Strategies for Improving the Interoperability of Private Practices’ Electronic Health Care Systems.

Section 1: Foundation of the Study

Information and communication technology is making it possible for all health-

related information, such as electronic health care records, patient accessibility, and other

related patient-generated data sources, to be captured and computerized (Lee et al., 2021).

Communication technology has become one of health care organizations’ most common

universal languages. Health care organizations hold the most appropriate and timely

communication forms of electronic health care systems that are most suitable and

predominantly supportive to improve the quality of care given to patients (Kushniruk,

2019). Although the allowance of care and demands have traditionally been met, private

practices and small businesses still face cost growth, medical errors, and misdiagnoses

due to the interoperability challenges that come with the use of electronic health care

systems. Interoperability is vital for private practice and small businesses to communicate

adequately and produce an operative workflow through health care technology.

In this study, I explored successful strategies that some private practices and

small businesses use to effectively sustain electronic health care systems with

interoperability. Health care organizations are known for their most valuable resolutions

for life-threatening conditions, diagnoses, and patient’s overall treatment; therefore, the

functioning of the interoperability system is essential for scheduling and maintaining the

electric heath care systems’ upcoming operations and productivity. Through the findings

of this study, health care organizations may have the opportunity to overcome the

challenges of interoperability and potentially change the face of information technology

(IT), which may also benefit the health care environment across the globe.

Background of the Problem

Electronic health records created a modern upgrade of data communication and

improved patient and physician relationships while strategically building financial

revenue for all health care organizations. According to Lite et al. (2020), in 2009, the

Health Information Technology for Economic and Clinical Health Act organized the

promotion of the electronic health care record and the incentive program. The Health

Information Technology for Economic and Clinical Health Act contributed to the

program by authorizing tens of billions of dollars to encourage private practices,

hospitals, and small businesses to buy into the implementation process. The electronic

health care system’s data communication exchange was implemented and advanced

rapidly to meet measures and avoid unwanted penalties. These results concluded with

gaps in care, lack of training in vital areas, loss of revenue, and lack of an operative

workflow with interoperability.

Many potential barriers can be surmounted by using electronic health care

systems and gaining an operative workflow. To overcome potential barriers, Kruk et al.

(2018) stated that efforts must be made to ensure high-quality, competency-focused

clinical education and ethics training for providers as well as the development of a

supportive environment to help them achieve quality goals. I conducted this study to

explore gaps and missed opportunities that have been neglected to build a stronger

connection between physicians and patients while restructuring a more robust data

communication system and financial foundation.

Problem and Purpose

Health care technology investment has reached an all-time-high, with

approximately $7 billion spent in 2018 in the United States alone (Shull, 2019).

Despite

the many improvements made to electronic health care systems, private practice and

small business health care clinicians still feel the prognoses of interoperability that

remain below expectation with many data exchange errors and other ongoing significant

barriers (Sutton et al., 2020). The general business problem was that some private

practices and small businesses do not understand how to effectively sustain electronic

health care systems with interoperability. The specific business problem was that some

private practices and small businesses lacked the strategies to effectively sustain

electronic health care systems with interoperability.

According to Tsai et al. (2020), implementing electronic health care records was a

positive success; however, health care clinicians still have valid concerns about poor

interoperability and integration between systems, and these concerns have ignited a lack

of trust in their usage of the systems. The purpose of this qualitative multiple case study

was to explore successful strategies that some private practices and small businesses use

to effectively sustain electronic health care systems with interoperability. The targeted

population comprised three private practices and three small businesses located in the

metropolitan area of Detroit, Michigan. The results of this study may provide new

developments for effectively sustaining electronic health care systems with

interoperability. The results from this study may also contribute to positive social change

by increasing the quality of health care that patients receive.

Population and Sampling

The population and sampling of doctoral research are generally based on the

chosen research methodology’s internal and external validity, and the findings are

isolated and sampled based on the exploration’s detailed aspects (Andrade, 2018). The

data for this doctoral study were collected from multiple participants from the targeted

population: three private practices and three small businesses located in the metropolitan

area of Detroit, Michigan. Each participant had knowledge of the job specifications that

are directly related to electronic health care systems. I collected data from participants

through interviews in which I asked them open-ended questions regarding their

successful strategies for effectively sustaining electrical health care systems with

interoperability.

Nature of the Study

There are three structured research methods for data collection: quantitative,

qualitative, and mixed methods (Yin, 2018). I chose to employ the qualitative method to

address the specific research problem of this doctoral study. Qualitative research is a

method of natural observation that is used to understand people’s real-world experiences,

performances, and opinions within their purest form (Adane et al., 2019). A quantitative

method was inappropriate for this study because the strategies being explored could not

be analyzed numerically to test hypotheses. Mixed methods research combines

qualitative and quantitative approaches for the broad principles of assortment and

complexity of comprehension and corroboration (Schoonenboom & Johnson, 2017). The

mixed-method approach was not suitable for this study because quantitative data were not

relevant to the research problem.

I considered several options for the research design of this study, including the

phenomenological and narrative designs. The phenomenological design is used to

psychologically address the participants’ existing experiences and psychological

perceptions (Neubauer et al., 2019). The narrative design is the process of collecting data

based on the personal stories of the research participants (Aishath et al., 2019). The

phenomenological and narrative designs were not suitable for this study since I am not

psychologically addressing the participants or exploring a topic through personal stories.

I employed a multiple case study design in this study. This approach was appropriate for

this study because a qualitative study requires various data, such as observations, text,

and interviews, to investigate the specific business problem in real-life, contemporary,

bound systems (see Alpi & Evans, 2019).

Research Question

I developed this research question to explicitly focus on exploring the specific

business problem: What strategies do private practices and small businesses use to sustain

electronic health care records (EHR) systems with interoperability?

Interview Questions

1. What strategies did you use to successfully sustain private practices and small

businesses using EHR systems with interoperability?

2. How did you develop and implement these strategies within your private

practice and/or small business as an operative workflow solution enjoining

interoperability with EHR systems?

3. Was the development strategy method effective and sustainable?

4. How were supporting staff able to adjust to these modifications?

5. How did the strategy development method motivate and encourage supporting

staff members?

6. What types of obstacles or challenges did you experience during this process?

7. What strategic role did the IT team play during this development process?

8. Have you identified or developed any strategies to increase productivity and

enhance interoperability with EHR systems?

9. What strategies did you incorporate to increase productivity?

10. How did the overall experience impact the quality of care for patients?

Conceptual Framework

The conceptual framework for this multiple case study was the technology

acceptance model (TAM). Davis first proposed the TAM in 1989 to increase users’

acceptance, skills, ease of use, and future intentions of utilizing IT. This model coincides

with health care clinicians’ skills that demonstrate their self-efficacy levels (Bandura et

al., 1999). The accumulation and levels of proficiency can be defined as one’s belief in

their skills and competencies to formulate and organize the execution of course actions

required within the health care industry (Bandura, 1999). It is necessary to enhance

proficiency and cohesively communicate amongst different locations within health care

organizations to establish acceptance and knowledgeable intentions of utlizing EHR

systems (Vos et al., 2020). According to Roohi et al. (2020), the existing gap between

learned knowledge and inefficient practice within health care organizations causes a

significant increase in wasteful spending. Wasteful spending in health care may be a

nationwide issue for health care organizations and implementing and adapting to the

TAM standards may give private practices and small businesses the ability to capitalize

and execute cost-effective processes successfully under the restraint of challenging

endeavors.

Use of the TAM allowed me to effectively explore the successful strategies of

increasing users’ acceptance, skills, ease of use, and future intentions of utilizing IT

within private practices and small businesses. These successful strategies can be used to

create goals regarding utilizing outsourced means to properly sustain patient care and

workflow. Use of the TAM may also allow health care clinicians to manipulate the

system to fit the demands of health care organizations and their ability to conduct an

operative workflow, enjoining interoperability (Rich et al., 2010).

Operational Definitions

These terms and phrases are most commonly used within the health care

environment; therefore, the words are reliable and correlate with academics and business

literature.

EHRs: Electronic versions of individuals’ medical histories kept by their health

care providers throughout their treatment and may include demographic information,

progress notes, medications, vital signs, immunizations, laboratory results, and

radiography results (Kruse et al., 2017).

Quality of care: A necessary level of care for achieving high productivity levels

within health care organizations. The degree to which the possibility of achieving the

expected health outcomes is significantly increased, aligning with updated professional

knowledge and skills in health services (Sfantou et al., 2017).

TAM: A model used to increase users’ acceptance, skills, ease of use, and future

intentions of utilizing IT (Davis, 1989).

Assumptions, Limitations, and Delimitations

Assumptions

An assumption is an expectation or belief that something is true in the absence of

proof (Dagan & Somech, 2021). I assumed that the study could explore and construct

meaning through multiple realities (see Kivunja & Kuyini, 2017). Another assumption in

this study was that EHRs have contributed to the improvement of the health care industry

by demonstrating the highest quality of care provided to patients and the success of the

implementation of electronic health care systems. I also assumed that I would have the

opportunity to explore strategies relevant to further improving electronic health care

system usage with interoperability through this study and that the results may be used to

develop a more robust financial foundation.

Limitations

Limitations are defined as aspects of the study that may potentially be out of the

researchers’ ability to control and may affect the potential to obtain a successful research

outcome (Theofanidis et al., 2019). The potential limitations of concern in this study

included the access I had to participants while adhering to health care facility agreements,

privacy rules related to Health Insurance Portability and Accountability Act violations

from being granted access to EHR systems, and the ability to recruit potential participants

for the interviewing process.

Delimitations

Delimitations describe the author’s conscious setting of boundaries through

established restrictions so that the aims and objectives of the study remain achievable

(Theofanidis et al., 2019). This study was limited to participants who had access to the

health care organizations’ portal daily. This delimitation was established so I could

capture the participants’ experiences of how a successful operative flow during the use of

electronic health care systems and finances may increase revenue.

Significance of the Study

This study is significant because it provides data regarding successful strategies

for using electronic health care systems with interoperability. There has been a

fluctuating balance for health care clinicians to work efficiently and effectively within the

limitations of health care organizations’ strategic workflows. During the past few

decades, technologies have transformed health care, producing changes and broad

support for health care organizations This study was necessary to add valuable

understanding for private practices and small businesses to establish a successful

operative workflow with integrated systems.

Contribution to Business Practice

As the implications of data communication increase in development, health care

organizations are more inclined to increase growth and compete with a competitive edge

(Purcarea, 2019). The consistent contribution and practices for change have become an

economic boost for the health care environment (Kruk, et al., 2018). Private practices and

small businesses are keeping pace with the modern times and changing to continually

implement health care system improvements. There is the opportunity to shift business

perspectives to align with a practicable flow and increase revenue through the

implementation of the strategies employed from the findings of this study.

Implications for Social Change

Health improvements and the advancements in technology have positively

impacted the social changes in modern society, exposing the means to create a better life

for patients. The use of the electronic health care system improves the quality of care

given, making it beneficial to the promotion of health care services the surrounding

community receives. In addition, the study results impact positive social change that

benefits the health care industry and allows clinicians to better utilize captured data to

improve patient care and patient experience.

A Review of the Professional and Academic Literature

Producing proper patient care is one of health care clinicians’ leading concerns.

Servicing patients effectively and efficiently in electronic health care systems supports

communication with how patients receive treatment and diagnosis. Electronic health care

systems are a positive contributing factor to the modifications in health developments

within the business. Introducing electronic health care systems and technology helps

build the health care industry and join bureaus worldwide. In this qualitative study, I

explored some strategies that private practices and small businesses use to sustain

electronic health care systems with interoperability.

In this literature review, I sought to survey the extant data, concepts, records, and

evidence that relate to the research topic (see Zuiderwijk et al., 2020). This literature

review also contains a discussion of the conceptual framework of the TAM. There are

continuous barriers faced by private practices and small businesses with regard to

maintaining an operative workflow with interoperability while using EHR systems, so

additional research studies are necessary to address these challenges. In this literature

review, I attempted to establish and identify the successful implementation of effective

and efficient strategies for applying an operative workflow with interoperability during

the use of EHR systems. The literature review is comprised of the following segments:

(a) the TAM, extended versions of the TAM, and alternatives to the TAM; (b) an

overview of electronic health care systems and their functionality; and (c)

interoperability, health care barriers, and challenges related to cost.

I used the Walden University Library to find relevant literature for this doctoral

study. The databases and search engines used were Google Scholar, Sage Journals,

JMLA, PubMed, and NCBI Journals. I used the following keyword search terms to locate

literature for this review: close financial gaps with EHR, interoperability, enhancing

coding operability with EHR systems, EHR, and inefficiencies with private health

practices and small businesses. My search mainly focused on sources that had been

published in the last 5 years to gain an in-depth wealth of knowledge on the topic. A total

of 150 sources were cited in the study, of which 137 were peer-reviewed sources, which

accounted for 91% of the references.

Conceptual Framework: The TAM

Davis (1989) first proposed the TAM. The TAM has been one of the most applied

models of variations to research health IT’s ease of use; intentions to engage with users;

and individuals; attitudes, behaviors towards use, and perceived usefulness of IT (Beldad

& Hegner, 2018). The approach toward technology adaptation depends on the

individuals’ acceptance of and attitudes toward the systems employed (Vladova et al.,

2022). For example, suppose a health care clinician can function proficiently and

effectively through data exchange. They may support and accept technology

implementation and incorporate that ability as an operative system. The technology is

then perceived as valuable by a health care clinician’s belief in applying electronic health

care systems. The acceptance of the user may also encourage improvement in their job

performance. In unison, perceived ease of use refers to their certainty that electronic

health care systems require minimal effort once trained in use (Nguyen et al., 2020).

Health care clinicians are subject to working in fast-paced environments within private

practices and small businesses, making it possible for many challenges to occur, such as

medical errors, excessive spending, misdiagnoses, and interoperability. If electronic

health care systems were easier to use, health care clinicians would deem the portal more

beneficial for private practices and small businesses.

The benefits and perceived usefulness of an operative workflow are crucial to

simplifying specific efficiency goals. In addition, the workflow of private practice and

small businesses is essential to maintain an operative flow of patient visits and consistent

revenue (Kurk et al.,2018). The benefits of technology and its perceived usefulness to the

electronic health care system are critical components of patient visits and operational

processes, but, over the years, the implementation of the TAM and its perceived

usefulness has demonstrated how improved health care workflow may allow accessible

modifications with the necessary improvements to care gaps (Davis, 1989). Nevertheless,

the lack of

interoperability and the electronic health care system’s perceived usefulness

approach to the workflow of traditional care has resulted in inappropriate care for patients

and misrepresentation of workflow for health care organizations and those who require

minor and extensive services (Nyguen et al., 2020).

Further evaluation of users’ apprehension about engaging with electronic health

care systems is necessary to evaluate employee adaptation and performance (Yulianti &

Pusparini, 2021). The TAM is more prominent and recognized for its perceived

usefulness and intention of use concepts (Davis, 1989); however, many health care

clinicians differ in their attitudes regarding the implementation of new resource

technology. Health care clinicians’ intention to engage in using electronic health care

systems can raise employees levels of apprehension to change.

According to Scholkmann (2020), for the timeframe of technology’s existence,

people have resisted it. The working environment is currently dominated by two opinion

groups, those who believe technology eliminates jobs and those who believe it drives up

costs (Snoswell et al., 2020). Change is inevitable when incorporating the pertinent use of

systems within private practices and small businesses. A health care organization’s

survival may solely depend upon their ability to introduce changes that is successful

(Rehman et al., 2021). The elements of unwillingness to change can present a hardship

for thriving private practices and small businesses.

Davis (1989) enhanced the TAM by introducing the extended version. Venkatesh

and Davis (2000) named this new, extended version of the TAM, TAM2. The TAM2

emphasizes social influence and cognitive processes on perceived usefulness and

intended usage (Hoong et al., 2017). The TAM2 provides a clearer understanding of the

direct effects of use and intention to use (Venkatesh & Davis, 2000).

According to Kruk et al. (2018), electronic health care systems are primarily

judged on their impact on how health care clinicians can contribute to care and their

perceived usefulness within health care organizations. Private practices and small

businesses heavily rely on the perceived use of the electronic health care systems’ job

specification intake and performance effectiveness for a productive workflow. The

TAM2

was primarily proposed to understand the health care clinicians’ use of electronic

health care systems within a health care organization (Racero et al., 2020). The perceived

significance of the input through the specified job intake by the health care clinician

determines the job’s relevancy and the system’s authenticity. If a system is at a

nonworking capacity, health care clinicians will consider the electronic health care

system’s performance invaluable. For instance, if the electronic health care system was

deemed valuable by perceived usefulness, positive usefulness might increase the level of

usage over some time (Momani et al., 2018).

Davis developed the original TAM to provide essential elements with which to

explore the decision-making and acceptance process of electronic health care systems by

users in a clinical setting (Henshall et al., 2020). The original prototype of the TAM by

Davis (1989) and the extended version of the TAM2 by Venkatesh and Davis (2000)

offered a considerable amount of in-depth detail on the relationships between perceived

usefulness, job specification, resistance, and authenticity relating to electronic health care

systems, private practices, and small businesses. Venkatesh and Davis created a third

version of the model, the TAM3, to extend further the model.

Regardless of the complexity of the social environments they occur in, such as

health care facilities, the determination of health care clinicians’ decision-making process

has been considered an essential element of the acceptance of, perceived usefulness of,

and engagement with technology of the workforce that determines and contributes to a

health care organization’s efficiency and workflow satisfaction (Ceschi et al., 2017).

Private practices and small businesses may have the opportunity to build on the

effectiveness of the user’s experience with electronic health care systems. Using the

frame of the mindset development of each health care clinician that interacts with the

electronic health care system generates a different component of a decision-making

process regarding how the system is deemed valuable or invaluable. The determination

and acceptance of electronic healthcare systems profoundly affects a successful workflow

within health care organizations.

I also considered using Smircich and Morgan’s (1982) health care leadership

theory as the conceptual framework for this study. The demands of leadership and the

teaching and training of employees on implementing the electronic health care system for

a successful workflow are crucial to maximizing practical administration skills and

decreasing costs (Xu, 2017). According to Smircich and Morgan, the health care

leadership theory is used to shape and define the opportunity for an organized

understanding of formed leadership styles and their behavioral approaches within private

practices and small businesses. Utilizing the health care leadership theory, I would have

had the opportunity to develop and understand the phenomenon of critical aspects of

significant leadership roles. These leadership roles align with health care organizations’

structured management guidelines that are needed to give a deeper meaning to organized

development of leadership behavioral approaches within private practices and small

business organizations and their employees’ participation. However, my specific

concerns in this doctoral study were more aligned with the TAM (see Davis, 1989). The

TAM focuses on the employees’ perceived usefulness and behavioral outcomes, which I

applied to the use of the electronic health care system that produced an operative

workflow to enhance the quality of care for patients and be cost effective.

Electronic Health Care Systems

The electronic health care system produces a digital edition of a patient’s paper

chart, has forced a cultural shift and transformed the focus of dialect, and is now a

standard medical technology (Wolfe et al., 2018). The electronic health care system is a

strategic version of real-time, patient-centered records that instantly make information

available to health care clinicians within private practices and small businesses

(Ammenwerth et al., 2017). Private practices and small businesses heavily depend on the

electronic health care system for the modern changes in increased revenue, clinical data

collection, health-related issues, quality of care, and the ability to store (Uslu &

Stausberg, 2021). As the electronic health care system evolves within private practices

and small businesses, changes should occur. Health care clinicians’ challenges with the

technology should be considered when using electronic health care systems for the new

types of data collected from patients, additional privacy and security policies, ethics, data

sharing for user ability, decreases in revenue, and communication (Zayas- Caban et al.,

2021).

The transition from traditional to modern technology has resulted in a

professional transformation regarding the use of electronic health care systems. The

proficiency of physicians’ skills allows them to notate in-depth clinical documentation

and develop the craft of medicine. According to Honavar (2020), health care records have

4,000 years of development history, and the progression of medicine and health care

records has existed in some shape or form since the beginning of medical history.

For many years, traditional paper charts have been an established source of

communication within private practices and small businesses; however, this conventional

sense of paper-based health record charting systems costs private practices and small

businesses precious time and money. The traditional sense of charting also interferes with

providing the best care for patients (Mijin et al., 2019). The use of paper charts

transitioning into the implementation of electronic health care systems is one of the most

secure ways of handing pertinent information that pertains to patients’ private

demographics and intimate details of care. In addition, the EHRs provide information in

the form of data that was not available with the traditional chart form. For example, using

EHRs, health care clinicians can access, manage, and share pertinent health information

with other health care facilities authorized privately in a secured, controlled environment

(Ruhi et al., 2021).

Successful accessibility of EHRs during the use of the electronic health care

system is essential for an operative workflow. Since the launch of the electronic health

care systems process, more than 94% of hospitals across the United States have applied

some form of the EHRs system (Khairat et al., 2018). The accessibility afforded by the

electronic health care systems exists as an avenue to accommodate a successful operative

workflow within private practices and small businesses. The relevancy measurements of

a successful operative workflow are supported by the accessibility of the electronic health

care system’s capacity to input and output demographic and general information, track

and dispense medication, verify insurance, and retrieve relevant lab results for patients

during an office visit. The electronic health care systems’ elements of accessibility are a

daily resource for users from private practices and small businesses and contribute to

structured functionality. Each state of the electronic health care system has been proven

beneficial to the health care industry and is regarded as vital to development, but the

ability to support end users is still an ongoing operational development process that has

not been met. As a result, the accessibility of the electronic health care system is a critical

element that has been unsuccessful in advancing at an increasing rate (Sieck et al., 2020).

Many limitations of electronic health care systems result from implementation

process variation. Third-party vendors allow access to applications that extend the

capabilities and features of health care organizations’ electronic health care systems

(Ritchie & Welch, 2020). Due to the widespread use of electronic health care systems and

third-party applications, it has become necessary to perform a systematic review and

analysis of functions in electronic health care systems application marketplaces

(Kawamoto et al., 2019). Konnoth and Scheffler (2020) conducted a systematic review of

third-party vendors, analyzing nearly half of the participants in the most recent health

care information and technology exchange study. The authors learned that electronic

health care systems vendors routinely partake in electronic health care systems blocking.

Konnoth and Scheffler also found that 25% of the participants indicated that hospitals

and some electronic health care systems routinely do so too. These methods of conduct

should be sanctioned and revised with prevention penalties to ensure successful

accessibility.

The defined characteristics of electronic healthcare systems allow access to

private practices and small businesses. The electronic health care systems were created

and designed to fit the population’s needs and expanded to improve patients’ health. The

federal government placed the electronic healthcare system’s foundation into operation to

improve technology and patients' diagnoses to advance healing further. The background

of electronic healthcare systems describes how modifications of the characterized system

continues to contribute to medicine, taking the world into the future (Evans, 2016). The

defined characteristics and the structured quality are the desired features of an electronic

healthcare system that emphasizes usability or measurement of performance. The

accessibility, complexity, effectiveness, ease of use, information and exchanges,

utilization, versatility, integration, interaction, dependability, responsiveness, system

correctness, system features, and reversal time are distinct elements of the system's

capability (Alazaam et al., 2021). The technology of health has bridged a form of

communication through the use of electronic health care systems. The use of the system

has also created a better relationship between physicians and patients. Private practices

and small businesses can summarize their findings to build on the health diagnosis to

contribute to the care relationship. With the electronic health care systems, relationships

are finding ways to improve daily use.

Electronic health care systems enable care and also administrative support.

Electronic health care systems allow private practices and small businesses to help

securely transmit patient data and provide high-quality patient care. Private practices and

small businesses are also streamlining their focus on patient safety and reducing errors.

The implementation of data administration ensures that the most proper patient care is

protected and precise transfer of confidential retrieved data (Bates & Singh, 2018).

Health care clinicians are steadily responsive to the demand to improve and support the

population by reducing errors and increasing the quality of care for patients. Although

many versions are ready and available for the electronic health care system, one critical

element is inputting and exporting the appropriate data. Implementing the electronic

health care systems should come close to managing the needs of the private practice and

small businesses’ requirements to meet measures of intricate care, cost, and trust and

assist in sustaining an operative workflow. Implementing the appropriate electronic

health care system with the proper case definition enables efficient data extraction,

improves interaction for clinical decision-making in private practice and small business

research, and enhances the quality of health care services (Adane et al., 2019).

One of the primary and targeted goals of electronic healthcare systems is to

enhance the relationships of healthcare organizations. The electronic health care system

enriches collaboration within multifunctional health care facilities (Vos et al., 2020).

Private practices and small business professionals can improve collaboration as an

opportunity for health care team members to utilize the electronic health care systems and

presume roles to work together cooperatively. These assigned roles may consist of

different perspectives and skills for sharing the accountability for solving problems and

making critical decisions to formulate and carry out plans to be effective and efficient

within the quality of workflow and patient care (Morley & Cashell, 2017).

The defined enhancement of electronic health care systems collaboration within

private practices and small businesses is critical for developing aims of meeting goals and

objectives. As health care clinicians continue the connection in work performance within

private practices and small businesses, it further develops the use of the electronic health

care systems and the skillset of the health care clinicians. Deviation from these

developments may yield an opportunity for a non-alignment of goals and perceived

usefulness of the electronic health care system.

The electronic health care systems globalization and significant data impact the

overall health care technology’s development. The utilization of electronic health care

systems and the ability to collaborate is a critical endeavor for the United States and

globally. Implementing electronic health care systems establishes globalization’s

perceived usefulness and the need for development and expansion within different

countries. The global health electronic system is an avenue for mapping the relationships

between various online and offline networking (Hoffman & Cole, 2018). Data sharing

across sanctions are still in high demand to collaborate for all health care entities. The

health care organizations’ advantages of exchanging patients’ health information through

the electronic health care system globally across providers have been a long-awaited

recognition and participation in health information exchange. The cause of these

measures based on collaboration has different cultures lagging in implementing electronic

health care systems (Mello et al., 2018).

Although there is a tremendous push for the electronic health care system, many

challenges still go beyond the scope of technology to involve social and behavioral

detriments (Jacob et al., 2020). The electronic health care system’s social and behavioral

domain is a vital element of private practices and small businesses. The social and

behavioral determinants of health care are the cultural environments people are born,

work, or have adapted to within the population (Marmot, 2018). These social and

behavioral determinants often consist of the development and integration that correspond

with the economic systems’ societal structures and sanctions responsible for most health

discriminations (Chen et al., 2020). These determinants can contribute to and often relate

to a way of life from adaptation.

Consequently, these determinants may also become contributing factors that are

critical causes of the results of society’s unfortunate outcomes and hardships that affect

everyone near and beyond those measures (Magnan, 2017). The description of social and

behavioral determinants aligning with health and its concentration on technology explains

how the electronic health care system can contribute to meeting different levels of

meaningful use standards. Meaningful use in the healthcare environment is applied to

obtain specific objectives such as the cultural environment, demographics, patient

engagement, variations of change, and other life cycles (Nielsn et al., 2020). These

objectives allow healthcare organizations to recoup meaningful use of incentive funding

and meet quality care measures. Capturing social and behavioral determinants with the

electronic health care system is a point of opportunity to identify and enhance different

regions and levels of care for patients. Electronic health care systems’ social and

behavioral determinates reiterate how the incentive program’s meaningful use can be

accomplished by obtaining measures specific to the culture and needs of the patients.

Electronic health care systems improve the needs of the patients and the requirements of

private practices and small businesses to meet many measures of care.

The population and support of electronic healthcare systems are effective across

the globe. Population health is the science and prevention of the health effects of a group

of individuals (Baba et al., 2018). The population of health groups of individuals is

classified as the support to improve the most vulnerable population. The population

health individuals have primarily focused on private practices and small businesses

(Kindig & Magnan, 2019). The electronic health care system is a crucial segment of

population health; health care clinicians can capture and track health issues through this

feature. Electronic health care systems have emerged among health care systems as a

critical piece for monitoring population health and supporting meaningful use. The

federal government launched meaningful use to measure areas for improving the health

proficiency of patients and quality care (Bau et al., 2019). It is also a way for private

practices and small businesses to gain incentives. These incentives can increase revenue

for health care organizations and mend the financial disparity that private practices and

small businesses face (Erickson et al., 2020).

Although the electronic health care system has improved by supporting

population health and capturing and tracking the population, electronic health care

systems still resume with the lacking interoperability, functionality, and many medical

errors in other instances (Kruse et al., 2018). In addition to the errors, Kruse et al. (2018)

found that most medical errors occur when staff is not adequately trained to use the

electronic health care systems. By shaping and forming information technology,

complimenting health information technology is changing the face of healthcare.

The positive impact of health care delivery and electronic healthcare systems can

be an increase in cost for improvement in private practice and small businesses. Moro

Visconti and Morea (2020) stated in 2019, a study was conducted on the financial

stability of health care delivery and electronic healthcare systems; the United States

projects an increased rate of 5.4 % from 2017 to 2022. Moro Visconti and Morea also

stated this would reflect the demanded increase for modifications within technology and

lifetime resulting conclusions. Health information technology is an asset that bridges gaps

between hospitals and remote paying participants. It also breaks down the study into

categories. The impact of health digitalization helps pinpoint the growth of the aged

population. When hospitals consistently meet their measures and follow the rules and

regulations, bridging gaps occur.

Private practices and small businesses can be affected by operations and the cost

of health care. According to Moro Visconti and Morea (2020), if profits are not taken into

account, a two-headed sword will result and can be damaging to private practices and

small businesses. Traditionally, private practices and small businesses used traditional

methods, but new technology has altered this. Health care operations and costs have been

impacted by technology. To maximize value and leverage patient care, health care

organizations can utilize a variety of itemized categories. When skills and communication

are at the forefront of the clinician's usage, profitability has an opportunity to be

maximized.

Electronic health care systems’ delivery of ethical conduct plays a vital role

within private practice and small businesses. The safety of daily medical information

during a workflow process can present a crucial challenge for private practices and small

businesses. Private practice and small businesses may encounter busy health care

facilities that leave them vulnerable to experiencing ethical issues. Often, health care

clinicians face unethical situations during their engagement with electronic health care

systems, and these issues cover an extensive assortment of areas within private practice

and small businesses (Rasoal et al., 2017). According to Tafie (2020), these vast areas

may exist through the service delivery task provided to patients during the daily use of

electronic health care systems. For example, data privacy, security violations, and

medical errors. Ethical conduct is a supporting mechanism for the functionality of private

practices, small businesses, patients, and health care clinicians. Filling the gap in medical

technology is a critical piece.

Analyzing and exploring ways to improve the workflow process during the use of

electronic health records may benefit all health care clinicians. By studying its

functionality, private practice and small businesses have the opportunity to understand

the functionality for a better user experience of the electronic health care system and

decrease the vulnerability of ethical issues. The understanding will also have the

opportunity to balance the improvement of quality care provided to patients and cost-

effective avenues.

Utilization of the electronic healthcare system may have severe effects when

improper use occurs, and medical errors can result. Poor use of electronic health care data

processing systems is one of the critical indicators for medical errors. Implementation of

standardized data management systems assists in the reduction of errors that are

associated with data processing and suffering elements (Adane et al., 2019). Electronic

health care systems have supported health care clinicians in capturing errors related to the

overall clinical process of data entry. According to Harron et al. (2017), EHR are

essential to researchers for their potential for successful levels within technology

applications.

As many health care organizations across the globe expand from the use of

technology, its opposition should have the potential to reduce errors and produce a higher

quality of care for patients. The success of the data that has been collected depends on the

research that has been collected. The quality of the information is critical and relies on

the collection process. EHR have a disadvantage, just as traditional charts with medical

errors. Some links can lead to misdiagnosis and mistakes within the electronic health

records platform due to different diagnosis methods for patients. A study was performed

to capture these mistakes using data identifiers. Similar data have been investigated to

ensure that errors are captured to ensure safety and the highest quality of care for patients.

These methods are implemented to ensure that electronic health records remain an

essential asset for healthcare organizations. In addition, the errors of studied elements

about electronic health records are furnished further to advance technology use within the

healthcare environment.

The electronic health care system can secure and track data usage, integration, and

communication. Electronic health care systems have been an onset for improving health

care through their trust and communication development. However, the intricate details

of electronic health care systems' implementation and further interoperability

development are still debated. According to Tsai et al. (2020), there is a decrease in

communication and the lack of integration of health care clinicians' workflows. The lack

of connective communication with other health care organizations in electronic health

care systems could increase providers' workload. Communication and trust play critical

roles in all health care environmental relationships between private practice and small

businesses (Molina- Mula & Gallo - Estrada, 2020). Patients often trust when entering a

health care facility that physicians will meet all the patient's health care needs through the

transaction of communication. This sentiment applies to patient and physician

relationships and the relationship between the communication workflow of patients,

health care clinicians, and the use of electronic healthcare systems. Health care clinicians

rely on the data usage of transactions of the electronic health care system and its ability to

compile, store, and evaluate extensive amounts of healthcare information data. Collecting

and integrating data is one of the most critical aspects of the workflow process, care of

patients, and the electronic health care systems (Adjekum et al., 2018). The electronic

health care system’s strategy progression of communication can only be of prominent

detail if integration is adhered to as a valuable substance of resource.

There are still barriers to utilizing electronic health care systems and telehealth.

Telehealth is a technology that has become an outlet of communication for private

practices and small businesses to medically treat, diagnose, engage, and interact with

their patients through a secured virtual appearance. Health care clinicians can connect

with established patients anywhere and anytime permitted through telehealth. Many

patients based with private practices and small businesses have found the virtual

connection convenient and a more innovative way of communication.

Private practices and small businesses' managed care workflow routines have

been shaken by the COVID-19 pandemic. Countless errors related to the implementation

of electronic health care records surfaced during the COVID-19 pandemic. For example,

most electronic health care systems do not communicate between health systems which

causes significant delays in the facility-to-facility prompt application of appropriate

precautions (Pryor et al., 2020). The uncertainties of real-time events showed countless

challenges of despair for the access to trade and commerce and the nation's population.

As stated for health care facilities, the invention of telehealth was an opening channel of

supply to continued practice. During the COVID-19 pandemic, there was a significant

decline in recouped revenue and cost within private practices and small business

physician visits. As a result, many private practices and small businesses were compelled

to close their business doors and utilize the virtual connection of telehealth. Through the

use of electronic health care systems, telehealth has contributed to health care delivery

modalities (Androga et al., 2022). Although COVID- 19 was able to show private

practices and small businesses how interoperability is still a challenge by describing

unwanted medical issues, increased revenue, and redundant costs.

The economic rates of insurance and day-to-day preventive practices continue to

rise. Private practices and small businesses feel the added pressure of insufficient

electronic healthcare standards. Private practices and small businesses have similar

experiences with clinical data transactions that all have substantiation costs that align

with interoperability challenges (Lite et al., 2020). Thomas et al. (2022) conducted a

study on COVID- 19 pandemic. Thomas et al. found that since the COVID-19 pandemic,

there has been a rapid increase in global telehealth utilization within the United Kingdom,

with a 1,000 % increase in Scotland for 2 weeks in March. Thomas et al. also stated that a

similar event occurred in Australia, with an increased percentage of 0.2 % in February

2020 to 35 %. As a result of these events, the Centers for Medicare and Medicaid

Services (CMS) have expanded the access for patients to utilize telehealth services to

decrease Medicare beneficiaries and the need to seek care at private practices and small

businesses (Rubin, 2020). Although telehealth visits align with convenience and improve

the quality of patient care, there are still excessive barriers to electronic health care

systems' levels of communication. Despite this, heavy regulatory laws and an insufficient

payment structure hinder the widespread implementation of telehealth (Kichloo et al.,

2020). As a result, within some private practices and small businesses, a challenge

remains in obtaining updated patient signatures and demographics before approving

insurance authorizations for telehealth visits. The rapid occurrences of increased

telehealth visits elevated the urgency for local and broader information exchanges to

become available nationwide.

Interoperability

Interoperability is yet an unrefined component of technology that plays a

significant role in data exchange throughout health care networking. Private practices and

small businesses dedicate themselves to transforming the global health care industry.

Utilizing electronic health care systems and incorporating interoperability is underlining

this process. Interoperability can assist in using electronic health care systems at their

total capacity of interchanging data. To extend the highest quality of care to patients,

private practices and small businesses depend on a cohesive version of the technology in

the form of modern communication.

This doctoral study aims to demonstrate why interoperability is most important to

the healthcare industry by exploring some private practices and small businesses that lack

the strategies to effectively sustain an operative workflow with interoperability during the

use of electronic healthcare systems. The foundational access and interoperability

exchange have four stages generally classified and designed into four primary levels:

base, sematic, organization, and the structure of health information technology exchange

(Shah et al., 2016). The foundation of interoperability is when data are produced and

exchanged from one computer system to another (Golzarpoor et al., 2018). According to

Bombard et al. (2018), patient engagement and data exchange are critical components of

healthcare delivery. For example, to encourage patient interaction with the development

of data exchange, patients can manually enter patient demographics on a secured patient

portal. The document is then uploaded. Depending on the document's location resource,

the assistance of third-party vendors would exchange this data with private practices and

small businesses.

In addition to data exchange, patient surveys after a doctor's appointment are

complete and serve as an example of patient interaction. Patients are once more

encouraged to interact with the development of exchanging data. The patients are invited

by private practices and small businesses to give their opinion about the quality of their

experiences. The basis of the format is participated by manually uploading their feedback

from the experiences. This information is an intimate exchange between the user, third-

party vendors, private practices, and small businesses. Having patients interact with the

system allows patients to share the responsibility of actively accessing and exchanging

data; without interoperability, patients are held accountable for remembering to share

their own experiences in a traditional sense of pen and paper method. Organizational

interoperability is the description. Semantic interoperability is a direct data exchange that

enables shared computer knowledge and data sharing among organizations or systems

(De Mello et al., 2022).

De Mello et al. (2022) stated that semantic interoperability ensures that the data

exchange is understood and interprets the data regardless of who participates, using

medical terminologies and vocabularies. (Lehne et al., 2019). Lehne et al. also stated by

combining foundational and structural process concepts, the semantic interoperability

exchange is recognized as one of the most critical stages of interpreting the highest

quality of patient care. Semantic interoperability’s ability to exchange is heavily relied on

to communicate and transfer procedural information by private practices and small

businesses for its functionality. According to Seyed- Nezhad et al. (2021), through a

referral system, health care clinicians ensure the efficiency of close relationships within

healthcare on all levels. Based on Seyed-Nezhad et al.’s findings, 1,245 relevant studies

were included in the first stages, and 63 studies were affected by referral system

performance. Health care clinicians utilize the referral processing system within private

practices and small businesses to outsource patients who need additional or special care.

Outsourcing patients for specialist care allows health care clinicians to meet and align

with quality measures while diagnosing and treating a patient on different methods. To

monitor and track a diagnosis, physicians rely on exchanging information from one

system to another. Another example of semantic interoperability would be workflow

process management; healthcare clinicians routinely work with physicians to ensure that

the patient flow is smooth and continuous. Communication to generate labs, referrals, and

the ability to maximize open access to available exam rooms after triaging patients.

Communication that promotes semantic interoperability promotes an effective working

relationship. Sutton et al. (2020) found that reorganizing the clinical workflow process is

beneficial and crucial for reducing costs and improving the turnaround time of clinical

evaluations. Without the systematic interoperability of exchange, health care clinicians

would have continuous communication barriers.

The structure of semantic interoperability has many barriers that can disrupt and

interfere with the use of the electronic healthcare system. The exchanging of data from

one system to another has barriers to private practices and small businesses’ eprescribing.

For instance, once a patient has completed an office visit, the physician generates the

prescriptions. The electronic health care system must be able to communicate and

exchange prescribed medication with pharmaceutical systems. For example, Lehne et al.

(2019) discussed how the volume of pharmaceutical requests could increase from revised

medicine to newly diagnosed medication requests. Private practices and small businesses

rely on the electronic health care system to produce multitudes of data to exchange these

medication requests. Interoperability is relevant for proper treatment; an inaccurate

exchange may cause a lapse in time and treatment for patients to receive adequate care.

Third-party vendors play a critical role with interoperability barriers. Third-party

vendors allow the electronic health care system to develop and expand with continued

unified use (Kawamoto et al., 2019). These intricate details are most valuable for a

continued seamless office visit workflow process, such as being able to schedule

appointments, checking in and checking out patients, self-check-in, patient survey

feedback, verification of insurance, ordering labs, and electronic prescribing of

medication.

Many private practices and small businesses have invested in implementing

electronic healthcare records systems. Savage and Savage (2020) conducted a study and

found in 2015, 96 % of hospitals and 78 % of private practices and small businesses

successfully implemented some electronic health care system.

Interoperability within

health care assists is essential in restoring the disparities in the deliverance of health and

increasing the purpose of modern technology. The lack of interoperability is a continuous

phase in this doctoral study to drive the crucial elements of patient care, decreasing the

shortage of data exchange and the opportunity to increase revenue within private

practices and small businesses. Each level of development is a nuance of description vital

to building on health improvement within the metropolitan areas of Detroit, Michigan

communities and across the globe.

Consistency with electronic healthcare systems will allow private practices and

small businesses to benefit with improved net value. According to Pine (2019), with the

inclusion of workflow services, the electronic health care system's standardized

productivity to provide interoperability offer a net value of $77.8 billion per year. An

increased net worth and improved interoperability offers private practices and small

businesses appropriate real-time diagnosis of patients yielding a higher quality of care.

Furthermore, private practices and small businesses will also have the opportunity to

fully extend the expansion of clinical services and increase the perceived usefulness of

the electronic health care system with improved net value.

To deliver organized medical treatment for health care, private practices, and

small businesses have developed consistently high ratings and trusted relationships with

large and prestigious hospitals. These established relationships are vital for supporting

services that provide a mutual reference for a progressively working flowed treatment for

minor and critical conditions. Although private practices and small businesses have long-

standing clinical health work relationships with hospitals, small businesses and private

practices are at a much higher rate to experience interoperability. Pendergrass and

Chandrasekaran (2019) found that in 2014, 76 % of hospitals were able to conduct

successful data information exchange. Only 42% of private practice and small businesses

could engage in any kind of information, and only 26% were able to exchange. Several

years following Holmgren et al. (2017), Pendergrass and Chandrasekaran's findings

discovered some minor improvements in data exchange within hospital settings were at a

growing rate of 29.7% in 2015. With the advancement of interoperability, health care

organizations can improve more than just patient care in one central location;

improvements to patient care can be made across the nation. For example, suppose a

patient decides to visit another state. If that patient becomes ill and has to seek medical

care, that patient is at risk for improper medical treatment if needed. Because

interoperability is not available nationwide to adequately exchange patient information

from one system to another, patients with inaccurate diagnoses may not receive the

proper medical treatment they require. The deficiency of interoperability is a critical

distraction to the appropriate patient care and makes it impossible for adequate diagnosis,

resulting in higher demand and costs.

In some cases, the improved rate of technology has significantly increased the

growing demands of health care services leaving private practices and small businesses

under pressure to meet their and patients' needs. Subsequently, barriers resulting from

improper diagnosis may also be an attributed factor to private practices and small

businesses that cannot afford to consistently modify their electronic health care systems

to meet the integration demand. Although many health care organizations have

transitioned into the modern version of the electronic health care system, the traditional

IT systems and technology still exist in many health care organizations, causing

interoperability to be practically impossible (Javaid et al., 2022). Per the Centers for

Medicare & Medicaid (2022), severe penalties might be imposed on those participants

not adhering to the newly reformed obligation for participants of federally governed

health plans called the Promoting Interoperability Program. The Promoting

Interoperability (PI) Program, formerly recognized as the Medicare & Medicaid Incentive

Program, rewards participants for employing certified health information technology and

the certification of the electronic health care system (Pylpchuk et al., 2021). These

particular programs are intensely involved in promoting interoperability and ensuring that

electronic health care systems are utilized to demonstrate the meeting of quality

measures. Patients are also aggressively engaged in restructuring and promoting the

reformed program. According to Pylpchuk et al. (2021), enhancing health care

technology management was based on three stages. Such as setting the basis for capturing

data from the electronic health care systems, expanding and improving electronic health

care systems, and improving patient access. Pylpchuk et al. found that the functionality

involved surrounds these particular stages. The Centers for Medicare & Medicaid created

rules and regulations to promote interoperability. With the nuance of expanding

incentives and the laws and guidelines to encourage prompt interoperability, many new

studies were conducted to measure and address the alignment of the attempted

restructuring of quality measurements

Hoong et al. (2017) conducted a study involving data exchange nationally within

U.S. hospitals. Hoong et al. developed four areas to measure interoperability in the

surveys from 2014-2018. Hoong et al. found that the Technology for economic and

clinical health act of 2009 treated their focuses on increasing incentives. Still, data

sharing with the use of the electronic healthcare systems results from one quarter were

fewer than expected throughout the hospital survey for 4 years. Hoong et al. also stated

that the decreased experience of rating involving data exchange may not be a success

until sometime in the year 2027.

Strategies dealing with interoperability, rules, regulations, errors, and elevated

costs may encourage different workflow operations of training structures. There are many

barriers related to interoperability and electronic healthcare systems. Using electronic

healthcare systems to their fullest capacity continues to be challenging within private

practice and small businesses. As a result, the success of the implementation process of

electronic health care systems also remains an ongoing barrier related to the usage and

training of staff members. Training staff members often generates multiple ways of

coping mechanisms. Earlier, the study expounded on the TAM by Davis (1989). The

TAM was examined with variations of ease of use and apprehension. Incorporating a

development of training methods may have an opportunity to offset the adverse effects on

a user's ability.

Developing strategic and standardized methods of dealing with operational

problems is essential for private practices and small businesses. According to Carayon et

al. (2019), a critical synthesis of understanding system barriers emphasizes how workers

experience job specifications and handle them. For example, the development of

resilience, electronic health care systems adaptation, workflow problem-solving, and the

potential to create workarounds.

According to Henshall et al. (2020), resilience is the ability to cope and be

successful despite adverse circumstances. For instance, interoperability barriers may arise

for health care clinicians confronted with one or multiple providers. Coping with

interoperability during the high demands and added pressure of an operative workflow

may designate the behavior of a health care clinician being overwhelmed with numerous

obligations. The development of resilience may assist a user in planning and organizing

their workflow when utilizing the electronic health care system and interoperability.

Health care clinicians' prioritization skills allow for the unexpected of any disturbance to

be rectified promptly with unified resolution.

Private practices and small businesses are rapidly changing with the refinement of

modifications of the electronic health care systems; health care clinicians must adapt and

handle these sudden changes (Kristensen et al., 2020). The electronic health care systems'

variations of change took on their shape and form during the implementation process of

electronic health care systems. Health care clinicians' apprehension about these

modifications became accustomed to the transition from traditional charting to the

transformation of electronic health care systems. For example, health care clinicians rely

on resilience skills to pull through unexpected disturbances and, over time, adapt to the

changes that take place with similar occurrences. From the adaptation and organization of

the transition and coping with interoperability during the use of the electronic health care

systems, health care clinicians can seek to find stability to complete many tasks.

Several segments comprise the workflow of private practice and small business

responsibilities while using electronic health care systems and functioning with

interoperability barriers. An effective and efficient workflow depends on health care

clinicians carrying out their duties, yet everyone works together for one common goal.

However, many workflow problems often arise that are caused by deviation from an

adapted workflow. A health care clinician could identify the problem and make necessary

changes through proper training. Alluring, adequate training to healthcare clinicians may

have the opportunity to ease use and unwanted tension.

Davison et al. (2021) stated that the post adoption setting of electronic healthcare

systems may have several consequences with workarounds. Workarounds may contribute

to the limitation and the ability of health care clinicians to fully access the electronic

health care system and interoperability. Although workarounds can be a temporary fix to

a problem, they often leave health care clinicians in the direction of deviating from the

accomplished goal of having a seamless and effective workflow during the use of

electronic health care systems and interoperability. The ability to communicate from

system to system is vital and is a very useful feature and cost efficient for private

practices and small businesses.

Golzapoor et al. (2018) stated that there is a compelling need to move beyond the

scope and limitations of integrated systems to leverage cloud-based information systems

to enable communication and collaborative relationships between distributed stakeholders

and enable the electronic health care system. The value of exchanging data from one

system to another is the foundational basis of interoperability (Rajkumar et al., 2022).

Interoperability opens up a direct line of communication on all levels of care that is

critical within private practices and small businesses. Private practices and small

businesses are most effective when all productivity measures can be exceedingly met

during an office visit or outsourced specialty care. The ability to conduct the highest

quality of care is the driving force of all actions throughout health care organizations.

Increasing the effectiveness and efficiency of an operative workflow was also a goal of

interoperability.

Conclusion

This review represents the professional and academic literature on the consistent

barrier to interoperability during the use of electronic health care systems. The literature

review has also exhibited that not all strategic angles of interoperability have been

explored and addressed. Since transitioning from the traditional charting of records to the

current EHR specification, private practices and small businesses rely heavily on utilizing

a successful and continuous workflow.

According to Dutton & Koehler (2020), the majority of revenues in the U.S.

health care industry is from fee-for-service and billing to patient insurance companies,

80% –90% or from the patients themselves, 10%–20% and growing. In a rapidly

changing environment, the collaboration between enterprises is becoming increasingly

diverse. It has been emphasized that interoperability is essential for the success of private

practices and small businesses (Jwan & Hakan, 2020). With the evolutionary

development and ability of the electronic health care system, healthcare revenue has a

chance to continue to increase with a successful operative workflow incorporating

interoperability. Interoperability is the basis of health care's ability to build a seamless

way for private practices and small businesses to meet and succeed in quality care

measurements for patient care. Without interoperability, private practices and small

businesses will continue to experience fragmented attempts to communicate and connect

with additional costs through modern technology.

The gap in the literature defining interoperability provided the means to analyze

current events evolving in the study. The support of the TAM framework by Davis

(1989) and its researched content offered a more profound and saturated understanding to

assist with resolving disparities with interoperability for future reference. These resolving

issues with the lack of interoperability can bring short and long-term benefits from

utilizing the TAM.

Transition

This transition statement aims to explore successful strategies that some private

practices and small businesses use to effectively sustain an operative workflow with

interoperability during the use of electronic health care systems.

Section 1 established a foundation and exhibited details exploring the problem of

the lack of the ability to sustain an operative workflow during the use of electronic health

care systems. These details were also presented within the problem statement, the nature

of the study, the conceptual framework, and the significance of the study. Within Section

1, the problem was a driven force to produce the research question and combined

literature review.

In Section 2, I discussed the methodologic component of the study. It also

describes information about the role of the researcher and the specific guidelines for the

data collection and analysis. The research method and justification of the qualitative

multiple case studies is discussed within this study. Throughout this process, I maintained

the study's rules, regulations, and ethical standards.

Section 3 addressed the study's research and presentation findings by submitting a

professional review. In conclusion, the researcher reflected on the studied results and

made the necessary recommendations to follow suit regarding the topic of the inquiry.

Section 2: The Project

Section 2 begins with an explanation of the study’s purpose. In Section 2, I also

the methodological steps taken in this multiple qualitative case study of strategies to

effectively sustain an operative workflow with interoperability during the use of

electronic health care systems. This study’s success depended on applying the advanced

process development aspects, and each stage of development was critical.

Purpose Statement

According to Tsai et al. (2020), implementing EHRs was a positive success;

however, health care clinicians still have valid concerns about poor interoperability and

integration between electronic health care systems, and these concerns have ignited a lack

of trust in the usage of the system. The purpose of this qualitative multiple case study was

to explore the successful strategies of some private practices and small businesses to

effectively sustain electronic health care systems with interoperability. The targeted

population comprised three private practices and three small businesses located in the

metropolitan area of Detroit, Michigan. The results of this study may provide new

developments regarding effectively sustaining EHR systems with interoperability. The

results from this study may also contribute to positive social change by increasing the

quality of health care that patients receive.

Role of the Researcher

The qualitative multiple case study design allows for the researcher to explore and

dive deeper into complex, real-world issues (Alase, 2017). From my days in the clinical

setting as a medical assistant to the present as a practice manager (in administration), I

have gained vast knowledge of electronic health care systems. My background has

provided me with specific training and insight into the nuances that private practices and

small businesses experience daily regarding the use of electronic health care systems.

Having witnessed the transition from paper charts to EHRs, I have always been

fascinated by the process of electronic health care systems and being a part of the

operational team that provides quality patient care.

The researcher is responsible for attempting to collect data relevant to the study.

In this study, I collected data through participant interviews. The Belmont Report

summarized the ethical principles that the National Commission for the Protection of

Human Subjects of Biomedical and Behavioral Research (1979) identified during its

deliberations relating to human research. To be aligned with The Belmont Report

guidelines, I needed to be receptive and transparent in gathering pertinent information

and selecting participants in Detroit’s metropolitan area who had experience with

successfully sustaining electronic health care systems with interoperability. The data

collected from the targeted participants provided the opportunity to better understand and

develop strategies for private practices and small businesses to use to improve the

interoperability of their electronic health care systems.

Participants

Qualitative research is the most robust way of understanding what the participants

think about an innovation (Hamilton & Finley, 2019). The critical concepts distilled from

the target population’s experiences and perspectives of real-time events are what the

researcher uses to answer the research question(s) in a qualitative study (Collins &

Stockton., 2018). In qualitative research, information is collected through interviews from

participants experiencing the phenomenon concerning what is occurring and why

(Bradshaw et al., 2017). I chose the participants of this qualitative multiple case study

based on the categorized relationship that is directly aligned with the healthcare service

line of EHR systems. Adhering to ethical principles must be a prominent factor when

establishing strategies for gaining access and sustaining workable relationships with

participants in qualitative research (Vuban & Eta, 2019). The first step to gaining access

to participants is a researcher requesting access to the targeted population. I had to obtain

written consent from the human resources departments, CEOs, managers, and/or leaders

of the participants who had worked in the three private practices and three small

businesses located in the metropolitan area of Detroit, Michigan that were the target

population in this study. After receiving approval from the human resources departments,

CEOs, managers, and/or leaders, I had to develop a level of rapport with the participants

to maintain a balance of trust, privacy, and professionalism during the research process.

Research Method and Design

Researchers use three approaches to comprehensively understand their research:

quantitative, qualitative, and mixed methods (Dawadi et al., 2021). In this study, I used a

qualitative approach. The multiple case study research design was most appropriate

because it strategically aligned with the goals of the study and allowed for the collection

of data from the targeted population of qualified participants. In qualitative studies,

various data, such as observations, texts, and visual interviews, are gathered to investigate

the specific business problem justified in real-life, contemporary, confined, and

structured events (Dejonckheere & Vaughn, 2019).

Research Method

The purpose of this multiple case qualitative study was to explore a more

profound interpretation of the participants’ natural experiences and perspectives of a

phenomenon while enhancing the qualitative comprehension of utilizing electronic health

care systems (see Daher et al., 2017). While exploring the participants’ natural and

holistic experiences, the researcher must focus on the context perspectives that arose

from the participants’ authentic responses (Alase, 2017). I aimed to provide real-time,

saturated data comprising in-depth descriptions of successful strategies used to

effectively sustain electronic health care systems with interoperability.

According to Noyes et al. (2019), a quantitative approach is insufficient to address

health systems-related questions; however, the quantitative method remains essential to

the most recognized algorithm-based research approaches (Zellner et al., 2021). Because

the quantitative method relies on anticipating what needs to be measured to achieve

accuracy, it was unsuitable for this study.

According to Regnault et al. (2018), a mixed-method approach integrates both

qualitative and quantitative methods. Although a mixed-method approach would have

been a robust way to research health systems, it was not appropriate for this study

because quantitative data were not relevant to answering the research question.

Research Design

I employed a multiple case study design in this study. By using a case study

research design, the investigator was able to collect and analyze evidence that enabled

them to answer the specific business problem question (Priya, 2021). Phenomenological

questions concern a phenomenon that is not well known and requires an investigation

within the environment in which it occurs, and this requires a case study approach (Tobi

& Kampen, 2018). Utilizing a case study has many benefits. Case studies are frequently

used to conduct research because the interest is focused explicitly on the complexity of a

single or multiple cases (Rashid et al., 2019).

For this study, I chose a multiple case study design to concentrate on the

contemporary phenomenon and explore it through various lenses, extracting data from

sources to achieve triangulation (Ebneyamini & Sadeghi Moghadam, 2018). To conduct

the study, I needed to request access to the health care organizations’ employees for

participant interviews. These participant interviews focused on the successful strategies

that the private practices and small businesses have used to effectively sustain electronic

health care systems with interoperability. I selected multiple participants from the

targeted population of three private practices and three small businesses located in the

metropolitan area of Detroit, Michigan. The recruited participants partake in the

interviewing process specifically focused on the research questions. The data collected

from the participant interviews included itemized logs and notes I took during the

interviews to assist with data analysis. Other data types included articles related to the

study and government resources from the U.S. Department of Health and Human

Services, Office for Civil Rights, and CMS. The collected data and interview responses

allowed me to address the study’s problem and purpose.

Population and Sampling

Qualitative sampling comprises the use of various interviews conducted during

multiple case studies to ensure that the findings provided rich and saturated data

(Korstjens & Moser, 2018). I used purposive sampling in this qualitative study to ensure

a sufficiently saturated sample size. In purposive sampling, participants are selected

according to their purpose in relation to the case study and characterized by the

characteristics that enhance an understanding of real-life experiences (Andrade, 2021).

My objective was to interview and collect data from the qualified participants of the

targeted population of three private practices and three small businesses located in the

metropolitan area of Detroit who had direct knowledge of and experience with the EHR

systems. The data collected in this study answered the research question and provided

real-time information that may contribute to the health care environment.

Ethical Research

The multiple case study design allows researchers to gain experienced

information from participants’ knowledge in specific fields of business. Each aspect of

ethical research defines the magnitude of the participant's lives, well-being, dignity, and

respect for privacy (Sng et al., 2016). Therefore, gaining pertinent information from an

outside source should be protected at all costs. In addition, researchers must adhere to the

moral elements of a research study. By following the principles outlined in The Belmont

Report, the researcher ensures that they uphold and implement ethical research and

analysis processes (Sng et al., 2016).

After being granted approval under IRB approval number 09-09-22-1016775 to

conduct the study by following the guidelines of ethical research conduct put forth by

Walden University’s Institutional Review Board (IRB), I began the data collection

process by obtaining consent from the qualified participants. To obtain informed consent,

pertinent information about the study must be disclosed to the participant, the consenter

must have the capacity to consent, and the decision must be voluntary (O’ Sullivan et al.,

2021). I either emailed or hand delivered a written consent form to the potential

participants (i.e., CEOs, managers, and/or leaders of the three private practices and three

small businesses located in the metropolitan area of Detroit). I informed the participants

that no pressure would be applied to coerce them into participating; therefore, the consent

form included a clause stating that they could withdraw from the study at any point and

could do so without penalty. The consent form also included a clause informing

participants that no incentives would be provided for their volunteered participation.

Research ethics stress the importance of confidentiality and requires researchers

to ensure that they respect the dignity and autonomy of human subjects when using or

sharing information about them and to ensure their interests are not violated (Bos, 2020).

To follow Walden University IRB guidelines, I am storing the collected data from the

participants in a secure and safe location for a period of 5 years. The collected data is

stored in a locked cabinet with a combination that only I have access to. Securing the

collected data in a locked cabinet and safe location ensures that the participants’ rights to

confidentiality are not violated.

Data Collection Instruments

Within health care systems, a research document study is a standard method used

to collect data (Busetto et al., 2020). Collecting accurate data from participants is critical

for conducting a qualitative multiple case study. These participants worked in various

organizations across Detroit’s metropolitan area and had pertinent insights into successful

strategies that some private practices and small businesses use to effectively sustain

electronic health care systems with interoperability.

Balancing the advantages and disadvantages of formulating a doctoral study is

essential. One advantage of this doctoral study was that it provided the opportunity to

collect saturated data from the targeted participants to produce a successful strategic

conclusion. The strategic conclusion can be used by other private practices and small

businesses. The disadvantages of collecting data in this manner included the amount of

access to participants afforded by health care facility agreements, privacy rules related to

HIPPA violations complicating being granted access to EHR systems, and the ability to

recruit qualified potential participants.

After receiving IRB approval, I moved forward with data collection. The data

collection involved contacting three private practices and three small businesses. The

organizational data technique of this study was based on multiple data collected from the

instruments of the targeted participants' interviews. During the data collection process, I

used a cell phone to record all the collected data from the targeted participants. All data I

was able to obtain within this doctoral study is being stored and accessible for future

reference with recorded information.

Additionally, I kept track of pertinent information gathered using research logs. I

employed color- coding to examine the collected data. By color-coding, I had the

opportunity to analyze qualitative text data by taking them apart in order to uncover value

before putting them together again (Elliott, 2018). All data collected and utilized within

this process from the targeted participants will be stored for approximately 5 years after

the completion of the study.

Data Collection Technique

The purpose of this qualitative multiple case study was to explore the successful

strategies of some private practices and small businesses to effectively sustain electronic

health care systems with interoperability. According to Busetto et al. (2020) the value of

research involves analyzing the nature of a phenomenon, often by using semi structured

interviews. Busetto et al. also stated in order to perform an analysis of the data collected

from semi structured interviews transcripts and protocols must be created. To explore

these strategies, I followed a guided interview protocol (See Appendix B) that consisted

of 10 interview questions while conducting virtual Teams and or Zoom interviews. The

potential participants had knowledge of the job specification that were directly related to

EHR systems were contacted by phone and email. The participants received a copy of the

consent form and were made aware the interview process would be recorded and strictly

confidential. Teams and Zoom interviews with a cellphone for every recording of the

interview session, enabled me to record the duration of the interview and accurately

transcript the participant's statements. Each interview was expected to last approximately

30-60 minutes to allow for questions, follow up responses and notations. The interviews

were scheduled around the convenience of both the participant and myself. Follow up

phone calls and emails were conducted to validate the information obtained. Utilizing the

interview protocol allowed me to obtain accurate data that is essential for gaining a

detailed understanding of lived experience and to integrate a systematic approach.

Data Analysis

Multiple case studies are qualitative research methodologies used to analyze

various data sources in order to gain a better understanding of a problem. By visualizing

the case study through multiple lenses, multiple facets of the phenomenon can be

revealed (Rashid et al., 2019). Erlingsson and Brysiewicz (2017) stated that an analysis of

multiple qualitative case studies primarily focuses on describing the results of vast

amounts of data collected clearly and concisely. The data analysis for this doctoral study

addressed each research question pertaining to the doctoral study. I prepared the analysis

by utilizing NVivo. NVivo l assisted in allowing me to facilitate and identify principal

themes for my doctoral study. Utilizing the color-coding analysis enabled me to

differentiate between each response of the participants and to cross-analyze each case

within the doctoral study.

Reliability and Validity

Reliability

The credibility of an adequately formed researched study should always stand on

the consistency that the authentication of the research conducted can be validated within

its findings of the research method. The researcher can demonstrate the difference

between a successful or failed research development through the reliability process. The

researcher would need to maintain an open account of reliable research practices,

analysis, and conclusions while remaining cognizant of the partiality of the information

presented (Cypress, 2017). Ultimately, the study's dependability must be shown and

proven by the researcher as a source of credibility and is essentially a trustworthy

element. A qualitative research study that follows the suggested format, style, and

research techniques can turn into a valuable piece of evidence that validates the study’s

intent (Forero et al., 2018).

Validity

Validity can be viewed as the quality of being grounded in facts, relevant,

meaningful, logical, and confirming to accept principles and being sound, just, and

consistent (Cypress, 2017). The goal for this doctoral study is to explore the data

collected from an array of instruments of the targeted participants' including interviews,

questionnaires, and document reviews. In addition to exploring the collected data, I

checked for accuracy within the researched findings to establish the study as a reliable

source.

As a component of the study’s intentions to determine reliability and validity, a

researcher would verify the study’s objectives by utilizing the credibility, transferability,

and confirmability process. The concept of credibility refers to the degree of confidence

in the validity of the data and its interpretation (Renjith et al., 2021). I incorporated the

triangulation method of multiple in-depth approaches to enhance the value of credibility

strategically and address the research question (Korstjens & Moser, 2017). The

transferability is a characteristic of relevancy and the dynamic interaction of conditional

criteria in the research process's primary and target context, which must adhere to the

transfer process (Schloemer & Schröder-Bäck, 2018). By providing audit trails, revisions,

and decisions on the choices, the researcher can increase transferability by

communicating the generalizability analysis of the research assumptions (Nowell et al.,

2017). The ability for researchers to confirm their findings plays a crucial role in

qualitative research. Confirmability establishes that data and interpretations are not

fabricated from the inquirer’s imagination but based on empirical research (Korstjens &

Moser, 2017). To ensure confirmability, the researcher must make sure that they maintain

effective communication and keep accurate records of the data collected to avoid

miscommunication and accusations of bias (Dejonckheere & Vaughn, 2019). Qualitative

research uses data saturation as a criterion to determine when to stop collecting and/ or

analyze data. Failure to achieve data saturation would significantly impact the research

conducted (Saunders et al., 2018). In many cases, research findings cannot be replicated

because of errors in experimental design and statistical analysis (Prager et al., 2019). The

researcher must then demonstrate transparency and document the failed attempts.

Transition and Summary

This qualitative case study aims to explore successful strategies that have

successfully sustained small businesses and private practices to sustain electronic

healthcare systems with interoperability. Section 1 of this study describes the conceptual

framework based on the literature review analysis. The conceptual framework of this

study utilized the TAM by Davis (1989) in focusing on the specific research problem and

interview questions galvanizing the real-time information from the targeted participants

of the metropolitan area of Detroit, Michigan. Detailed information about the study's

methodology is presented in Section 2. In Section 3, I recapitulate the study's

methodology and discuss the findings in descriptive detail.

Section 3: Application to Professional Practice and Implications for Change

Introduction

In this qualitative multiple case study, I explored strategies used to successfully

sustain electronic health care systems with interoperability. The targeted population of

this study included a total of three private practices and three small businesses located in

the metropolitan area of Detroit, Michigan. I applied the conceptual framework of the

TAM guided this study data analysis. As part of the data collection process, I collected

data from participants via virtual interviews using Microsoft Teams and a cellphone that

enabled me to audio record and import the participant responses into the QSR NVivo R1

software for data analysis. QSR NVivo R1 software also assisted me in developing

itemized logs of data, notations, color-coding accuracy, and themes. Three key themes

emerged from my cross-analysis of the data: (a) effective communication and successful

training, (b) strategic decisions and technical support, and (c) electronic health care

systems’ ease of use.

In this section, I provide a comprehensive summary of the research findings and

the qualified participants’ experiences directly related to electronic health care systems

with interoperability. An in-depth analysis of the research findings is also presented in a

manner that applies the TAM.

Presentation of the Findings

This study was guided by the following research question: What strategies do

private practices and small businesses use to sustain EHR systems with interoperability?

Participants from three private practices and three small businesses in Detroit, Michigan

were interviewed for data collection. The participants were six CEOs, managers, and/or

leaders of private practices and small businesses that sustained an operative workflow

with interoperability. Participants were informed through the consent process that all

information obtained would be kept confidential, and their identities would not be

disclosed. Participant numbers (i.e., Participant 1, 2, 3, 4, 5, and 6) were substituted for

their original names. I conducted data analysis in QSR NVivo R1, which assisted with the

color-coded analysis and differentiating between each response of the participants.

Three main themes emerged from the cross-analyzed data: (a) effective

communication and successful training, (b) strategic decisions and technical support, and

emerged from implementing updated technology and consistent staff training. An

employee’s ability to navigate and use the electronic health care system efficiently and

effectively is critical for processing and developing essential data entry and workflow

clinical operational skills (Aguirre, 2019). The second theme was strategic decisions and

technical support, primarily driven by an employee’s need for assistance. Employees

must have a sound support system to make effective decisions that will enhance their

ability to perform successfully. The third theme is the EHR system’s ease of use. In the

TAM, Davis (1989) stated that the ease of use of a system directly influences an

employee’s willingness to accept the electronic health care system. Inadequate training,

errors, misunderstandings, and other problems can result from the rejection of the

electronic health care system, which may negatively impact not only the utilization of the

system but also the profitability of private practices and small businesses.

The TAM by Davis (1989) served as the conceptual framework for this study. The

TAM focuses on factors determining an individual’s behavior intentions to use new

technologies from the perspective of the end-user (Kalayou et al., 2020). Using the TAM

in this study generated an opportunity for the findings to be further enhanced with a

significant level of understanding of how the electronic health care system would be

perceived as useful, easy to use, and be accepted by the user. Besides being able to

describe a technology’s perceived usefulness and acceptance by its users, use of the TAM

helped to identify the dominant challenges faced by private practices and small

businesses due to ongoing barriers resulting from a lack of strategies for maintaining an

effective operative workflow and interoperability while using an electronic health care

system.

According to Pereira et al. (2022), multiple factors can affect the acceptance and

use of successful strategies, including behavior, clinical care, and operating workflow

system structure levels. As a result, use of the TAM was a valuable method of

determining a system’s success by examining behaviors, ease of use, and acceptance. In

this multiple qualitative case study, I gained valuable insight into how interoperability

can be used to create effective workflows in an operational setting and the distinct

characteristics of electronic health care systems.

Theme 1: Effective Communication and Successful Training

Based on the results of this study, effective communication and successful

training are directly correlated with TAM. Change management and technology

modifications are necessary for organizations implementing electronic health care

systems. From the finding of this study, I also learned that modified changes often require

employees to adjust overtly or convertly, but employees' ability to adapt is paramount.

According to Anthony and Petersen (2021), in the TAM, users’ inclination to use or not

use an application depends on the degree to which they believe it will improve their job

performance. Additionally, in the TAM, Davis (1989) stated that building self-confidence

is integral to effective communication and successful training.

Effective communication and successful training were identified as a theme that

all participants agreed are crucial elements in ensuring that the knowledge acquired by

private practices and small businesses is further nourished and maintained for the

deliverance of effective, efficient, quality care to patients. The quality of care that health

care private practices and small businesses provide to patients can be enhanced by

developing the employees’ communication skills and sharpening their abilities through

essential training (Mata et al., 2021). In a health care environment, communication and

essential training are inextricably linked. The importance of communication and training

for employees ensures that private practices and small businesses are building trust with

their employees and helps establish a solid foundation for learning and productive work

environments. In addition, some participants commented and added value of improved

efficiency from the integration of (Davis’s, 1989; see also Tsai, 2020) TAM regarding the

perceived ease of use of the electronic health care system when communication and

training were implemented.

A lack of communication between health care organizations and patients can

cause several errors. Training deficiencies may lead to resistance from employees to

change and the acceptance of electronic health care systems. In correspondence to the

literature review, errors may also be caused by the lack of training users have with the

electronic health care system; nevertheless, through training and communication, that can

be minimized to ensure that electronic health care systems are usable (Henshall et al.,

2020). Participant 1 stated, the “electronic health care system is changing every day. So

the first strategy is to keep on educating; training, training, training is key for new

information anywhere.” Participant 2 also noted two things crucial to sustainability:

training and testing. Using electronic healthcare systems to capture and use clinical

information and knowledge is vital for a quality, safe, sustainable health care system

(Fennelly et al., 2020). Participant 3 learned new staff did not have much knowledge of

technology; teaching them was challenging due to language barriers, but the

organization’s vision encouraged a successful implementation. According to Al Shamsi

et al. (2020), a language barrier has been shown to contribute to miscommunications that

may negatively affect patient care, and health care organizations have used online

translation tools to meet these challenges. Participant 4 acknowledged that after their

organization recruited individuals to train employees, their employees were eager to learn

newly implemented electronic health care systems strategies. Participant 6 reported that

employees willing to learn would learn the basics of operating the electronic health care

systems if given 1 week of training.

According to the participants, employees must remain engaged with electronic

health care systems and undergo training to stay up to date with developments and

improve patient care continuously. Concise communication and proper training will

ensure the development of the employees and the health care organizations.

Theme 2: Strategic Decisions and Technical Support

The concepts surrounding Theme 2 combine strategic decisions with technical

support and the TAM for employees’ ease of use of the electronic health care system. In

order for the electronic health care system to be effective, employees must feel capable of

making strategic decisions and know that technical support is nearby. The second theme,

strategic decisions and technical support, is also related to the importance of

communication and proper training. While ensuring adequate communication and

training, some participants felt that a support system was necessary and helpful to ensure

the systems were properly utilized and implemented in private practices and small

businesses. Participant 1 stated, “We sustain support with IT third-party support

partnership that has helped with communication and training. Working as a team with the

third party partnership, it has become very, very successful.” Participant 2 reported that

they were able to implement what their organization called subject matter experts. These

experts were a part of the organization and were referred to as super users. Through the

support of their colleagues, super users assist staff members and give them the confidence

they need. With the assistance of the super users, staff support is an ongoing process

implemented within the organization after the vendors have completed it. To ensure the

process is operating smoothly, the staffing support would consist of daily and multiple

meetings to provide proper support and correct errors as needed. Those who support that

practice represent the backbone of the organization. As a result of this process, all staff

will contribute to the organization’s sustainability.

Supporting employees in making strategic decisions and reducing costs is

essential. Proper staffing support will enable health care organizations to minimize errors.

According to Moloney et al. (2020), a healthy, high-performing, committed workforce

promotes sustainability and organizational effectiveness. Participant 3 found that staff

quickly understood new measures due to IT. Participant 4 described the electronic health

care system’s implementation as a case of a trial-and-error process. IT supports the

organization’s desire to be sustainable, but the implementation of electronic health care

system can be challenging without IT support. In addition, Participant 4 noted that the

electronic health care system was initially not sustainable, even with IT and its expertise.

The prognoses of the implementation process within the health care organization may

take up to a year to complete the sustainability method. As part of the strategy to ensure

compliance, Participant 4’s health care organization implemented a pilot program with

other companies to ensure the electronic health care system works appropriately.

Theme 3: Electronic Health Care Systems’ Ease of Use

The ease of use of an electronic health care system is essential to maintaining an

operative workflow. Operational workflow is fundamental to the clinical process to

minimize errors (Hess, 2018). According to Zheng (2020), the electronic health care

system has been a challenging transition over the past decade, impairing frontline

clinicians’ ability to provide safe, efficient, and effective care. Employee ease of use

during operative flow is critically important for not only minimizing errors but for

maintaining safe patient care for patients. Employees should be able to use the electronic

health care system seamlessly.

The third theme of the electronic health care system’s ease of use affects the

ability of private practices and small businesses to deliver quality care to patients

effectively. An employee’s ability to navigate the electronic health care system is

essential to private practices and small businesses’ success utilizing the system. A

product’s usability refers to whether it performs its intended function when used as

intended. All participants agreed that the system’s ease of use contributed to the quality

of patient care.

According to Participant 1, “It was challenging for the organization to go viral

since the employees were uncomfortably changing. However, as the health care

organization progresses, integrating electronic healthcare systems with interoperability

has become easier for patients and employees to integrate.” Participant 3 stated that

“implementing new features made the electronic health care system very user friendly.”

Participant 4 stated that,

electronic healthcare systems are needed. It is necessary at our facility, and we are

diligently pursuing it. As our company has 239 facilities, we implement more and

more of the electronic health care system daily. Our goal is to make it stick. We

are still working on it.

Participant 5 reported having an improved experience of using electronic health care

systems, saying, “Access to charts and work made it easier for me to see care plans and

additional information.” According to Participant 6, “the electronic health care system is

easy to navigate.” Participant 6 also noted,

through navigation that everything moves quickly; when a button is pressed to

give the electronic health care system a command, everything moves even faster.

The system moves fast; you can press a button, and everything moves even more

quickly. Each patient can be in and out of the office in less than an hour.

Some participants expressed change as a resistance barrier for many employees.

According to Davis (1989), and the TAM, change can impact behavior and become

influential to an employee’s intentions of use with the electronic health care system.

Consequently, this will affect the overall learning process associated with the electronic

health care system. However, as exhibited with positive reinforcement, change is

possible. Table 1 illustrates the word frequency query derived from the data analysis

assisted by the QSR NVivo R1 software.

Table 1

Frequency of Words in Participants’ Responses Characterizing Strategies for Electronic

Health Care Systems’ Interoperability

Word Frequency of occurrence

Communication 13

Successful 17

Training 17

Strategic 11

Decisions 17

Technical 17

Support 12

Electronic health care system 34

Ease 10

Applications to Professional Practice

In this multiple case study, I explored strategies that private practices and small

businesses used to successfully sustain workflow operations with electronic health care

systems’ interoperability. To minimize barriers to acceptance of change in private

practices and small businesses, Mallon (2019) suggested that electronic health care

systems and strategic planning for quality improvement should be a consistent focus for

integrating interoperability into an operational workflow. Sharing data amongst all health

care facilities is a need to expand the care provided to patients. Electronic health care

systems with interoperability have the capability to accomplish this, and private practices

and small businesses should seize the opportunity to increase the quality of care given to

patients and decrease the cost of the business acquired.

Throughout this study, the conceptual framework consistently aligned directly

with the findings of this study. The TAM by Davis (1989) was implemented as the

conceptual framework. Davis's TAM represents change through behavior and acceptance.

Backhouse & Ogunlayi (2020) estimated that about 80% of health care improvement

occurs through human interaction, while 20% occurs through technical means. In

addition, Backhouse & Ogunlayi argued that quality improvement can help improve

individual patient care and transform complex health care systems by empowering

employees and patients to lead and achieve change. Throughout the literature review, the

concept of change is emphasized as a positive reinforcement of health improvement.

The findings of this study and the data collected from the participants were

interpreted and analyzed, which derived from three prominent themes (a) effective

communication and successful training, (b) strategic decisions and technical support, and

practice and small businesses, effective communication and training are essential. In

addition, employees will be able to work more efficiently and provide relevant

information to patients more quickly. Clinical communication is also crucial to patients'

well-being. Being able to trust that the information given is key to the provided quality of

care that the patient will receive. As a result of employee communication and training,

errors are reduced, and valuable information is learned. Based on the response of all

participants in this study, effective communication and technical support were strategic

tactics for seamless operational workflows. Strategic decisions and technical support are

also critical elements for employees. Employees must feel empowered to embrace change

so that strategic decisions can be created with substantial support. Employee confidence

is built with substantial support, which reinforces different avenues of meeting challenges

and achieving goals. Participant responses indicated that having support allowed them to

embrace change and utilize the electronic health care system, so they were more inclined

to accept it. As previously mentioned, with the expansion of the electronic healthcare

system, productivity and quality of care will increase as well as data sharing across

jurisdictions will be enhanced. Private practices and small businesses can improve service

lines based on these findings. Additionally, the findings of this study may contribute to

the body of existing knowledge that suggests strategies for improving an operative

workflow through the interoperability of electronic healthcare systems. This study will

not only provide further insight into the existing barriers, but it will also have the

potential to facilitate growth and a positive impact of change for private practices and

small businesses.

Implications for Social Change

Health care organizations within their communities play a significant role in

servicing and healing the districts daily. In an era where health care is increasing and

demand is rising, finding ways to improve access to quality care has never been more

critical (Hartzler, 2018). Health care organizations must keep up with technological

changes when providing community services. According to Alotaibi and Federico (2017),

many opportunities exist to improve and transform health care through the use of health

information technology, including reducing human errors, improving clinical outcomes,

facilitating care coordination, improving practice efficiency, and tracking data over time.

The rise of contemporary technology and the modern era have rapidly enabled health care

organizations to adapt to the current health and social environment. A direct link exists

between the changes and the use of electronic health care systems. As a result, health care

organizations have been able to transform and achieve new ways of life that enhance the

wellness of patients due to the direct impact and rapid changes in health care.

The objective of the multiple case study was to improve the workflow of private

practices and small businesses' electronic health care systems with the use of

interoperability. The implications of social change from this study may have the ability to

assist private practices and small businesses ability to increase productivity, and job

sufficiency, while utilizing the electronic health care system and also improve the quality

of care given to patients. This study may potentially be used as a road map to enhance

patient care goals and be cost effective.

Recommendations for Action

The findings of this qualitative multiple case study have been presented as

recommendations for action in accordance with the participant's responses and the themes

identified from the data analysis. Additionally, this study's results may help develop and

implement an operative workflow based on interoperability barriers in electronic health

systems. Patients' health and well-being can be improved by continuously improving

health care services offered by private practices and small businesses. In order to improve

the efficiency of electronic health care systems, I recommend the following actions: (a)

Private practices and small businesses should think about eliminating paper within the

operational workflow to contribute to promoting Davis's (1989) the TAM’s ease of use

with electronic health care systems. If the employees utilize the electronic health care

system continuously, it gives them an opportunity to become accustomed to the use of the

system. (b) Through the data collection process of this study, I have learned that most

private practices and small businesses have not transitioned from paper to the electronic

health care system. Private practices and small businesses not being able to transition

from paper to electronic is another barrier. Studies conducted by Shachar et al. (2020)

have found that clinicians generally support using electronic health care systems;

however, the service would be difficult to provide without adequate funding. An

affordable electronic health care system should be available for private practices and

small businesses that cannot afford to convert from paper to electronic health care. The

state should consider sponsoring an electronic health care system platform with specified

rules and regulations to comply with patient care requirements for private practices and

small businesses. (c) The implementation of continuous support and communication,

along with additional training, should be carried out on a monthly basis for minor updates

and on an annual basis for significant updates. (d) To ensure uninterrupted patient care,

electronic health care systems should be mandated to be shared data with private

practices, small businesses, and hospitals nationwide. (e) With the addition of

uninterrupted patient care with the use of electronic health care systems and shared data

nationwide, data security should be updated to comply with HIPPA and eliminate

violations of errors. (f) The electronic health care infrastructure should be supported and

updated by all private practices and small businesses with an information and technology

department to keep up with changes. To improve the efficiency of health care, it is

recommended that these recommendations be considered to assist and further advance the

improvement and interoperability of electronic care systems in small businesses and

private practices.

Recommendations for Further Research

As electronic healthcare systems have gradually replaced paper records over the

past decade, clinicians have faced significant challenges supporting clinical workflow,

hindering safe, efficient, and effective care (Zheng et al., 2020). This study aimed to

identify and explore strategies for a successful operational workflow with the use of

electronic healthcare system interoperability. Three prominent themes were identified

from the findings of this study and the data collected from the participants. (a) effective

communication and successful training, (b) strategic decisions and technical support, and

example, conducting in-person interviews with participants was difficult due to access

restrictions, COVID-19 restrictions, and precise timing due to the job specifications in a

healthcare setting. The recruitment process for interviewing prospective participants

related explicitly to the doctoral study was also a limitation. In accordance with COVID-

19 and restrictions, nonpatients were not allowed on the premises if the health care

organization did not serve them. Therefore, recruiting participants was challenging due to

COVID-19's limitations. The alternative of using Teams and or Zoom enabled me to

overcome this limitation.

Healthcare is continuously changing as a result of technological advancement and

improving the quality of care for patients. Further research would be recommended to

broaden the knowledge base of health care not only for Detroit, Michigan but nationwide,

in light of participants' responses and the explored strategies for preventing obstructed

care through shared data and excessive errors. A national exploration of the findings of

this study will allow for a more thorough and robust understanding of the limitations of

operative procedures with electronic health care systems interoperability, which will

further contribute to reducing the cost of access for private practices and small

businesses.

Reflections

I have gained a substantial amount of health understanding throughout my clinical

background, from my experience as a medical assistant to now practice manager

(administration), earning well over 20 years of experience within the health care

environment. The concept of electronic health care systems piqued my interest. I became

fascinated by the transition from paper charts to electronic health records, further

strengthening my desire to contribute to patient care as an operational team member.

Obtaining IRB approval and beginning data collection were challenging segments; after

acquiring IRB approval, I gained a deeper understanding of the data collection process.

My next challenge was getting participants, but I was able to achieve it after struggling to

search and making numerous unsuccessful attempts. My experience in the health care

field made it challenging for me to avoid becoming biased when using electronic health

care systems. As I engaged the participants in the discussion on electronic health care

systems, I avoided adverse effects that could potentially impact the study and kept an

open mind, allowing the participants to give their lived experiences.

While I faced many obstacles during the writing process of this doctoral study,

one of the most significant setbacks was losing my dad to COVID-19. I have also been

infected with COVID-19 twice and experienced many other personal and work-related

issues during the last couple of years. The hardships reminded me of a conversation with

my dad about how proud he was of my decision to pursue a doctorate. My journey was

not easy, but I kept going. This doctoral study provided me with valuable knowledge and

an in-depth understanding of the electronic healthcare system, which has broadened my

perception and perspective. In addition, these findings could also benefit private practices

and small businesses as a result of the research conducted in this study.

Conclusion

Health care workers use an electronic health information system to provide

healthcare services to individuals and exchange data between them (Khubone et al.,

2020). Poor interoperability has the opportunity to lead to inadequate performance of

information technology in private practices and small businesses, leading to medical

errors and obstructing data exchange. This qualitative study aimed to explore private

practices and small businesses lack of strategies to effectively sustain electronic

healthcare systems with interoperability. Three themes emerged from the findings of this

study (a) effective communication and successful training, (b) strategic decisions and

technical support, and (c) ease of use of the electronic healthcare system. Increasing

productivity by supporting the front line and reducing costs are necessary strategies for

private practices and small businesses to continue to operate in the healthcare sector by

maintaining an effective workflow with the interoperability of electronic healthcare

systems. Additionally, it is essential for patients to receive quality care. The study’s

findings revealed a number of valuable benefits and liabilities associated with the

electronic healthcare system with interoperability. Davis’s (1989) the TAM was utilized

throughout this study to describe how real-time experiences of perceived usefulness, ease

of use, and overall behavior of resistance to change influence private practices and small

businesses. Nevertheless, through its researched content, the TAM (Davis, 1989) may

also have the opportunity to provide a deeper and more comprehensive understanding to

address gaps in interoperability for future applications.

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