Ceiling effect in EMR system assimilation: a multiple case study in primary care family practices

Abstract Background There has been indisputable growth in adoption of electronic medical record (EMR) systems in the recent years. However, physicians’ progress in using these systems has stagnated when measured with maturity scales. While this so-called ceiling effect has been observed and its consequences described in previous studies, there is a paucity of research on the elements that could explain such an outcome. We first suggest that in the context of EMR systems we are in presence of a “tiered ceiling effect” and then we show why such phenomenon occurs. Methods We conducted in-depth case studies in three primary care medical practices in Canada where physicians had been using EMR systems for 3 years or more. A total of 37 semi-structured interviews were conducted with key informants: family physicians (about half of the interviews), nurses, secretaries, and administrative managers. Additional information was obtained through notes taken during observations of users interacting with their EMR systems and consultation of relevant documents at each site. We used abductive reasoning to infer explanations of the observed phenomenon by going back and forth between the case data and conceptual insights. Results Our analysis shows that a ceiling effect has taken place in the three clinics. We identified a set of conditions preventing the users from overcoming the ceiling. In adopting an EMR system, all three clinics essentially sought improved operational efficiency. This had an influence on the criteria used to assess the systems available on the market and eventually led to the adoption of a system that met the specified criteria without being optimal. Later, training sessions focussed on basic functionalities that minimally disturbed physicians’ habits while helping their medical practices become more efficient. Satisfied with the outcome of their system use, physicians were likely to ignore more advanced EMR system functionalities. This was because their knowledge about EMR systems came almost exclusively from a single source of information: their EMR system vendors. This knowledge took the form of interpretations of what the innovation was (know-what), with little consideration of the rationales for innovation adoption (know-why) or hands-on strategies for adopting, implementing and assimilating the innovation in the organization (know-how). Conclusions This paper provides a holistic view of the technological innovation process in primary care and contends that limited learning, satisficing behaviours and organizational inertia are important factors leading to the ceiling effect frequently experienced in the EMR system assimilation phase

History of the Guineo-Congolian forest: insights from phylogeographic patterns in plants

info:eu-repo/semantics/nonPublishe

The Evolution and Pollination of Oceanic Bellflowers (Campanulaceae)

11 p., tablas, gráf.Oceanic islands provide a good model for the study of species dispersal and evolution. We focus here on the evolution of pollination modes of oceanic island bellflowers (Campanulaceae), examining the degree of parallel evolution in different lineages of this family. Plants colonizing islands might either have experienced selective pressures on floral traits from vertebrate pollinators such as birds and lizards or have been pre-adapted to pollination by vertebrates prior to their colonization. The reconstruction of the ancestral pollination biology of Campanulaceae suggests that pollinators of the ancestors of bird-/lizard-pollinated bellflowers were insects. Moreover, in four island Campanulaceae lineages, only one was pre-adapted on the continent, and three made de novo shifts on the islands. Evolution towards bird pollination from insect-pollinated ancestors is also common in other island-groups, possibly because opportunistic birds are more efficient than insects. We review to what extent related species converge in their pollination ecology in related habitats on oceanic islands.Peer reviewe