survey result by saying
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 109

Well the therapy notes are always documented in EHRS, I have to read it and make
corrections and swipe. In terms of grading the students, sometimes it’s on paper and
sometimes it’s in EHRS especially if it is a competency exam then we have a separate
paper form that we fill out. For some of those we still do fill them out in EHRS as well.
This statement justified the 2% accounted for by one participant. It can be understood
that the participant maybe was referring to the process then answering the question. The
interview findings supported the survey results as there was no gap. As a result, this influence
was not validated in the interviews.
Observations. It was also witnessed that all the eight participants observed, reviewed
students documented notes electronically. An example as observed was Participant 9 pointing at
the computer screen as they, the student and the faculty, discussed the notes in the EHRS.
Document analysis. This influence was not addressed.
Summary. With 98% respondents noting that they made sure accurate notes were entered
electronically showed that this influence was not validated as there was no procedure knowledge
gap.
Assumed knowledge influence #10: Faculty members need to know how to approve
and assign grades to the students’ completed work. The assumption was that faculty did not
know how to approve and assign grades to students’ completed work.
Survey results. As shown in Table 16, this gap was not validated in the survey as 100%
predoctoral faculty participants show knowledge on how to approve students’ completed work.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 110

Table 16
Survey Results for Procedural Knowledge of Electronic Health Records System
# Procedural Knowledge Item % Count

How do you approve students’ completed work?

1 On paper --** --**
2 Electronically through swiping my card* 100 48
3 I tell someone, and they enter it into the computer for me --** --**
4 Verbally --** --**
5 I do not approve students’ completed work --** --**
Total 100 48
*Correct response; **Not reported

Interview findings. All ten interviewed participants acknowledged knowing the process
of approving students’ completed work. Participant 3 described the process by saying
I check the procedures and sometimes, I have to give them feedback. I have to show
them how to do something then I check the final product. I work with dentures, so I
check the appliance itself and I have to look in the patient’s mouth and then I go to check
what they’ve done in the EHRS, I have to make sure they entered the right notes, then
check that we are not missing any information. And I also have to grade them
afterwards.
The interview findings agreed with the survey results, thus, demonstrating no procedural
knowledge gap.
Observations. All the eight participants observed, approved students’ completed work in
the EHRS. Participant 1 looked at the data in the computer and approved the student’s work by
using his ID card to swipe on the computer. This gap was not validated through observations.
Document analysis. This influence was not addressed.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 111

Summary. All surveyed, interviewed, and observed predoctoral faculty members
demonstrated knowledge on how to approve and assign grades to students completed work. The
gap was not validated as there was no procedural knowledge gap.
Metacognitive Knowledge
Assumed knowledge influence #11: Faculty members need to know how to reflect on
their utilization of the EHR system. The assumption was that faculty did not know how to
reflect on their utilization of the EHRS.
Survey results. This influence was not surveyed.
Interview findings. The interview findings did not validate this gap. During the
interview, the 10 participants explained how they reflect on their use of EHRS. Participant 1
noted
I wish I knew more about the EHRS. I know how I have learned over the years, we teach
ourselves and students teach us believe it or not, how to find certain things, how to input
certain things but there’s so much more in the EHRS that we don’t know, and I will like
to be able to a little more vest in it. I feel more comfortable in using it.
Participant 3 felt almost the same by saying
To me, right now, I feel very comfortable using EHRS. I just do get annoyed sometimes
when it doesn’t let me do something such as phasing or for any other reason, so I learned
a few tricks, I don’t even know if I was supposed to do or not, but I have to make sure
we’re going to keep moving.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 112

Participant 6, also reflected by stating
I could see more proficiency, but it gets better, better and better to find what I need.
Occasionally, it becomes frustrating because I have access to patients but stuff like, could
you please unlock the chart, is not mine to have, occasionally frustrates me but it’s a good
one, there’s a reason and so when I reflect on it, I feel very powerful with EHRS because
there’s no location I cannot check on.
Observations. This influence was not observed.
Document analysis. This influence was not addressed.
Summary. This gap was not validated. The interview findings indicated the participants
were able to reflect on their EHRS use. They also felt better with their use of the EHRS. As a
result, there was no knowledge gap.
Results and Findings for Motivation Causes
The results and findings of the motivational causes were reported using the motivation
category and assumed motivation influences for each category. In the motivation category,
value, self-efficacy, mood, and attribution were the motivation types considered as shown in
tables below.
Value
Assumed motivation influence #1: Faculty needs to value their use of the electronic
health records system in patient care and students’ education. They need to value reviewing
students documented patient treatment codes and notes electronically on the computer. They
need to value knowing how to correctly enter patient treatment codes and notes in the EHRS,
value recommending next steps in patient care to the students, and value the process of
electronically approving and assigning grades to students’ completed work which will increase
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 113

their use of EHRS. The assumption was that faculty did not value their use of electronic health
records system in patient care and in students’ education.
Survey results. As shown in Table 17, the value category was not validated in the survey
based on the mean of all the scores. The threshold for validation of the survey results for
motivation was a mean of 7.5. Only one out of the nine value items had a mean of less than 7.5.
The item involved using the EHRS for students’ education was a mean of 7. If faculty members
do not value their use of EHRS for students’ education, it is assumed they will not use it
effectively. The two statements with the highest mean of 9 measured faculty’s value on
reviewing students’ documented notes electronically and faculty’s value on knowing how to
correctly enter notes in the EHR system. Thus, the gap was not validated in the survey.
Table 17
Survey Results for Value Motivation of Electronic Health Records System
# Value
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
Using the scale below, please rate the extent to which you value the following.
1 Using EHRS
for patient care
1 10 8 2 4 47
2 Using EHRS
for students’
education
1 10 7 3 7 47
3 Reviewing
students’
documented
patient
treatment codes
electronically
1 10 8 2 4 47

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 114

Table 17 (Cont’d.)
# Value
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
4 Reviewing
students’
documented
notes
electronically
2 10 9 2 2 47
5 Knowing how
to correctly
enter patient
treatment codes
in the EHR
system
3 10 9 2 3 46
6 Knowing how
to correctly
enter notes in
the EHR
system
3 10 9 2 3 47
7 Using EHRS to
recommend
next steps in
patient care to
students
2 10 8 2 5 46
8 The process of
electronically
approving your
students’
completed
work
4 10 9 2 3 47
9 The process of
electronically
assigning
grades to your
students’
completed
work
1 10 8 2 6 46

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 115

Interview findings. The 10 interviewed predoctoral faculty members expressed valuing
the use of EHRS in patient care and in students’ education. They all felt it very important to use
the EHRS. Participant 6 said
I value it so highly that when there’s a change in EHRS, I feel like a 3-year-old holding a
tantrum, I’m not kidding, it’s like going to your favorite market and knowing where
everything is and everything is arranged efficiently and well and when they change it,
I’m in a very bad mood for like two weeks until I learn it quite well, or a week
depending, then I feel I have control of the ship.
Participant 3 continued the discussion by stating that
It is very important, I think it’s a very important tool that we have here because we have
all the patient information there starting with X-rays that I have to check, I have
everything in front of me that I have to gather, the films, then I can check the charts, I can
go back to the notes quickly.
Also mentioned by Participant 1 is
Oh, I think it’s important for faculty to be able to know how to use EHRS. Because
that’s what we use to instruct students and students rely on us to tell them where to go in
EHRS. Sometimes, it is the other way around though, students tell faculty how to find
things in EHRS but even the valuable tools, I think that with the way things are going
with technology, you know, everyone is trying to go paperless and electronic. I think that
what makes that successful is that you are trained, and you know you are getting
guidance on how to use products.
The interview response did not validate the gap and it clarified the survey results showing
no gap with faculty valuing their use of EHRS.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 116

Observation. During observation, it was observed that the predoctoral faculty members
used the EHRS with the students in providing care to the patients. It was assumed as the faculty
used the system, that they valued using it. This assumption was due to the response from the
interview findings combined with the observations. A noted observed exampled was Participant
6 who reviewed the notes from the computer as he discussed his findings with the student and
the patient.
Document analysis. This influence was not addressed.
Summary. The gap was not validated as the majority of the questions were answered
with higher than 7.5 mean value. The interview findings also justified that the predoctoral
faculty members valued using the EHRS in patients care and in students’ education. As a result,
there was no gap in value.
Self-efficacy
Assumed motivation influence #2: Faculty members need to have confidence that
they can use the electronic health record system to document patient care, in reviewing
student’s documented patient treatment code and notes electronically on the computer, and
in following the steps in using the EHR system. Faculty needs to have confidence using the
electronic health record system to recommend next steps in patient care to the students, in
electronically approving and assigning grades to students’ completed work, and in using the
whiteboard to know when the students need them. The assumption was that faculty did not have
confidence in their use of the electronic health records system in patient care and in students’
education.
Survey results. As shown in Table 18, the gap was not validated in the survey. Five out
of the eight items asked had a mean score of 7.5 and above. On a scale of 0 to 10, scores below
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 117

7.5 indicated that faculty did not have confidence in the use of EHRS. The three items below 7.5
were (a) how confident the predoctoral faculty members were in using the whiteboard to know
when the students need assistance (6), (b) using EHRS in assigning grades to students’
completed work (7), and (c) using EHRS to recommend next steps in patient care to the students
(7). Thus, the gap was not validated.
Table 18
Survey Results for Self-efficacy Motivation of Electronic Health Records System
# Self-efficacy
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
Using the scale below, please rate how confident you are that you can do the
following right now.
1 Using the
electronic
health records
system to
document
patient care
electronically
2 10 9 2 3 47
2 Reviewing
students’
documented
patient
treatment codes
electronically
3 10 9 2 3 47
3 Reviewing
students’ notes
electronically
3 10 9 2 3 47
4 Following the
steps involved
in using EHRS
system
1 10 8 2 5 47

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 118

Table 18 (Cont’d.)
# Self-efficacy
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
5 Using EHRS to
recommend
next steps in
patient care to
the students
10 7 2 7 46
6 Using EHRS in
approving
students’
completed
work
3 10 9 2 3 47
7 Using EHRS in
assigning
grades to
students’
completed
work
10 7 3 8 47
8 Using the
whiteboard to
know when the
students need
my assistance
10 6 4 4 45

Interview findings. The 10 interviewed participants said they were confident using the
EHRS. Participant 1 noted that
You know, I feel pretty good about it, from a scale of 1 – 10, I will say about a 9.5. I
make sure I enter important information in it. I make sure that I enter it in the main
therapy note, I list all my concerns, and everything that I like students to know about that
particular patient.
Participant 2 noted that “I’m confident. I think it works fine and I don’t have any
problem for what I do right now.” Participant 3 agreed by stating that “I feel pretty confident,
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 119

every once, in a while I get stuck, but I feel very comfortable and confident.” Thus, faculty has
confidence and the gap was not validated in the interview findings.
Observations. The eight participants observed seemed confident walking to the
whiteboard and from there to the computers to document, review, and or approve students’ work.
Participant 5 walked to the white board, crossed out S5, and then walked to the cubicle where the
student was waiting. Participant 5 looked at the computer, spoke with the student, and then
swiped a card.
Document analysis. This influence was not addressed.
Summary. This gap was not validated in the survey as only three responses had a mean
score of lower than 7.5. The interview findings and observations of the predoctoral faculty
members also did not validate the gap as faculty demonstrated confidence using the EHRS. In
sum, this gap was not validated.
Mood
Assumed motivation influence #3: Faculty need to feel positive using the electronic
health records system in: correctly entering patient data and notes, reviewing students’
documented patient treatment code and notes electronically on the computer, following the
steps on using the EHR system, using EHRS for recommending next steps in patient care to
the students, and electronically approving and assigning grades to students’ completed
work. The assumption was that faculty did not feel positive using the electronic health records
system in patient care and in students’ education.
Survey results. As shown in Table 19, this gap was not validated in the survey. Most of
the questions were responded to with a mean of 7.5 and above. The survey threshold for
validation of motivation is 7.5. The lowest mean score was 7 and it was on faculty feeling
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 120

positive in using EHRS for recommending next steps in patient care to the students. The highest
score was on the faculty feeling positive in using the EHRS to electronically approve students’
completed work. There was no noted gap in this influence.
Interview findings. During the interviews, the interviewed participants sounded positive
in using the EHRS. Participant 9 said “I think it’s, was a little ummm not hard to get used to but
I go along, pretty straight forward, ummm, I like it, I think it works well” Participant 6 added
that “I could see more proficiency, but it gets better, better and better to find what I need.” From
the interview findings, it was not determined that faculty did not feel positive in using the EHRS
for recommending next steps in patient care to students. When asked to explain how they used
the EHRS to recommend next steps, Participant 1 stated that
At the end of every students’ notes, we train the students to write NV which stands for
next visit, we check at the start of the next visit to make sure student is on time to what
should be done. Of course, something may come up, patient may have emergency, may
have pain, so it doesn’t necessarily follow the next visit if the patient presents something
ummm that we didn’t foresee but for the most part, it’s a way for us to know what the
patient should be in line for next at the end of every note.
The interview findings did not validate the gap.

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Table 19
Survey Results for Mood Motivation of Electronic Health Records System
# Mood
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
Using the scale below, please rate how positive you feel about doing the following.
1 Using the
electronic
health record
system in
correctly
entering patient
data
2 10 8 2 5 47
2 Using EHRS in
correctly
entering
treatment notes
2 10 8 2 4 47
3 Reviewing
students’
documented
patient
treatment code
electronically
2 10 9 2 4 46
4 Reviewing
students’
documented
notes
electronically
2 10 9 2 4 47
5 Following the
steps in using
EHR system
2 10 8 2 6 46
6 Using EHRS in
recommending
next steps in
patient care to
the students
1 10 7 3 7 46

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 122

Table 19 (Cont’d.)
# Mood
Motivation
Item

Minimum

Maximum

Mean
Std.
Deviati
on

Variance

Count
7 Electronically
approving
students’
completed
work
3 10 9 2 3 47
8 Electronically
assigning
grades to
students
completed
work
1 10 8 3 7 47

Observations. This influence was not observed.
Document analysis. This influence was not addressed.
Summary. An overall take away from this category was that the gap was not validated.
The predoctoral faculty members demonstrated a positive mood in using the EHRS in students’
education and patient care.
Attribution
Assumed motivation influence #4: Faculty members need to attribute the success of
the electronic health records system to their efforts to use it and they need to believe that
using the EHRS is important for patient care and students’ education. The assumption is
that faculty did not know what to attribute the success of the electronic health records system to.
Survey results. As shown in Table 20, the gap was validated in the survey. The survey
responses did not show uniformity. The expected correct response would have been all the
above as all itemized factors affect the implementation outcome. Majority of the respondents
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 123

selected “the requirement to use it” as a successful implementation factor. “The training” was
the second most selected answer as an essential implementation factor. Interestingly, one
participant selected “None of the above.”
Table 20
Survey Results for Attribution Motivation of Electronic Health Records System
# Attribution Motivation Item % Count
Any successful implementation of EHR system is due to;
please check all that apply.

1 Incentives* 6 12
2 Leadership* 15 30
3 Dentists helping each other* 11 21
4 The requirement to use it* 19 37
5 The training* 18 35
6 My efforts to use the system* 16 31
7 The effectiveness of the system* 17 33
8 None of the above 1 1
Total 100 200
*Correct response

Interview findings. When participants were asked to what they attributed the success of
EHRS, they listed a variety of things such as a well-designed system, hands-on practice, and
helping each other. Participant 1 stated
A good manager of EHRS, someone who when you call, they can come and help you
with EHRS, and they won’t say well ummm let me look it up, they can help you, they
know more than you, that’s to me, that’s what I find exciting.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 124

Participant 3 felt differently by stating “I think you have to have a lot of hands-on and practice a
lot until you take the advantage of all the good things that it has to offer but otherwise you can
get pretty overwhelmed.,” and Participant 6 felt
An excellent system that comes with all I need to begin with and then good resources
backing it up and just the time to use it. It’s like driving my personal car, I don’t want to
use another person’s car, I don’t want to go back walking, which is pen and pencil, it’s
excellent.
Document analysis. This influence was not addressed.
Summary. The gap was validated as there was no consistency regarding factors for
successful implementation of EHRS.
Results and Findings for Organizational Barriers
The results and findings on organizational factors are reported using the organizational
factors category and assumed organizational influences for each category. In the organizational
factor category, resources, policies and procedures, and culture were the types considered as
shown in the tables below.
Resources
Assumed organizational influence #1: Faculty members need resources to
successfully implement the electronic health records system, such as swipers, signature
pads, and so forth. They need effective training on EHRS for their first-time use, ongoing
professional development to meaningfully continue using EHRS, and technological support to
effectively use EHRS. Faculty members need to have confidence that the system won’t break
down when they use it as well as need the time to be able to use EHRS effectively and
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 125

efficiently. The assumption is that faculty did not have the needed resources in using the
electronic health records system for patient care and in students’ education.
Survey results. As shown in Table 21, the gap was validated in the survey results. The
survey threshold for validation of the organization was 50%. The majority, three out of five
items, of the predoctoral faculty members disagreed that the organization provided resources
such as time to use the electronic health records system, signature pads, and scanners.
Table 21
Survey Results for Organizational Resources of Electronic Health Records System

#

Resources
Organization
al Item

Strongly
Disagree

Moderately
Disagree
Neither
Agree
nor
Disagree

Moderately
Agree

Strongly
Agree

Total
Using the scale below, rate the extent to which you agree or disagree with the
following statements regarding the resources you have for using EHRS.
1 The school
provides
resources
such as
swipers for
approving
students’
completed
notes
electronically
2% 9% 11% 28% 51% 47
2 The school
provides
Computers
for
electronically
documenting
patient
information
2% 13% 23% 62% 47

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Table 21 (Cont’d.)
# Resources
Organization
al Item

Strongly
Disagree

Moderately
Disagree
Neither
Agree
nor
Disagree

Moderately
Agree

Strongly
Agree

Total
3 The school
provides
Signature
Pads for
patients’
consent
41% 15% 22% 11% 11% 46
4 The school
provides
Scanners for
storing
patients’
records
electronically
13% 13% 24% 30% 20% 46
5 I have
enough time
to use EHRS
in educating
the students
9% 26% 21% 28% 17% 47

Interview findings. The interviewed participants agreed to having resources and would
like to have much more such as in training sessions, seminars, and manuals. Participant 4 noted
I think we have it, we talked about the different things we can connect to EHRS, I know
that EHRS has the capacity; signature pads, I know many schools use it or like a laptop
that we can show the patient's treatment plan.
Participant 6 noted,
I will like a good orientation of what EHRS changes are and then written so that when
whoever or whatever that is orienting me, isn’t around, I can refer to that to get what I
need. There’s nothing more frustrating as having to change something that you know
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 127

very well. It’s been a long time since they changed it majorly. For my admissions
people that are coming into this clinic as part-timers, they should have regular access to
user-friendly instruction for whatever works best for them, a person, or written down on
paper, whatever, getting them up to speed. You know, you don’t want to ask students.”
Thus, the gap was validated.
Observations. The volunteered participants were observed using available resources in
the predoctoral clinic. The resources notably observed were computers, swipers, and the
whiteboards. Participant 6 walked to the computer and swiped the card using the swiper.
Document analysis. This influence was not addressed.
Summary. The organizational gap was validated as shown in the survey results and in the
interview findings.
Policies and Procedures
Assumed organization influence #2: Faculty need to have policies that align with
their goal to use the electronic health records system all the time. They need procedures on
how to use the EHRS in recommending next steps in patient care to the students. The
organization needs to have a policy and procedure on electronically approving students’
completed work 100% of the time as well as on electronically assigning grades to students’
completed work 100% of the time. The assumption is that faculty did not have policies and
procedures that guide their use of the electronic health records system in patient care and in
students’ education.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 128

Table 22
Survey Results for Organizational Policies and Procedures of Electronic Health Records System

Policies and
Procedures
Item

Strongly
Disagree

Disagree

Somewhat
Disagree
Neither
Agree
Nor
Disagree

Somewhat
Agree

Agree

Strongly
Agree

Total
Using the scale below, rate the extent to which you agree or disagree with the following
statements regarding school’s Policies and Procedures for EHRS implementation.

We have a
standard
procedure on
how to use the
EHR system for
recommending
next steps in
patient care to
our students
9% 11% 9% 22% 17% 22% 11% 46
The school has a
policy governing
electronically
approving
students’
completed work
4% 2% 2% 26% 15% 17% 34% 47
The school has a
policy governing
electronically
assigning grades
to students’
completed work
4% 9% 0% 30% 9% 17% 32% 47
The school has a
procedure on
how to
electronically
assign grades to
students’
completed work
4% 6% 2% 28% 11% 15% 34% 47
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 129

Survey results. As shown in Table 22, the gap was validated in the survey. The survey
threshold for organization validation was 50%. All items had less than 50%. Two out of the
four items gave the highest response of 34% in strongly agreeing to the existence of policies and
procedures on approving students’ completed work and in assigning grades to students’
completed work. Thus, the gap in organizational influence was validated.
Interview findings. All 10 interviewed predoctoral faculty members did not know
whether policies govern what they do in the predoctoral clinic exist. Participant 2 said “I
haven’t, actually no, I haven’t been involved in any policies and I don’t know,” and Participant 3
said “I’m not sure.” Participant 7 when asked, noted differently by saying
I hope there are any, are my aware of any right now, written down, I haven’t seen any. I
mean there are certainly policies that for example, Dr. X, announces that notes and codes
have to be completed on the same day especially in the students’ clinic and recently, we
are supposed to swipe the procedures only on the clinic where it was performed so the
billing does not get messed up, so yes, this kind of things I am aware of, yes.
Thus, the gap was validated with the interview findings.
Document analysis. Policies and procedures governing the approval process of faculty
members were identified.
Summary. Policies and procedures governing the expectations of the faculty members
were identified during the document review, but the survey and interviews showed gap. In sum,
the assumed gap was validated.
Culture
Assumed organization influence #3: Faculty need to be part of a culture that aligns
with the organizational goal of 100% use of the electronic health records system. Faculty
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needs to be part of the implementation team for successful implementation. The assumption was
that faculty were not part of the culture that aligns with the organizational goal of 100% use of
the electronic health records system in patient care and in students’ education. This influence
was measured using six survey items.
Survey results. As shown in Table 23, the gap was validated in the survey results. None
of the items had an above 50% which is the survey threshold for validation of the organization.
Forty nine percent neither agreed nor disagreed on the items regarding the culture of the
organization recognizing their efforts to use the EHRS for students’ education and patients’ care.
Forty three percent of the respondents moderately agreed to learn more about using EHRS
effectively from seeing others use it. Only Thirty six percent strongly agreed to the culture of the
school supporting 100% of their use of EHRS. Thus, the gap was validated in the survey.
Table 23
Survey Results for Organizational Policies and Procedures of Electronic Health Records System

#
Culture
Organizational
Item

Strongly
Disagree

Moderately
Disagree
Neither
Agree
Nor
Disagree

Moderately
Agree

Strongly
Agree

Total
Using the scale below, rate the extent to which you agree or disagree with the
following statements regarding the culture of the school in EHRS implementation.
1 The culture of
the school
supports 100%
use of EHRS
4% 9% 17% 34% 36% 47
2 We help each
other use
EHRS
effectively
4% 6% 19% 38% 32% 47

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Table 23 (Cont’d.)

#
Culture
Organizationa
l Item

Strongly
Disagree

Moderatel
y
Disagree
Neither
Agree
Nor
Disagree

Moderate
ly Agree

Strongl
y Agree

Total
3 I learn more
about using
EHRS
effectively
from seeing
others use it
2% 4% 21% 43% 30% 47
4 The school
provides
incentives to
use EHRS
23% 21% 38% 13% 4% 47
5 My efforts to
use EHR
system for
student
education are
recognized
19% 13% 49% 15% 4% 47
6 My efforts to
use EHRS for
patient care
are
recognized
17% 12% 49% 15% 6% 47

Interview findings. Eight out of 10 participants stated that they agreed to be supported
by the culture of the organization to use the EHRS 100% of the time. Participants 1, 3, 4, 6, and
8 said in their statements that they felt supported “100% of the time.” Participant 7 said
Well, it is expected we use EHRS, we have the support physically and personally; the
staff. So, I think everyone is behind it and I think the trend is to use it even more. That’s
something that is heavily supported. Because the advantages are that it’s always
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available even if you are on the clinic floor, remotely and getting into it, even if I get a
call, emergency patient, with the system, I can easily look it up. It’s a very good thing.
The interview findings did not validate the gap.
Observation. The influence was not validated
Document analysis. The influence was not validated
Summary. The survey results validated the gap while the interview findings did not
validate the assumed gap. As more faculty participants validated the gap, the assumption is that
the gap exists in the culture of the organization.
Summary of Validated Influences
The following section summarizes the assumed gaps validation. Survey, interviews,
observations, and document analyses were used for triangulation. The data were grouped into
knowledge and skills, motivation, and organizational influences.
Knowledge and Skills
Four of 11 assumed knowledge gaps were validated through one survey, interviews,
observations, and document analysis. Table 24 presents an overview of the results of the
assessment of each assumed knowledge influence.

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Table 24
Summary of Assumed Knowledge Causes Validation
Assumed Knowledge Gaps Validated?
Declarative Factual
Faculty members need to know what electronic health records systems
are

No
Faculty members need to know where the whiteboard is located Yes
Faculty members need to know the goal of the electronic health records
system implementation

No
Declarative Conceptual
Faculty members need to know the purpose of the whiteboard.

Yes
Faculty members need to know the purpose of the electronic health
records system.
No
Faculty members need to know the relationship between electronic
health records system and the whiteboard

Yes
Faculty members need to know how their use of EHRS measure up to
the goal of the school

Yes
Procedural
Faculty members need to know how to review students’ documented
patient treatment code electronically

No
Faculty members need to know how to correctly enter notes in the
EHRS
No
Faculty members need to know how to approve and assign grades to the
students’ completed work
No
Metacognitive
Faculty members need to know how to reflect on their utilization of the
EHR system

No

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 134

Motivation
One of the four assumed motivation gap was validated through survey results, interviews,
and observations. Table 25 presents an overview of the assessment results for each assumed
motivational influence.
Table 25
Summary of Assumed Motivation Causes Validation
Assumed Motivation Gaps Validated?
Value
Faculty members need to value their use of EHRS in patient care and
in students’ education.

No
Self-Efficacy
Faculty members need to have confidence that they can use the
electronic health record system to document patient care, in reviewing
student’s documented patient treatment code and notes electronically
on the computer, and in following the steps in using the EHR system.

No
Mood
Faculty need to feel positive using the electronic health records system.

No
Attribution
Faculty members need to attribute the success of the electronic health
records system to their efforts to use it.

Yes

Organization
All three assumed organizational gaps were validated through survey results, interviews,
observations, and document analysis. Table 26 presents an overview of the assessment results
for each assumed organizational influence.
Due to the gaps found in knowledge, motivation, and in the organization, solutions
proposed were researched using scholarly literature in Chapter Five. Kirkpatrick and
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Kirkpatrick’s (2016) four levels of evaluation were used to determine if the proposed solutions
will lead to the desired goal and are presented in Chapter Five.
Table 26
Summary of Assumed Organization Causes Validation
Assumed Organization Gaps Validated?
Resources
Faculty members need resources to successfully implement the
electronic health records system, such as “swipers,” signature pads,
and so forth.

Yes
Policies, Processes, & Procedures
Faculty need to have policies that align with their goal to use the
electronic health records system 100% of the time.

Yes
Culture
Faculty need to be part of a culture that aligns with the organizational
goal of 100% use of the electronic health records system.

Yes

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 136

CHAPTER FIVE: RECOMMENDATIONS AND EVALUATION
Purpose of the Project and Questions
The purpose of this project was to conduct a gap analysis through examining the
knowledge and skills, motivation, and organizational influences that interfere with ABZ Dental
School’s goal to be 100% electronic in providing patient care and dental education to the
students, 100% of the time. Using the research discussed in Chapter Two, recommendations for
a program to close the knowledge and skills, motivation, and organizational gaps that exist with
the predoctoral faculty members of the ABZ Dental School and a proposed plan to implement
and evaluate the program will be presented in Chapter Five.
Stakeholder of focus questions:
1. What are the knowledge and skills, motivation, and organizational barriers that prevent
the faculty members of the predoctoral clinic of the ABZ Dental School from utilizing the
electronic health records system 100% of the time?
2. What are the knowledge and skills, motivation, and organizational solutions for faculty
members of the predoctoral clinic of the School to use the electronic health records
system 100% of the time?
Recommendations to Address Knowledge, Motivation,
and Organization Influences
The framework for this project was the Clark and Estes’ (2008) GAP Analysis Process
Model. This model examined knowledge and skills, motivation, and organizational influences.
The knowledge types used in assessing the predoctoral faculty members of the ABZ Dental
School were factual, conceptual, procedural, and metacognitive knowledge types. For
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motivation, value, self-efficacy, mood, and attribution were used. Resources, policies, processes,
and procedures, and culture were examined for organizational influences.
Knowledge Recommendations
Introduction. Factual, conceptual, procedural, and metacognitive knowledge types were
assessed for knowledge gaps. In the factual knowledge type, three items were assessed of which
one gap was found in the faculty’s knowledge of where the whiteboard is located. Four items
were assessed in the conceptual knowledge type, with gaps found in three. The conceptual
knowledge gaps were (a) faculty members need to know the purpose of the whiteboard, (b)
faculty members need to know the relationship between the electronic health records system and
the whiteboard, and (c) faculty members need to know how their use of EHRS measure up to the
goal of the school. Of these, one factual and three conceptual knowledge types were considered
high priority due to the expected faculty behavior in patient care and in students’ education.
There were no gaps in procedural and metacognitive knowledge types. Table 27 lists the
validated knowledge gaps, priority, research-based principle, and recommendations. Following
the table, a detailed discussion for each high priority cause, recommendation, and the literature
supporting the recommendation is provided.

Table 27
Summary of Knowledge Influences and Recommendations

Validated
Knowledge Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
Factual
Faculty members need
to know where the
whiteboard is located.
High Modeling to-be-
learned strategies or
behaviors improves
self-efficacy, learning,
Help learners know
where the whiteboard
is through
demonstration and
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 138

Table 27 (Cont’d.)

Validated
Knowledge Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
and performance
(Denler, Wolters, &
Benzon, 2009)

modeling.
Visual Integrating
auditory and visual
information
maximizes working
memory capacity
(Mayer, 2011)

Provide to faculty, job
aid poster showing the
location of the
whiteboards in the
clinic.
Conceptual
Faculty members need
to know the purpose of
the whiteboard.
High Information learned
meaningfully and
connected with prior
knowledge is stored
more quickly and
remembered more
accurately because it
is elaborated with
prior learning
(Schraw &
McCrudden, 2006)

Provide instruction
connecting faculty’s
prior knowledge of
sign-up sheets with
new knowledge of the
whiteboard purpose.
Faculty members need
to know the relationship
between the electronic
health records system
and the whiteboard.
High How individuals
organize
knowledge influences
how they learn and
apply what they know
(Schraw &
McCrudden, 2006)
Provide job aids (self-
help tool) such as
instructional handouts
with picture
identification of the
relationship between
the whiteboard and
electronic health
records system which
will help scaffold the
knowledge of
whiteboard and EHRS
identification.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 139

Table 27 (Cont’d.)

Validated
Knowledge Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
Faculty members need
to know how their use
of EHRS measure up to
the goal of the school.
High Behavior that is
reinforced is
strengthened
(Daly, 2009)
Identify specific
behavioral objectives
for
learning such as
making sure faculty
understand how the
use of EHRS measure
up to the goal of the
school through job
aids such as constant
reminders of the
expectations of the
Schools’ goal through
professional
development
meetings, manuals,
and email reminders
of expectations.
Procedural

Not validated.

Metacognitive

Not validated.

Declarative knowledge solutions. In the knowledge types, four high priority item gaps
were validated. One in the factual and three in the conceptual. The high priority, factual
knowledge, validated gap was on the faculty members need to know where the whiteboard is
located. As shown in Mayer (2011), integrating auditory and visual information maximizes
working memory capacity. This would suggest that providing faculty with job aid posters or
maps showing the locations of the whiteboards in the predoctoral clinic would support faculty
learning the whiteboard locations. In addition to visual aid, Denler et al. (2009) found that
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 140

modeling to-be-learned strategies or behaviors improves self-efficacy, learning, and
performance. They suggested having models, whom faculty trust, show faculty members where
the whiteboards are located. The recommendation for the predoctoral faculty members might be
to provide them with a model, someone, who will not only show them the locations of the
whiteboards but give them visual aids such as maps to whiteboard locations.
Boonstra and Broekhuis (2010) described barrier-related intervention, on the faculty not
knowing where the whiteboard was located, as, to educate faculty and support ongoing training.
Boonstra and Broekhuis (2010) recommended promoting the communication of reliability and
availability of the system such as the whiteboard to faculty members. Lorenzi et al. (2009)
suggested using a champion. They noted that a champion is an absolute necessity for a
successful implementation. Lorenzi et al. (2009) described the optimal approach in identifying
the champion, as to identify one of the most clinically-respected providers, who has technology
knowledge and who is committed to use EHR, to fulfill this champion role. The champion
would provide direction, encourage, promote, and create trust in the process. Ultimately,
everyone in the practice who trust, respect, and communicate effectively with the champion
would most likely follow the process. Recommendations suggested by studies and through noted
principles would be to have a champion, one who faculty looks up to as a model, to educate
faculty on the location of the whiteboard with the use of visual job aids.
Conceptual knowledge solutions. In the conceptual knowledge type, the highest
priority was found in faculty members need to know how their use of electronic health records
system measure up to the goal of the school. This is considered highest priority as not knowing
the goal of the school will influence the use of the electronic health records system, 100% of the
time. As found in Daly (2009), behavior that is reinforced is strengthened. This would suggest
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 141

that when the goal of the school is identified, and then reinforced with the use of job aids, the
goal will be strengthened. The recommendation for faculty members might be to provide job
aids which would identify the goal of the school. The job aid would reinforce and constantly
remind faculty to use the electronic health records system 100% of the time as that is the school's
goal.
As cited by Denomme et al. (2011), when faculty understand their use of EHRS as the
goal of the school, through guidance and encouragement, they would have the desire and be
eager to learn more about the benefits and possibilities of the electronic health records system.
In turn, often, this would lead to faculty continuation and even further interest in the use of the
electronic health records system (Denomme et al., 2011). Denomme et al. (2011) noted
addressing EHRS use challenges through champions/problem solvers who would make sure the
team and faculty were “on the same page” through communication and messaging. O’Malley,
Draper, Gourevitch, and Scholle (2015) said goal challenges were overcome by documenting and
teaching everyone in the practice where and how to enter certain types of data and clearly
defining who enters what information into the EHRS. Studies and noted principle as shown in
Table 28 recommended reinforcing faculty behavior by helping them understand that using
EHRS is the goal of the school. Also, that the use of EHRS could be strengthened by
encouraging faculty through documentation and reminders to consistently enter data into EHRS.
Procedural knowledge solutions. No procedural knowledge gaps were validated.
Metacognitive knowledge solutions. No metacognitive knowledge gaps were validated.
Motivation Recommendations
Introduction. Value, self-efficacy, mood, and attribution motivation types were
assessed. Gaps were not found in value, self-efficacy, and mood items. An attribution item was
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 142

validated in that faculty needs to attribute the success of the electronic health records system to
their efforts to use it. This high priority motivation type gap is essential to close as faculty not
attributing their use of the electronic health records system to their efforts will result to low
motivation to use it. Table 28 lists the motivation gaps, priority, principle, and
recommendations. Following the table, a detailed discussion for each high priority cause and
recommendation and the literature supporting the recommendation is provided.

Table 28
Summary of Motivation Influences and Recommendations

Validated Motivation
Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
Value

Not validated.

Self-Efficacy

Not validated.

Mood

Not Validated.

Attribution
Faculty members need to
attribute the success of
electronic health records
system to their efforts to
use it.
High Learning and
motivation are
enhanced when
individuals
attribute success or
Provide accurate
feedback that
identifies the skills or
knowledge that
faculty lack.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 143

Table 28 (Cont’d.)

Validated Motivation
Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
failures to effort rather
than ability
(Anderman &
Anderman, 2006)
Follow up with the
teaching of these
skills and knowledge
through scheduled
training and handouts
demonstrating the
effect of success or
failure of using or not
using EHRS.

Attribution solutions. For attribution, the high priority gap item was found in the
faculty members need to attribute the success of the electronic health records system to their
efforts to use it. As cited by Anderman and Anderman (2006), learning and motivation are
enhanced when individuals attribute success or failure to effort rather than ability. This would
suggest that providing faculty with accurate feedback that identifies their success or failure in
EHRS use will increase efforts to use. They recommended follow up with faculty by teaching
those skills and knowledge through scheduled training and handouts demonstrating the effect of
success or failure of using or not using EHRS.
Mayer (2011) described motivation as the amount of effort an individual put in and
engaged in to make sense of a skill. Lorenzi et al. (2009) recommended having faculty models
train and provide directions to faculty with content specific documentation and relevant
handouts. Lorenzi et al. (2009) also recommended providing detailed feedback to faculty
identifying their success or failure in the use of EHRS. Weiner (2000) noted that success or
failure attributed to effort are generally more adaptive and lead to more positive expectancies.
With appropriate faculty training strategies, faculty efforts to use the electronic health records
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 144

system will improve. Learners who attributed their outcome to their skill efforts are usually
motivated (Anderman & Anderman, 2006). As such, recommended from studies and principle
are to identify the cause of success and failure, and to provide targeted, timely feedback to
improve efforts in faculty use of EHRS.
Organization Recommendations
Introduction. Resources, culture, and policies and procedures were assessed for
organizational gaps. Gaps were found in all organizational items assessed: (a) resources –
faculty need resources to successfully implement the electronic health records system, such as
swipers, signature pads, and so forth; (b) culture – faculty need to be part of a culture that aligns
with the organizational goal of 100% use of EHRS; and (c) policies, processes, and procedures –
faculty need to have policies that align with their goal to use the electronic health records system
100% of the time. All the organizational gap items were considered high priority as the
organization has a huge influence on how faculty use the electronic health records system. Thus,
as noted by Clark and Estes (2008) was that the lack of efficient and effective organizational
work processes can contribute to the causes of performance gap. Table 29 lists the organization
causes, priority, principle and recommendations. Following the table, a detailed discussion for
each high priority cause and recommendation and the literature supporting the recommendation
is provided.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 145

Table 29
Summary of Organization Influences and Recommendations

Validated Organization
Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
Resources

Faculty members need
resources to successfully
implement the electronic
health records system,
such as “swipers,”
signature pads, and so
forth.
High Effective change
efforts ensure that
everyone has the
resources (equipment,
personnel, time, etc.)
needed to do their job,
and that if there are
resource shortages,
then resources are
aligned with
organizational
priorities (Clark and
Estes, 2008)
Work with faculty to
establish, from the
beginning, what the
needed resources
should be.

If organization
cannot provide all
resources, work with
faculty for the
priorities on available
resources, so that
when hard choices
have to be made, the
guidance is already in
place.
Culture

Faculty need to be part
of a culture that aligns
with the organizational
goal of 100% use of the
electronic health records
system.

High Effective change
efforts insure that all
key stakeholders’
perspectives inform
the design and
decision-making
process leading to the
change (Clark and
Estes, 2008)
Expand membership
of planning teams to
be inclusive of
influencers, whom
faculty look up to as
models and diverse
thinkers.

Regularly meet and
share information
with faculty such as
the organizational
goal of 100% use of
EHRS.

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Table 29 (Cont’d.)

Validated Organization
Gaps
Priority
High
Low

Principle and Citation

Context-Specific
Recommendation
Give feedback and
generate ways to
receive feedback and
encourage
participation of all
faculty members.

Policies and Procedures
Faculty need to have
policies that align with
their goal to use the
electronic health records
system all the time.
High Effective
organizations insure
that organizational
messages, rewards,
policies and
procedures that govern
the work of the
organization are
aligned with or are
supportive of
organizational goals
and values (Clark and
Estes, 2008)
Verify that the
existing policies and
procedures align with
the organizational
goal to use EHRS
100% of the time.

Educate faculty on
the established
policies and
procedures.

Make the policies
and procedures
accessible to the
faculty as a resource.

Make faculty aware
of the location where
the policies are
housed.

Resources solutions. A high priority gap item for resources was found in “faculty need
resources to successfully implement the electronic health records system, such as “swipers, for
signature pads, and so forth.” As noted by Clark and Estes (2008), effective change efforts
ensure that everyone has the resources (equipment, personnel, time, etc.) needed to do their job,
and that if there is a shortage in resources, then, the resources should align with the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 147

organizational priorities. This would suggest that ABZ Dental School should work with their
faculty to establish, from the beginning, the resources that are needed for their job
responsibilities. If ABZ Dental School cannot provide all required resources, Clark and Estes
(2008) recommended working with faculty for priorities on available resources, so that when
hard choices have to be made, the guidance would already be in place.
Morton and Wiedenbeck (2010) cited that understanding the needs of faculty will help
organizations facilitate smooth EHRS implementation and use. They studied 802 faculty, fellow,
and resident physicians to explore EHRS adoption. Morton and Wiedenbeck (2010) noted that
formal computer training and flexibility in the timing and structure of the training program is
essential. Terry et al. (2008) concurred with Morton and Wiedenbeck (2010) by adding that the
type of training was important such as in-house versus remote training. They recommended that
time should not be underestimated as it is a crucial component in the implementation process
(Terry et al., 2008). Terry et al. (2008) suggested having the presence of an Information
Technology (IT) champion leader as a critical factor in effective use of EHRS. As such, the
recommendation is to provide faculty with the resources they need, such as time, trainer,
training, type of training, and so forth for successful implementation of the electronic health
records system.
Culture solutions. A high priority gap item for culture was found in “faculty needs to be
part of a culture that aligns with the organizational goal of 100% use of the electronic health
records system.” Clark and Estes (2008) found that effective change efforts insure that all key
stakeholders’ perspectives inform the design and decision-making process, leading to the change.
This would suggest that the members of the EHRS implementation planning teams should be
expanded and be inclusive of influencers, whom faculty look up to as models and diverse
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 148

thinkers. The identified role models should regularly meet and share information with faculty
such as the organizational goal to use EHRS 100% of the time. Also recommended, were role
models to give feedback and generate ways to receive feedback and encourage participation of
all faculty members. The recommendation for the ABZ Dental School is to have all key
stakeholders as members in the EHRS implementation team. The key stakeholders should be
role models, someone who faculty respects and looks up to as their representative, in the
implementation process. The role models will be transparent, give feedback, and encourage
faculty participation in EHRS implementation and use.
Lorenzi et al. (2009) described gaining faculty buy-in a necessity in the use of EHRS.
They explained that the buy-in should start with an early and effective communication to all
members of the practice starting at the first consideration of adoption of an electronic health
records system (Lorenzi et al., 2009). They also recommended that leaders must encourage all
members of the practice to provide input into the process, to set expectations, and to anticipate
and report potential strengths and weaknesses of an EHR implementation, within the practice.
Jha et al. (2006) cited available expert models help reduce resistance on the part of faculty
members to implement and use the EHRS. As shown in Jha et al.’s (2006) research, 36% of
physicians’ resistance was cited as barriers among hospital employees and 30% in lack of
available staff with adequate expertise in information technology. Thus, recommended through
principle and research ABZ Dental School should create a culture consisting of faculty’s early
participation and involvement in the use of EHRS. Role models who would encourage all
faculty buy-ins, set expectations, and provide valuable feedback to faculty were also
recommended.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 149

Policies and procedures solutions. A high priority gap item for policies and procedures
was found in “faculty need to have policies that align with their goal to use the electronic health
records system all the time.” Clark and Estes (2008) found that effective organizations insure
that organizational messages, rewards, and policies and procedures that govern the work of the
organization are aligned with or are supportive of organizational goals and values. This would
suggest that ABZ Dental School should verify that the existing policies and procedures align
with the organizational goal to use EHRS 100% of the time. ABZ Dental School should educate
faculty on the established policies and procedures. The established policies and procedures
should be made accessible to faculty as a resource and faculty should be aware of the existence
and where it’s housed.
Studies by Sittig and Classen (2010) acknowledged that organizations should perform
and document extensive reviews of EHRS policies and procedures yearly. As agreed by Sittig
and Singh (2009), regulations to safeguard patient privacy are very important but if not
monitored, can cause great unintended consequences on national EHRS implementation.
Bowman (2013) recommended documentation on governing principles of the organization’s
expectation through policies and procedures. He also recommended that the process to get the
expected tasks accomplished should be documented as that would give faculty clarity on
organizational goals. Bowman mentioned that faculty will find policies and procedures easier to
adhere to if they feel they belong in a cultural setting that abides to the same policies and
procedures. As such, the recommendation is that ABZ Dental School should have policies and
procedures that highlight, through detailed documentation, the expectation of faculty to use
EHRS 100% of the time. Existing policies and procedures were recommended to be reviewed
yearly. Also recommended, ABZ Dental School should make their faculty feel like they belong
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in a culture where set policies and procedures are adhered to. Steps to make faculty belong to a
culture were discussed previously in the culture solutions.
Summary of Knowledge, Motivation and
Organization Recommendations

Solutions were recommended for the gaps found in knowledge, motivation, and
organization. The summaries of the recommendations from principles and studies are shown in
Table 30.

Table 30
Summary of Knowledge Gaps Solution Recommendation
Knowledge Gaps Recommendations
Declarative factual solution on:
Faculty members need to know where the whiteboard is
located.
● Provide visual job aids.
● Use Models /
champions to train.
● Provide ongoing
training.

Declarative conceptual solution on:
Faculty members need to know how their use of EHRS
measures up to the goal of the school.
● Provide job aid as a
reminder.
● Document and
demonstrate how their
use of EHRS measure
up to the goal of the
school.
● Use champions to make
sure faculty are on
“same page” through
communication and
messaging.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 151

Table 30 (Cont’d.)
Knowledge Gaps Recommendations
Motivation Gaps
Attribution solution on:
Faculty members need to attribute the success of the
electronic health records system to their efforts to use it.
● Have models train and
provide direction
through specific
documentation and
relevant handouts.
Provide targeted timely
feedback that identifies
success and failure of
Organizational Gaps
Resources solutions on:
Faculty members need resources to successfully implement
the electronic health records system, such as “swipers,”
signature pads, and so forth.
● Work with faculty to
establish from the
beginning, what the
needed resources
should be.
● If organization cannot
provide all resources,
work with faculty for
priorities on available
resources, so that when
hard choices have to be
made, the guidance will
already be in place.
● Provide formal
computer training.
● Consider type of
training (remote or in-
house).
● Provide flexibility in
timing and structure of
training program.
● Provide an IT
champion.
Culture solutions on:
Faculty need to be part of a culture that aligns with the
organizational goal of 100% use of the electronic health
records system.
● Expand membership of
planning teams to be
inclusive of influencers,
whom faculty look up
to as models and
diverse thinkers.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 152

Table 30 (Cont’d.)
Knowledge Gaps Recommendations
● Regularly meet and
share information with
faculty such as the
organizational goal of
100% use of EHRS.
● Give feedback and
generate ways to
receive feedback and
encourage participation
of all faculty members.
● Gain faculty buy-in
with an early and
effective
communication to all
faculty.
● Faculty leaders to
encourage all faculty
members to provide
input into the process,
set expectations and
provide feedback.
Policies and procedures solutions on:
Faculty need to have policies that align with their goal to
use electronic health records system all the time.
● Verify that the existing
policies and procedures
align with the
organizational goal to
use EHRS 100% of the
time.
● Educate faculty on the
established policies and
procedures.
● Make the policies and
procedures accessible
to the faculty as a
resource.
● Make faculty aware of
the location where the
policies are housed.
● Document extensive
reviews of EHRS
policies and procedures
yearly.
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Table 30 (Cont’d.)
Knowledge Gaps Recommendations
● Document expected
faculty process in using
EHRS 100% of the
time.

Integrated Implementation and Evaluation Plan
Organizational Purpose, Need, and Expectations
The ABZ Dental School’s goal was by the end of February 2019 to be 100% electronic in
providing dental education and patient care 100% of the time. This goal was derived from the
mission of the school which is to offer outstanding dental education as well as provide
comprehensive and compassionate care to the patients. The goal of 100% electronic has always
been a subject of discussion and proposed plan of implementation by the upper management of
the predoctoral clinic. Thus, the stakeholder of study was the faculty of the predoctoral clinic.
The stakeholder’s goal, was, that by November 30, 2018, all faculty members will review all
students’ entered patient data electronically. The achievement of this goal will be measured by
the usability of the electronic health record system by predoctoral faculty in the predoctoral
clinic 100% of the time. The predoctoral faculty not reviewing all students entered patients’ data
electronically will defeat the purpose of the goal of the organization, to be 100% electronic in
providing dental education and in patient care 100% of the time.
Implementation and Evaluation Framework
The model that informed this study’s implementation and evaluation plan is the New
World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), based on the original Kirkpatrick
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Four Level Model of Evaluation (Kirkpatrick & Kirkpatrick, 2006). This model suggested that
the four levels are planned in reverse, starting with Level 4, which is the organizational goal and
then, work backwards to Level 1, keeping the focus on what is most important. Kirkpatrick and
Kirkpatrick (2016) identified the four levels of evaluation as Level 4 - Results and leading
indicators, Level 3 - Behavior, Level 2 - Learning, and Level 1 - Reaction. As defined by
Kirkpatrick and Kirkpatrick (2016), Level 4 is the targeted global outcome, the goal of the
organization. Level 3 is the degree at which participants apply what they learned during training
when they get back at work. Level 2 is the degree at which participants acquire the intended
knowledge and skills, attitude, confidence, and commitment based on their participation in
training activities. And, Level 1 is the degree at which participants find the training favorable,
engaging, and relevant to what they do. Once planned in reverse, the four levels are
implemented starting with Level 1. Designing the implementation and evaluation plan in this
manner bridges the recommended solutions to the larger organizational goal, as well as solicits
proximal “buy in” to ensure success (Kirkpatrick & Kirkpatrick, 2016).
Level 4: Results and Leading Indicators
The new Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), Level 4, measures the
factors leading to global outcome which is the organizational goal. As defined by Kirkpatrick
and Kirkpatrick (2016), Level 4 – Result, means accomplishing the mission. It targets the results
through leading indicators. The leading indicators as defined by New World Kirkpatrick Model
(Kirkpatrick & Kirkpatrick, 2016) is the short-term observations and measurements that suggest
critical behaviors are on track to create a positive impact on the desired outcome. This project
examined the knowledge and skills, motivational, and organizational barriers that prevent ABZ
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 155

Dental School from using the electronic health records system 100% of the time in providing
dental education and patient care.
The proposed solution, a comprehensive training program, related on-the- job supports,
and faculty buy-in, should produce the desired outcome. A culture that enables faculty leaders to
encourage all faculty members to provide input into the process, set expectations, and provide
feedback will reduce organizational gap. And improvement in reviewing policies and
procedures yearly will decrease the number of processes not followed. Table 31 shows the
proposed Level 4: Results and Leading Indicators in the form of outcomes, metrics, and methods
for both external and internal outcomes for the ABZ Dental School. If the internal outcomes are
met as expected, due to training and organizational support for the predoctoral faculty members
on the job performance, then the external outcomes should also be realized as well.

Table 31
Outcomes, Metrics, and Methods for External and Internal Outcomes

Outcome Metric(s) Method(s)
External Outcomes
Increase community’s
positive perception on
dental education

Scale items on satisfaction of
care
Feedback from patients
through surveys
Increase positive
feedback from alumni
Graduated students’ evaluation
of faculty use of EHRS
Feedback from students upon
graduation
Increase positive
feedback from dental
accreditation body
Accreditation body evaluation
data on faculty provided
patient care and students’
education
Feedback from the
accreditation body upon
portfolio revision

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Table 31 (Cont’d.)
Outcome Metric(s) Method(s)
Internal Outcomes
Increase in predoctoral
students’ use of EHRS

Number of procedure codes
entered in the EHRS by
students
Monthly report of entered
procedure codes in the EHRS
Increase in predoctoral
faculty members’ use of
the whiteboard to know
when they are needed
by the students

Observation checklist
developed by faculty lead
Faculty lead informal,
unannounced walkthrough in
the predoctoral clinic every
two weeks
Increase in predoctoral
faculty members to
review students’
completed work
electronically
Number of approved
procedure codes by
predoctoral faculty members.
Monthly report of approved
completed procedure code in
the EHRS

Level 3: Behavior
Critical behaviors. Level 3, as demonstrated by Kirkpatrick and Kirkpatrick (2016)
measures the behaviors needed in achieving the stakeholders goal, such as in the Chapter Two’s
listed critical behaviors. As defined by Kirkpatrick and Kirkpatrick (2016), Level 3 – Behavior,
means, to what extent do participants apply what they learned during training when they are back
on the job. For ABZ Dental School to achieve its desired outcome to be 100% electronic in,
patient care and students’ education, faculty members need to fulfill expected critical behaviors.
The behaviors are (a) Faculty checks the whiteboard to know when needed by the students, (b)
Faculty goes to student and reviews student’s documented data (patient treatment code and
notes) on the computer, (c) Faculty recommends next steps in patient care to student such as to
take X-rays, fill out forms, and so forth, and (d) Faculty electronically approves and assigns
grade to students’ completed work. Table 32 shows the proposed Level 3: Behavior indicating
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the critical behavior, metric, method, and the timing of evaluation on predoctoral faculty
behavior in the predoctoral clinic of the ABZ Dental School.

Table 32

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1. Faculty checks
the whiteboard to
know when
needed by the
students.

Number of faculty
who use the
whiteboard per
clinical session.
Faculty lead observes
that faculty checks the
whiteboard.
Every
month
2. Faculty
reviews students’
documented data
(patient treatment
code and notes)
on the computer.

Number of faculty
who sign off on
students’ data.
Obtain through reports
from the EHRS, number
of faculty who signed
off on students’ data.
Every
month
3. Faculty
recommends next
steps in patient
care to student
using EHRS such
as to take X-rays,
fill out forms, and
so forth.

Number of faculty
who recorded next
steps in the EHRS.
Obtain through reports
from EHRS, number of
faculty who put in
recommended steps in
the EHRS.
Every
month
4. Faculty
electronically
approves students’
completed work.

Number of faculty
who approved
students’ completed
work in the EHRS.
Obtain through reports
from the EHRS, the
number of faculty who
approved students
completed work.
Every
month
5. Faculty
electronically
assigns grade to
students’
completed work.
Number of faculty
who graded the
students using the
EHRS.
Obtain through reports
from the EHRS, the
number of faculty who
assigned grades to
students completed
work in the EHRS.
Every
month

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Required drivers. Kirkpatrick and Kirkpatrick (2016) defined required driver as the
processes and systems that reinforce, monitor, encourage, and reward performance on the job.
Motivation (value, self-efficacy, mood, and attribution) and organizational (resources, culture,
policies and procedures) influences drive the achievement of the stakeholder, faculty, and
outcomes. When faculty members are motivated, the assumption is that they will fully adhere to
their expected critical behaviors. The organization that the faculty functions out of influences
their critical behaviors. When faculty feels supported through having the needed resources and
feel that they belong in a culture that adheres to certain standards, policies and set procedures,
they will fully satisfy the expected critical behavior. Table 33 shows the required drivers that
supports faculty critical behaviors.

Table 33
Required Drivers to Support Critical Behaviors

Method(s)

Timing
Critical Behaviors
Supported
1, 2, 3 Etc.
Reinforcing
Faculty lead continually
communicates the policies and
procedures highlighting faculty
expectation in the use of whiteboards
and EHRS

Ongoing 1, 2, 3, 4, 5
Faculty lead communicates on-the-
job expectation of the whiteboard use
and its relationship with the EHRS.

Ongoing 1, 2, 3, 4, 5
Faculty lead supplies job aid on how
to use the EHRS

Ongoing 2, 3, 4, 5
Faculty meeting with faculty lead to
discuss problems using the whiteboard
in relation to EHRS
Ongoing 1, 2, 3, 4, 5
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 159

Table 33 (Cont’d.)

Method(s)

Timing
Critical Behaviors
Supported
1, 2, 3 Etc.
Encouraging
Faculty meeting with faculty lead to
discuss problems with using EHRS

Ongoing 2, 3, 4, 5
Faculty meet with other faculty to
discuss success in using the
whiteboard and the EHRS

Monthly 1, 2, 3, 4, 5
Faculty lead meets with faculty to
discuss the success of using the
whiteboard and the EHRS

Semester 1, 2, 3, 4, 5
Rewarding
Faculty lead publicly acknowledges
faculty success in progress toward
100% use of whiteboards

Monthly 1
Faculty lead publicly acknowledges
faculty success in progress toward
100% use of EHRS

Monthly 2, 3, 4, 5
Monitoring
Faculty supervisor will observe
faculty use of the whiteboard

Monthly 1
Faculty supervisor will review the
work of faculty such as their use of
the EHRS

Monthly 2, 3, 4, 5

Organizational support. From recommendations in empirical researches and studies
mentioned in Table 30, authors recommended how organizations can support their stakeholders.
The critical behaviors of the ABZ Dental School can be supported by providing (a) resources, (b)
culture, and (c) policies and procedures.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 160

Resources. The organization of the ABZ Dental School should work with faculty to
establish from the beginning (planning of any new project), what the needed resources should be.
It is recommended that if the organization is not able to provide all the resources, to work with
faculty and prioritize the available resources. Thus, when hard choices have to made, the
guidance will already be in place. The organization should provide formal training that will take
into consideration, the type of training; remote or in-house. The training should be performed by
models who faculty trust and respect. There should be an IT champion as well as flexibility in
timing and structure in the training program.
Culture. The organization of the ABZ Dental School should expand its planning team by
including influencers, whom faculty look up to as models and diverse thinkers. The faculty
leaders should build a culture where faculty feel encouraged to provide input into the process.
They should regularly meet and share information with faculty such as the organizational goal of
100% use of the EHRS. Faculty leaders should gain faculty buy-in with early and effective
communication to all faculty. They should set expectations, give feedback, generate ways to
receive feedback, and encourage participation of all faculty members.
Policies and procedures. The ABZ Dental School should verify that the existing policies
and procedures align with the organizational goal to use the EHRS 100% of the time. If the
policies do not exist, faculty leaders should document expected faculty procedures in using the
EHRS. Faculty members should be educated on the policies and procedures. The policies and
procedures should be accessible to the faculty as resources and faculty should be made aware of
the existence and location of the policies and procedures. It is recommended that faculty leaders
should extensively review all EHRS policies and procedures yearly.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 161

Level 2: Learning
New World Kirkpatrick (Kirkpatrick & Kirkpatrick, 2016) defined learning as the degree
to which participants acquire the intended knowledge, skills, attitude, confidence, and
commitment based on participants of the stakeholders, faculty, in the learning event. The New
World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) added confidence and commitment
to Level 2 to close the gap between learning and behavior and to prevent cycle of waste which
occurs when those with knowledge and skills are re-trained because they failed to perform
appropriately on the job.
Learning goals. Upon completion of the recommended knowledge, motivation, and
organizational solutions, faculty members will be able to perform the expected critical behaviors
as they will be able to:
1. Know what the whiteboard is. (Factual)
2. Know the location of the whiteboard. (Conceptual)
3. Know the relationship between the whiteboard and the electronic health records system.
(Conceptual)
4. Apply knowledge through training in the use of EHRS for patient care and students’
education. (Procedural)
5. Monitor their use of EHRS through peer feedback. (Metacognition)
6. Value using the EHRS in patient care and in students’ education. (Value)
7. Demonstrate confidence in using the EHRS in patient care and in students’ education
(Self-efficacy)
8. Feel positive using EHRS. (Mood)
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 162

9. Locate existing policies and procedures as well as use them as resources. (Policies and
Procedures)
10. Feel they belong in a culture that accepts using EHRS 100% of the time. (Culture)
Program. The learning goals provided in the previous section will be achieved through
training and activities that will increase the knowledge and motivation of learners, faculty
members. To develop faculty knowledge and skills, faculty will be (a) provided with targeted
on-time training, (b) provided with needed visual job aids, (c) provided with champions to train
them and make sure they are on the “same page” through communication and messaging, (d)
provided with documentation, and (e) shown how their use of EHRS measure up to the goal of
the school. As most of the faculty members stay in the same job for four years and more, while
new faculty come on board when the need arises, the program will be on-going. The new faculty
members will receive hands-on training with onboarding visual documentation upon hire. The
onboarding documentation can also be used as a go-to resource for faculty when performing their
day-to-day activities. Every semester, the faculty lead will review the outcome of faculty
members in using EHRS. They will give feedback to the success or need for improvement per
faculty. Next, the faculty lead will provide an in-depth training which will be a refresher for
existing faculty and new training for new faculty members. Furthermore, monthly, the faculty
lead will assess how faculty use the EHRS in providing patient care and students’ education.
The faculty lead, on an ongoing basis, will learn strategies to increase faculty motivation
in the use of EHRS 100% of the time in providing patient care and in students’ education. To
increase faculty motivation, faculty lead will (a) have the identified faculty champions train and
provide direction through specific documentation and relevant handouts, so they can value using
EHRS, (b) provide targeted timely feedback that identifies success and failure of faculty use of
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EHRS, (c) follow up with the teaching of the skills and knowledge through scheduled training
and handouts demonstrating the effect of success or failure of using or not using EHRS, and (d)
help faculty attribute the success or failure of EHRS to their efforts. Every semester, faculty lead
will survey faculty to understand (a) how much they value using the EHRS, (b) how confident
they feel using EHRS, (c) how positive they feel using it, and (d) how much they attribute the
success or failure to their efforts. With the outcome of the survey, the faculty lead will strategize
and give faculty feedback. Faculty will also be made to provide effective feedback to their peers
during monthly faculty meetings. In addition, each semester, faculty will be made to nominate
which of them made the most impact in accomplishing the organizational goal of using the
EHRS 100% of the time.
Evaluation of the components of learning. To apply what is learned in solving
problems and meeting performance goals, faculty must have the knowledge and skills, and
motivation to achieve their goals. Therefore, it is important to evaluate learning for both
declarative and procedural knowledge being taught. It is also important that faculty value the
training, are confident, and feel positive using what they’ve learned daily. Thus, Table 34 lists
the evaluation methods and timing for these learning components.

Table 34
Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks using multiple choice. In the beginning of the semester and mid-
semester during monthly faculty meeting.

Knowledge checks through peer discussion
and break out activities.
Periodically through the semester during
faculty workshops and documented as
follow-up evaluation.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 164

Table 34 (Cont’d.)
Method(s) or Activity(ies) Timing
Procedural Skills “I can do it right now.”
Use real scenarios in multiple choice
questions.
During the workshop.
Demonstrate individually and in groups
ability using visual job aids and
documentation to successfully perform the
skills.
During the workshop.
Individual application of skills in the testing
environment using non-real data, patients,
and students.
At the end of the workshop.
Attitude “I believe this is worthwhile.”
Discussions of the value of what faculty are
being asked to do on the job.

At the beginning of the workshop.
Pre and post test assessment survey to
determine if faculty value to use EHRS has
increased.
At the end of the workshop.
Confidence “I think I can do it on the
job.”

Discussions following practice During the workshop.
Feedback from peer and supervisor during
practice.
During the workshop.
Post-test survey item. After the workshop.
Commitment “I will do it on the job.”
Discussions following practice. During the workshop.
Post-test assessment item. After the workshop.

Level 1: Reaction
The New World Kirkpatrick (Kirkpatrick & Kirkpatrick, 2016) defined Level 1 –
Reaction, as the degree which participants find the training favorable, engaging, and relevant to
their jobs. As noted by Kirkpatrick and Kirkpatrick (2016), Level 1 was referred to as the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 165

customer satisfaction measurement of training. Table 35 lists the reactions of the participants to
the learning events being favorable, engaging, and relevant.

Table 35
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observation by the faculty lead

During workshop
Attendance During workshop
Relevance
Brief pulse-check with faculty via ongoing
discussion
During workshop and after each workshop
Workshop evaluation Two weeks after the workshop
Customer Satisfaction
Brief pulse-check with faculty via satisfaction
survey

After each workshop
Workshop evaluation Two weeks after the workshop

Evaluation Tools
Immediately following the program implementation. Immediately after the learning-
workshop events the participants will complete a survey as shown in Appendix B. The survey
will demonstrate relevance of the workshops’ material to the job, participant satisfaction,
commitment, attitude, and confidence in applying what has been learned. During the workshop,
the faculty lead through observation will fill out a checklist as shown in Appendix C. For Level
1 and Level 2, during the workshop, the faculty lead will fill out a checklist that rates the
effectiveness of faculty learning and their reaction in the learning and then will provide
feedback. During the individual and group workshops, the faculty lead will conduct pulse
checks by stopping momentarily during the workshop to ask questions and make sure faculty
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 166

find the material relevant to their work. At the same time, faculty will present realistic issues
which will be discussed by the group. Faculty will check for understanding of the materials
presented through individual questions and group discussion
Delayed for a period after the program implementation. Approximately six weeks
after the implementation of training and again at 15 weeks, the faculty lead will administer a
survey (see Appendix D for survey questions) containing open and scaled items using the
blended evaluation approach. Blended evaluation as described by Kirkpatrick and Kirkpatrick
(2016) was used to ask questions related to all dimensions of the four levels. This approach will
be used to measure, from faculty perspective, (a) satisfaction and relevance of the training to the
faculty’s ability to use the EHRS 100% of the time in patient care and in students’ education
(Level 1); (b) knowledge, skills, confidence, attitude, commitment, and value of applying the
training (Level 2); (c) application of the learning event to faculty’s ability to evaluate their use of
the EHRS (Level 3); and (d) the extent to which faculty are now more able to use the EHRS
100% of the time in patient care and in students’ education.
Data Analysis and Reporting
The Level 4 goal of the ABZ Dental School is measured by the number of faculty who
use the electronic health records system in patient care and in students’ education. It will
measure this by generating reports from the EHRS. The report will record the number of faculty
approved students’ data. Every two weeks, the faculty lead will track the number of faculty who
supervised students’ clinical sessions through the faculty assigned schedule. The faculty lead
will generate reports from the EHRS of all data (procedures and notes) entered by students and
approved by faculty. Comparing the data from faculty schedule and approved students’ work
will denote faculty members who used the EHRS and those who did not. At the end of every
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 167

semester, the faculty lead will summarize the reports for an aggregate data on how faculty
utilized the EHRS. The dashboard, Figure B, will be used to report data gathered from these
measures as a monitoring and accountability tool. Similar dashboards will be created to monitor
Levels 1, 2, and 3.

Dashboard Goal Fall, 2018 Spring, 2019
Number of faculty
who supervised
students
100% XX XX
Report from EHRS
showing the number
of faculty who
approved students’
work
100% XX XX
Differential number
of faculty who
supervised and
faculty who approved
students’ work in the
EHRS
O% XX XX
Figure B: Dashboard to Monitor the Goal for Fall, 2018 and Spring, 2019

Summary of the Implementation and Evaluation
The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) informed the
implementation and evaluation plan of this study. The four levels of the New World Kirkpatrick
(2016) model were used to ensure that the faculty had the knowledge, motivation, and
organizational support needed for them to use the electronic health records system 100% of the
time in patient care and in students’ education. This model measured the organizational goal of
ABZ Dental School through identification of outcomes, metrics, and methods. The results of the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 168

targeted outcomes are integrated in the organizational goals. This study also identified expected
critical behaviors of the stakeholders, faculty, and used it to assess their training outcome. Next,
faculty members were evaluated based on their knowledge, attitude, commitment, and
confidence during their training. Furthermore, methods to assess how faculty members react to
training were developed to determine faculty satisfaction, engagement, and the relevance of the
training on the job they perform. To implement change and to maximize the study results,
Kirkpatrick and Kirkpatrick (2016) recommended evaluating and analyzing data collection
during program implementation. They recommended analyzing data by answering three key
questions such as (1) “Does . . . meet expectations?” (2) “If not, why not?” and (3) “If so, why”
(Kirkpatrick & Kirkpatrick, 2016).
When Kirkpatrick and Kirkpatrick’s (2016) Level 1 and Level 2, reaction and learning
does not meet expectations, the faculty lead will need to identify what the issues are and then
make the needed changes. If faculty members are not reacting to training as expected, it is
recommended to stop and do a pulse check which will help to identify what the problem is. The
goal of the pulse checks as noted by Kirkpatrick and Kirkpatrick (2016) is to identify during
training or right after training, the issues that faculty might need help with, to discuss the issues,
and to help faculty find solutions (Kirkpatrick & Kirkpatrick, 2016). In Level 3 and Level 4, if
the behavior and results do not meet expectation, the faculty lead will need to meet with faculty
and solicit feedback through surveys to understand the underlying problem. While, if behaviors
and results meet expectation, the faculty lead will also need to solicit feedback through a survey
to understand the change and share the outcome with the organization (Kirkpatrick &
Kirkpatrick, 2016). Finally, to drive performance, stakeholder’s goal, and organizational goal,
Kirkpatrick and Kirkpatrick (2016) recommended generating reports and communicating the
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 169

outcome with the organization including faculty and faculty peers. Thus, the reports should
address relevance, credibility, and how efficient the program is (Kirkpatrick & Kirkpatrick,
2016).
Limitations and Delimitations
There were several limitations to this study such as the study concentrating only on the
faculty members of the ABZ Dental School. To get a full examination of the adoption of the
electronic health records system, the joint efforts of ABZ Dental School stakeholders need to be
reviewed. The stakeholders that need to be considered are the students and staff as they all use
the electronic health records system as well. Limitations were also seen as shown in Appendix
A, (Demographics of predoctoral faculty members). From a total of 237 ABZ Dental School’s
predoctoral faculty members, only 49 (21%) of them took the survey. As this did not represent
more than 50% of the population, there might be limitation to the responses received. An email
was sent to all predoctoral faculty including 97 volunteer faculty members to do the study’s
survey. Out of these 97 (41%) volunteer predoctoral faculty, only three (1%) responded to the
administered survey and none of them volunteered to be interviewed. This can be considered a
limitation as the volunteer faculty members’ involvement in this study were too low to be
successfully used in the determination of an existence of gap in the study. Finally, as the study
was only presented to faculty who volunteered to be surveyed, interviewed, and observed, the
assumption is that only those interested in the use of the electronic health records system
participated in the study. If this statement is accurate, then, it is assumed that more gaps might
be found if all the predoctoral faculty members participated in the study.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 170

Recommendations for Future Research
Areas for future research would involve conducting a Gap Analysis to examine all the
other stakeholders, students and staff, of the ABZ Dental School predoctoral clinic. Another
area for future research could involve expanding a Gap Analysis to include more volunteer
faculty members especially as they are expected to provide the same dental education and patient
care as the full-time and part-time faculty members. It would be helpful to research and
understand their expected behaviors while examining their use of the electronic health records
system. Finally, recommended for future research is the examination of the knowledge,
motivation, and organizational influences in the ABZ Dental School faculty divisions, as that
will individually identify the divisions that require its performance gap to be closed.
Conclusion
The organizational performance problem at the root of this study was the lack of
consistency and uniformity with students, staff, and faculty in using the EHRS for student
education, data entry, and in accessing patient records throughout the predoctoral clinic of the
ABZ Dental School. The dental faculty members were the stakeholder of focus as they hold the
uppermost role in the ABZ Dental School. Their roles were not limited to educating students,
but also treat patients, research on ways to improve the dental practice, and manage the whole
ABZ Dental School. The faculty members are looked upon as role models as they drive the
processes that occur in the ABZ Dental School. Students, administrators, and patients depend on
faculty decisions to be successful in their various functions and outcomes. Faculty ability to use
the electronic health records system effectively and efficiently will directly and indirectly inspire
all stakeholders to do the same.
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 171

The framework used for this study was the Clark and Estes’ (2008) Gap Analysis model.
The Gap Analysis model was used to examine the knowledge and skills, motivation, and
organizational barriers that contributed to the faculty of ABZ Dental School’s use of the
electronic health records system 100% of the time. This model also examined viable solutions to
the organizational problem. The results of the study found factual and conceptual knowledge
type gaps. Interestingly, no gap was found in the procedural knowledge type. Additionally,
motivational gap was found in attribution type of motivation. Organizational type gaps were
found in resources, culture, and policies and procedures. Peer reviewed research solutions were
used in recommending solutions to close found gaps. The New World Kirkpatrick Model was
used to inform the implementation and evaluation plan for this study (Kirkpatrick & Kirkpatrick,
2016). Thus, this Gap Analysis on examining the adoption of the electronic health records
system in the ABZ Dental School is a valuable case study as it can serve as a model for closing
performance gaps in other institutions.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 172

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Appendix A
Demographics of Predoctoral Faculty Members

Survey sent to a population of 237 predoctoral faculty
Characteristic Number (N) Percentage (%)
Predoctoral Faculty
Members

Yes
No
49
25
66
34
Total 74 100

Gender
Male
Female
24
25
49
51
Total 49 100

Faculty Status
Full-time
Part-time
Volunteer
33
13
3
67
27
6
Total 49 100

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 180

Faculty Divisions
1 = Pediatrics

2 = Periodontics, Diagnostic
Sciences

3 = Endodontics,
Orthodontics

4 = Restorative (Diagnostics,
Fixed, Operative,
Removable)

5 = Biomedical (No EHRS
use)

6 = Oral Surgery
8

11

3

24

0

3

16

22

6

49

0

6

Total 49 100

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 181

Number of years at the
Dental School (years)

<1
1-2
2-4
4-6
6-8
8-10
>10
Don’t know / Not
sure
1
1
5
10
4
5
23

2.04
2.04
10.20
20.41
8.16
10.20
46.94

Total 49 100

Number of years
using EHRS

< 1
1-2
2-1
4-6
6-8
8-10
> 10
Don’t know / Not
sure

1
2
10
5
11
20

2
2
4
20
10
22
41

Total 49 100

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 182

Appendix B
Immediate Survey after Program Implementation

Context: Survey presented immediately after learning event demonstrating relevance of
training, participant’s satisfaction, commitment, attitude, and confidence in applying what was
learned to current job.
For each of the questions below, please select the response that best describes how
you feel about the statement
Inquiry Statement Strongly Strongly
Disagree Agree
1. The training held my interest. 1 2 3 4 5 6 7
2. During training we discussed how
I will apply what I learned.
1 2 3 4 5 6 7
3. The material presented shows
relevance to the job I do.
1 2 3 4 5 6 7
4. I am committed to apply what I
learned.
1 2 3 4 5 6 7
5. I am satisfied with the training on
EHRS.
1 2 3 4 5 6 7
6. I am confident that I can apply
what I learned to my current job.
1 2 3 4 5 6 7
7. I feel positive using what I was
trained on at my job.
1 2 3 4 5 6 7

8. How can this implementation program be improved?
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 183

Appendix C
Checklist during Faculty Workshop

Context: Faculty lead checklist during workshop observation of faculty
Rating Scale
1 = Effective use of targeted behavior
2 = Moderately effective use of targeted behavior
3 =Ineffective use of targeted behavior
Feedback comment may be used for specific comments related to the question.
Targeted Behavior Rating Feedback Comment
Faculty lead asked open-ended
questions about faculty needs.

Faculty lead clarifies with follow-up
questions about faculty needs.

Faculty lead recommends appropriate
resources for faculty.

Faculty lead will work collaboratively
with faculty individually.

Faculty lead will work with faculty in
groups.

Faculty lead will give feedback to
faculty.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 184

Appendix D
Delayed Survey after Program Implementation

Context: Survey administered by faculty lead approximately six weeks after the
implementation of training and again at 15 weeks (Delayed Basis after Training)
For each of the questions below, please select the response that best describes how
you feel about the statement
Inquiry Question Strongly Strongly
Disagree Agree
1. After the training, I spent adequate
time with my faculty members to
discuss how they will use their new
skills on the job.
1 2 3 4 5 6 7
2. Faculty members have adequate
resources on the job to successfully
apply what they learned in training.
1 2 3 4 5 6 7
3. Faculty have successfully applied
the knowledge / skills learned in
this training to their jobs.
1 2 3 4 5 6 7
4. Faculty members have more peer
support.
1 2 3 4 5 6 7
5. Faculty is satisfied with the training
on EHRS.
1 2 3 4 5 6 7
6. I am already seeing positive results
from faculty because of the
training.
1 2 3 4 5 6 7
7. Faculty is referring to training
materials.
1 2 3 4 5 6 7

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 185

Appendix E
Informed Consent/Information Sheet
University of Southern California
Rossier School of Education
3470 Trousdale Pkwy, Los Angeles CA, 90089

Examining the Adoption of Electronic Health Records System in Patient Care and in
Students’ Education Using the Gap Analysis Approach

You are invited to participate in a research study conducted by Nkem Ukeje at the University of
Southern California. This study is not funded. Please read through this form and ask any
questions you might have before deciding whether you want to participate.

PURPOSE OF THE STUDY
This research study aims to examine the adoption of electronic health records system in patient
care and in students’ education using the Gap Analysis Approach at the predoctoral clinic.

PARTICIPANT INVOLVEMENT
If you agree to take part in this study, you will be asked to take a 10 to 20 minutes survey. At the
end of the survey, you will be asked to volunteer to be interviewed (20 minutes) in your
preferred space, as well as asked to volunteer to be observed (30 minutes) in the predoctoral
clinic. Your participation is voluntary, and you do not have to answer any questions you don’t
want to.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will not receive any compensation for participation

CONFIDENTIALITY
Any identifiable information obtained in connection with this study will remain confidential. At
the completion of the study, direct identifiers will be destroyed, and the de-identified data may
be used for future research studies. If you do not want your data used in future studies, you
should not participate.

Required language:
The members of the research team and the University of Southern California’s Human Subjects
Protection Program (HSPP) may access the data. The HSPP reviews and monitors research
studies to protect the rights and welfare of research subjects.

INVESTIGATOR CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact Nkem Ukeje
at ukeje@usc.edu.

IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to someone
EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 186

independent of the research team, please contact the University Park Institutional Review Board
(UPIRB), 3720 South Flower Street #301, Los Angeles, CA 90089-0702, (213) 821-5272 or
upirb@usc.edu.

EHRS IN PATIENT CARE AND STUDENTS’ EDUCATION 187

Appendix F
Recruitment Letter

Dear Faculty,

I am a doctoral candidate in the Rossier School of Education.

My dissertation study examines the adoption of Electronic Health Records System by the
predoctoral clinical faculty for patient care and in student education.

I am asking you to participate in this study by completing an anonymous survey, which should
take about 10 to 20 minutes. This survey will remain open until Tuesday October 24, 2017 at
11:59pm.

Please click on the link below to get to the Survey:

https://usc.qualtrics.com/jfe/form/SV_bkYyqbtKfBoYZEN

If you have any questions or concerns, you can contact me or my faculty advisors:
Drs. Kenneth Yates (kennetay@usc.edu) and Melora Sundt (sundt@usc.edu) at Rossier, or
Dr. Mahvash Navazesh (navazesh@usc.edu) at Herman Ostrow School.

Thank you very much for your time and consideration.

All the best,
Nkem Ukeje
Doctoral candidate
USC Rossier School of Education

Follow the link to opt out of future emails:
${l://OptOutLink?d=Click here to unsubscribe}

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Asset Metadata

Creator Ukeje, Nkemjika A. (author)

Core Title Examining the adoption of electronic health records system in patient care and students’ education using the GAP analysis approach

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Publication Date 07/20/2018

Defense Date 03/13/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag dental,Education,EHR,electronic health records,gap analysis,OAI-PMH Harvest,patient management system,students' education

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Sundt, Melora (committee chair), Yates, Kenneth (committee chair), Navazesh, Mahvash (committee member)

Creator Email nkem.ukeje@gmail.com,ukeje@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-22292

Unique identifier UC11671537

Identifier etd-UkejeNkemj-6434.pdf (filename),usctheses-c89-22292 (legacy record id)

Legacy Identifier etd-UkejeNkemj-6434.pdf

Dmrecord 22292

Document Type Dissertation

Format application/pdf (imt)

Rights Ukeje, Nkemjika A.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA