Doctors and Tablet Computers: A Case Study

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BACHELOR THESIS

Doctors and Tablet Computers

A Case Study

Alisa Cerimagic 2014

Bachelor of Arts Systems Science

Luleå University of Technology

Department of Computer science, Electrical and Space engineering

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Preface

This thesis is written for the International Bachelor’s Degree in the subject area of Systems Sciences at the Department of Computer Science, Electrical and Space Engineering, at the Luleå University of Technology, in Sweden.

I would like to thank my professors at LTU Harriet Nilsson and Dan Harnesk for their guidance and their feedback throughout the process of writing this thesis. Additionally, I would like to thank professor Morten Jacobsen and his friendly colleagues for valuable discussions.

Moreover, I would like to thank all respondents who participated in this study, for their time and their thoughts on this subject.

Finally, and most importantly, I would like to thank my parents for always believing in me, my husband for his endless support and our daughter for giving me the joy and motivation to study. I would never have come this far without you.

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Abstract

Title: Doctors and Tablet Computers: A Case Sudy Author: Alisa Cerimagic

Background: Hospital doctors work in a mobile environment. Access to the information that they need is provided on stationary computers, which are located in specific permanent spots. Tablets are mobile devices, which are a lot more convenient to use in a mobile environment than stationary computers.

Aim: The first aim of this thesis is to explore what the potential end-users, i.e.

doctors in Norwegian hospitals, think and feel about using tablets as a substitute for or complement to stationary computers in their daily work at hospital.

This thesis also aims to gather, identify and analyse the needs and wishes of the potential future users, i.e. hospital doctors.

Methodology: A qualitative case study was selected as the research method.

The data were collected using semi-structured interviews, supported by an interview guide. Template analysis was used to analyse the data.

Results: The results of this study show that doctors are very positive towards the idea of using the tablets in hospitals.

Conclusion: This study confirms most of the findings from previous studies.

For instance, that tablets could improve interaction and communication between doctors and patients, prevent errors, improve patient safety, help doctors to work more efficiently, and save time. It also confirms that technology in hospitals is not sufficiently developed for the implementation of tablets, because many manual systems are still in use today.

This study also concludes that the need for tablets in hospital settings depends on the work environment where doctors operate. Additionally, the tablets would be of great help to hospital doctors, if they were used as a complement to stationary computers. Most important is, however, that the tablets provide doctors with access to the EHR, i.e. all patient related information.

Keywords: mobile tablet computers, tablets, IT in healthcare

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Definition of Terms

Term Definition

app Application software is a part of system. An app is software especially developed to be used by users.

BYOD Bring your own device

EHR Electronic Health Records

ER Emergency Room

HIT Health Information Technology

IT Information Technology

learnability The time it takes for a user to learn how to use a product.

PDA Personal Digital Assistant

requirement The defined needs, what is expected of a system.

tablet Mobile tablet computer, Tablet PC, PDA, handheld device

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1 Introduction

This introductory chapter begins with some background information on tablets in general and IT in healthcare. The reader is subsequently introduced to the subject, problems, aim of this study and research questions. Additionally, the choice of the topic and delimitations of this thesis has been explained at the end of this chapter.

1.1 Background 1.1.1 Tablet computers

Mobile tablet computers, also known as tablets, have been on the market for many years, but the arrival of the iPad in April 2010 made them more popular than ever (History of tablet computers, n.d.). The iPad proved to be a better alternative than computers, for some tasks. Together with other tablets on the market in 2013, the iPad offers better mobility and easier information access, compared to stationary and even portable computers. On the other hand, the most sold tablets today, Apple’s iPad and Samsung’s Galaxy Tab (IDC Analyze the Future, 2013a) still lack physical keyboards. Instead, they offer a touch screen with a virtual keyboard.

However, as reported by a forecast from the International Data Corporation (IDC) tablets will surpass portable computers by 2013 and the total PC market by 2015 (IDC Analyze the Future, 2013b). Another report from IDC estimates that PC shipments are expected to fall by 7.8% in 2013 and continue to fall in following years as users turn to alternatives such as tablets and Smartphones (IDC Analyze the Future, 2013c).

A Portrait of Today’s Tablet User Wave II (2012) concluded that 31% of the U.S. Internet population used tablets (March 2012), 52% of them used a tablet with iOS platform (iPad/iPad 2/iPad 3) and 47% used a tablet with Android Platform. The most popular tablet with Android platform was Kindle Fire (Online Publishers Association, 2012).

A U.S. study showed that tablets are especially popular among members of a specific profession, namely doctors. A study by Modahl (2011) states that 30%

of doctors in the U.S. own a tablet. For the remainder of U.S. consumers that was only 5% at that time. In addition, 83% of doctors owned a Smartphone.

19% of the doctors who participated in this study answered that they use a tablet in clinical settings and additional 35% believed that they were extremely likely to do this in the near future. (Modahl, 2011)

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1.1.2 IT in Healthcare

Health Information Technology (HIT) improves efficiency in healthcare and facilitates the work of doctors. In addition, HIT improves the quality of healthcare and at the same time reduces costs and the amount of paperwork.

Electronic Health Record (EHR) is an important part of HIT. (Health information technology, n.d.)

Hospital doctors do not work in a classic office environment. Their work environment is often very mobile. In one shift they can walk up to 15 km and they sometimes even work while they are on the move (Bardram & Bossen, 2005). That is why it is important that the information that doctors require in their daily work is easy to access.

Fischer, Stewart, Mehta, Wax & Lapinsky (2003) performed a literature review and concluded that handheld devices, such as tablets, could offer doctors better support in their daily work, but that very few studies provide evidence-based information about their use.

The tablets are more mobile than stationary and even portable computers, they are in some circumstances even easier and more practical to use than computers. Those attributes make the tablets the logical solution for the problem of information access in mobile work environments.

1.2 Problem Discussion

Hospital doctors work in a mobile environment and they often work while they are on the move. A tablet is a mobile device, that is often more convenient to use outside the conventional office environment, for instance in a mobile environment. The question is whether tablets could facilitate the work of doctors by providing them information access everywhere around the hospital, for instance at the point of care.

For the past years, several international studies on how tablets are used by hospital doctors have been done. The studies have mostly explored if tablets can: help doctors save time and be more effective (Horng et al, 2011, Patel et al., 2012), make them better doctors (Sclafani et al., 21012), improve patient safety (Buus et al., 2012) and improve interaction between doctors and patients (Sclafani et al., 2012).

Not many studies, however, have been found that explore the Norwegian doctors thoughts on the use of tablets in hospital settings. Which is why this study aims to explore thoughts and opinions of the potential future users’

prior implementation of tablets.

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1.3 Aim

The first aim of this thesis is to explore what the potential end-users, i.e.

doctors in Norwegian hospitals, think and feel about using tablets as a substitute for or complement to stationary computers in their daily work at hospital.

This thesis also aims to gather, identify and analyse the needs and wishes of the potential future users, i.e. hospital doctors.

1.4 Research Questions

How do hospital doctors in Norway perceive the use of tablets instead of or as a complement to stationary computers, as a tool for improving their work performance?

What are the potential future users’ needs and wishes, considering the use of the tablets in hospital setting?

1.5 The Choice of the Topic

I selected this topic to write a thesis on for two main reasons. Firstly, I personally find HIT very interesting, mainly because it is a very large and complex field that deals with improvement of patient care and safety. By writing this thesis, I hope that I will gain new knowledge about HIT.

Another reason for selecting this topic of interest is because I wanted to collect thoughts on and also the needs and wishes about tablets from professionals who work in a mobile environment.

1.6 Delimitations

Due to the limited amount of time of 15 ETCS (or 400 working hours), and due to no access to hospital IT system, this thesis will not include any deeper analysis (such as requirements analysis) and no system will be developed nor designed.

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2 Theory

This chapter presents the theoretical framework of this study. The aim of this chapter is to present other studies on the subject “doctors and tablets”. The main theoretical concepts are summarised in number form at the end of this chapter.

2.1 Doctors and Tablets: Other Studies

Tablets have been on the market for approximately two decades. During the 90s tablets were known as PDAs (Personal Digital Assistant) and some of them were pen-based. In recent years, particularly since 2010 and the release of Apple’s iPad, the use of tablets has rapidly increased. (History of tablet computers, n.d., Personal digital assistant, n.d.).

Today’s tablets, like Apple’s iPad and Samsung’s Galaxy Tab, are mostly used for communication, as educational tools, and as a source of reference. In recent years, the media have written a lot about the consumerisation of IT, and the Bring Your Own Device (BYOD) phenomenon, which means that employees use their own private digital devices when working.

Nowadays, many businesses and organizations provide their employees with tablets in addition to PCs and mobile phones. Some hospitals around the world have also chosen to do this. A number of selected studies, which will be presented in this chapter, have explored the subject “tablets used by hospital doctors” and “mobile technology in hospitals”.

Tablets together with Smartphones are called mobile technology or mobile devices. Smartphones are slightly more sophisticated mobile phones. The first Smartphones were a combination of PDA and mobile phones. (Smartphone, n.d.)

The difference between a Smartphone and a tablet is that a Smartphone is somewhat smaller and can be used as a mobile phone, while most tablets are larger and do not have the “phone function”, i.e. tablets usually do not have a SIM card with unique phone number. However, this can probably change in the future.

All studies that have emerged during the process of writing this thesis proved that the need for mobile technology in healthcare exists and has existed for some time. There is considerable interest in mobile technology, especially among hospital doctors. This chapter will present and discuss 10 studies concerning this particular subject.

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2.1.1 Earlier Studies

The use of mobile devices, like tablets, in hospitals was an issue long before the introduction of the Apple’s iPad. Earlier research studied how hospital doctors used their PDAs and pen computers.

Many studies have been done on the subject and a systematic review of the literature concerning this subject concluded that PDAs had: “positively impact on areas of rapid response, error prevention and data management and accessibility”.

The greatest benefits of tablets in a hospital setting were: “in context where time is critical factor and a rapid response crucial.” Still, the authors acknowledge that the benefits of tablet mobility have not been investigated adequately.

(Prgomet, Georgiou & Westbrook, 2009)

In this thesis I have selected two earlier studies to refer to, one where a PDA was used and one where a mobile pen computer was used.

A PDA device with specially designed software for acute patient pain assessment was used in a Canadian study. In this study PDA assessments were compared to paper-based assessments. The results showed that the doctor who performed these studies felt comfortable using the tablet and software from the first day, after only 4-5 assessments. The assessment was efficient and more content rich in comparison to paper-based assessment.

Total encounter time decreased to 74 seconds per assessment when the PDA was used, which resulted in a 30-45 minute timesaving per day.

(VanDenKerkhof, Goldstein, Lane, Rimmer & Dijk, 2003)

In a somewhat older field study from 1999 an evaluation of a mobile pen computer was done to find out what users felt about having mobile access to EHR. Results showed that, even at that time in the 90s, many doctors wanted to have mobile access to the patient’s records. However, most respondents found this particular mobile pen computer difficult to use and would have preferred a smaller and lighter device. Apps they considered important were:

pharmacopoeias, reference literature and email access. The functions that the doctors required were: ordering different procedures, options for documenting diagnoses, as well as dictation of results and reports. (Buchauer, Pohl, Kurzel & Haux, 1999)

2.1.2 The Latest Research on Doctors and Tablets

The latest research has studied how doctors who work at hospitals use today’s modern tablets, like for instance Apple’s iPad. The studies have mostly explored if tablets can help the doctors save time and be more effective, make them better doctors, improve patient safety and improve interaction between doctors and patients.

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A study showed that 30% of doctors in the U.S. own a tablet and 83% own a Smartphone. The study concluded that doctors’ level of interest in using tablets is above that of average consumers. (Modahl, 2011)

A study was performed at the University of Chicago, where a few researchers stated that the implementation of EHR (Electronic Health Records) has led to doctors spending more time locating and working on the computer than treating patients. That is why they provided internal resident doctors with iPads, which had access to EHR. (Patel, Chapman, Luo, Woodruff & Arora, 2012)

The results showed that 90% of the respondents used their iPad for clinical tasks. 78% of respondents believed that they were more efficient when they used their tablet on the ward and estimated that they saved approximately one hour a day. In addition, doctors’ orders were placed faster than before the implementation of the tablets. The study concluded that the use of tablets improved both perceived and actual efficiency of resident physicians. (Patel et al., 2012)

Another study on the same group of residents, explored their perception 1- month before and 4-months after the implementation of iPads. The results were interesting because prior to the implementation, 79% of the respondents answered that they were excited about the implementation. The authors call it the “hype”. Four months after the implementation, the real use of the device was high for many tasks like reviewing lab results, paging and answering clinical questions. However, for some of the tasks, like placing orders, it did not match the expectations. In addition, many more respondents answered after the implementation than before (67% vs. 39%) that in some situations they would rather use pen and paper. Results also showed that if the respondents owned a private Apple product like iPad/iPhone/iPod then the long-term adoption was higher. The positive benefits of the iPad were efficiency, as stated in the previous study. (Luo, Chapman, Patel, Woodruff and Arora, 2013)

Luo et al. (2013) explains that some of the simpler tasks were inherently easier to learn and those tasks were done on the iPad by most respondents. While the tasks that were more complicated (time-consuming and difficult to learn) were not done on the iPad. In addition, those respondents who were more excited about the implementation of iPad together with the respondents who previously had owned an Apple product, were generally more likely to use the tablet, more motivated to learn and generally more prepared to invest a little more time and effort than others. (Luo et al., 2013)

In another study, a digital survey was performed on physicians with different levels of working experience. The results from the study showed that 40% of

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respondents who answered the survey used a tablet. 45% of them used their tablet in the clinical setting and 56% of institutions supported mobile technology. The most respondents believed that their institution should support mobile technology like tablets. The study also showed that, the less experienced the respondents were the more likely they were to believe that mobile technology made them better doctors. Furthermore, 69% of the respondents who used tablets in the clinical settings agreed that the tablet improved their interaction with the patients. The most popular types of applications were: primary resource applications, EHR and point of care apps. (Sclafani, Tirrell & Franko, 2012)

A both quantitative and qualitative study, at an Emergency Department, concluded that doctors saved 38 min per shift, when they were using tablets instead of computers. Additionally, the number of logins decreased by 5 per shift. The respondents answered that the tablet was “useful and easy to carry around” and “easy to get started with”. However, only 31% of the doctors in this study agreed that the tablet gave them more time at the patient’s bedside. In this study 62% of respondents agreed that the tablet gave them the opportunity to better communicate results to the patients. Many respondents, 69%, were afraid to misplace the tablet and 62% felt anxious that they, at some point, will drop it. (Horng, Goss, Chen & Nathanson, 2012)

A study performed in Denmark concluded that the implementation of mobile tablet computers in hospitals has the potential for improving patient safety and to streamline the workflow. However, the study concluded that the existing technology is not sufficiently developed for the implementation. In this study the respondents were very positive towards to the use of the tablets in healthcare. (Buus, Nyvang, Heiden, Haugaard, 2012)

Another report concurs with that previous statement about hospitals not being sufficiently developed for the implementation. The report states that due to many different reasons, the relatively limited amount of hospitals have totally implemented IT. For example other industries use much more IT than healthcare sector. The IT systems in healthcare can be extremely simple or very advanced. For example EHR can be used for storage of patient records only, or it can in addition include even advanced decision supporting functions. (Medicare Payment Advisory Commission, 2004)

2.1.3 The Latest Research on Doctors and Smartphones

In recent years very limited amount of research on tablets has been done.

Tablet- and Smartphone-technologies and most of their attributes are very much alike, that is why some of the studies that were done on the Smartphones were included in this thesis as well.

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The information and knowledge that doctors need, in their daily work, are massive. A study has explored what happens when young doctors get support from their Smartphones with access to a library of medical books in career transition phase from the medical student to the doctor. The study concluded that a Smartphone is most useful in starting phase of a medical career. In that phase an electronic library is highly valued by young doctors.

The study showed that although Smartphones are very helpful, they couldn’t replace discussion with senior doctors and other colleagues. The study concluded that Smartphones could be very helpful to young doctors in preparation for discussion with their colleagues. (Hardyman, Bullock, Brown, Carter-Ingram & Stacey, 2013)

A UK study among junior doctors showed that 75% of them owned a private Smartphone and the majority owned 1-5 medical apps, which they used several times a day to support their learning. (Payne, Wharrad & Watts, 2012) 2.2 Theoretical Concepts

Following twelve concepts are based on the theory findings that were previously presented in this chapter.

1. Tablets could improve interaction and communication between doctors and patients. (Horng et al., 2012, Scaflani et al., 2012)

2. Tablets could have positive impact on error prevention and improvement of patient safety. (Buus et al., 2012, Prgomet, 2009)

3. Doctors are generally very interested in tablets. (Modahl, 2011)

4. Junior doctors own a private tablet and/or a Smartphone and have a few of medical apps installed. (Payne, 2012)

5. Hospitals should support mobile technology. (Scaflani et al., 2012)

6. Mobile technology could make less experienced doctors better at their job. (Scaflani et al., 2012)

7. Tablets can help doctors save time. (Horng et al., 2012, Patel et al., 2012, VanDenKerkhof et al., 2003)

8. Tablets can make doctors work more efficiently. (Patel et al., 2012, VanDenKerkhof et al., 2003)

9. Doctors want mobile access to: EHR, pharmacopoeias, reference literature, point of care apps and email. (Buchauer et al., 1999, Scaflani et al., 2012)

10. Doctors want to make voice recordings on their tablet. (Buchauer et al., 1999)

11. Technology in hospitals is not sufficiently developed for the implementation of tablets. (Buus et al., 2012)

12. Doctors are afraid to misplace their tablet. (Horng et al., 2012)

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3 Methodology

This chapter provides an overview of the research methodologies that have been used in this thesis and it also clarifies the motives behind the choices. The aim of the research was to analyse hospital doctors’ thoughts and feelings about the use of tablets in hospital settings. This chapter presents research design, strategy and approach, data collection method, data analysis method and at the end of this chapter the methods are evaluated.

Figure 1 Overview of the research methodologies

3.1 Research Design and Strategy

Selecting a suitable research design and designing an appropriate research strategy are some of the main tasks when doing scientific research. Research design is the “framework for the collection and analysis of data”. In addition, it

“represents a structure that guides the execution of a research method and the analysis of the subsequent data”. (Bryman & Bell, 2011, p. 41)

According to Bryman et al., (2011) there are five different types of research design: “experimental design, cross-sectional or social survey design, longitudinal design, comparative design and case study design” (p. 45).

This thesis took a case study design approach. It explored what three hospital doctors in Norway, would feel about using tablets in their daily work at hospital. It also explored respondents’ thoughts and feelings about how

Case study

Deductive approach

Qualitative research strategy

Theory

Empirical data

Sampling

Data collection

Data analysis

Semi-structured interviews

Interview recordings Interview guide Convenience sampling

Thematic analysis Template analysis

Coding Method

evaluation

Reliability and validity Limitations

“… investigates a contemporary phenomenon within its real-life

context” English translation of the interviews

Theoretical concepts Interview questions

“… the words are collected and analysed”

“There are two different approaches in research,

deductive and inductive approach.”

“… is an important component of

quality assurance.” Analytical template

Interpretation of findings

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tablets could be used to facilitate their work performance and it also identified main needs from the potential future users perspective.

A number of reasons have justified the choice of the case study as a research method in this study. For instance, case study approach is appropriate to use when one need to answer how and why questions, but also when one needs to understand complex social phenomena with a focus on contemporary events, where behaviour events cannot be controlled. (Yin, 2003)

Deductive approach is the research approach used in this thesis. In deductive research approach, a hypothesis is deduced from the existing theory, which was presented in previous chapter. The hypothesis is then tested and confirmed or rejected. (Bryman et al., 2011)

Research strategies or orientations in case study design approach, can be either qualitative, quantitative or both (Yin, 2003, Bryman et al., 2011).

Qualitative research strategy has been selected in this study, which means that the words are gathered and analysed and not numbers and statistics (Bryman et al., 2011).

The results of this case study can be used in future research on this subject, or in future projects with the aim to implement tablets in hospital settings.

3.2 Data Collection

Bryman et al. (2011) declares that: “A research method is simply a technique for collecting data” (p. 41). The author continues by saying that the appropriate choice of the research methodology depends on the kind of data one needs to collect in their research.

Yin (2003) writes about six sources of evidence that are used in case study research: “documents, archival records, interviews, direct observation, participant- observation, and physical artefacts” (p. 85). Semi-structured interview is the data collection method that was used in this study, with the objective to collect the potential end-users perspective on tablets.

Semi-structured interview was selected for this study since the researcher is flexible to ask follow up questions that are based on the respondent’s previous answers. Furthermore, semi-structured interviews leave the researcher open to new ideas, perspectives, needs and wishes that I hoped would emerge from the interviews. (Bryman et al. 2011)

3.2.1 The Interview Questions

Since tablets have only existed for a short period of time and have not been implemented in many hospitals, there is not much research on the field.

However, from the studies that have been done on the subject in the recent

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years, it appears that the implementation of tablets in healthcare is still in the start phase and the best is yet to come.

Statistics indicate, that since the release of iPad in 2010, the use of tablets has rapidly increased. Even before 2010 some hospitals had implemented PDAs, which resulted in many improvements like error prevention, improvement of data accessibility etc. (Prgomet, 2009).

As presented in the previous chapter, the latest studies have shown that tablets, which have been implemented in hospitals, have improved work efficiency of doctors and helped them save time (Patel et al., 2012, Horng et al., 2012). Many doctors believed that tablets improved their interaction and communication with their patients (Scaflani et al., 2012). Tablets also improved patient safety and streamlined the workflow (Buus et al., 2012).

Additionally, many doctors felt that Smartphones are a helpful tool for doctors too. (Hardyman et al., 2013).

Studies have shown that especially young doctors are very positive towards implementation of tablets in healthcare (Scaflani et al., 2012). In addition access to a digital library has proved to help young doctors in transition from medical student to a young doctor (Hardyman, 2013). That is why this study includes only respondents that have from 1 to 10 years of experience as doctors.

In this thesis three interviews were performed with three doctors, who work at a hospital in Norway that has not implemented tablets yet. The objective was to explore doctors’ opinions and thoughts about the topics presented in theory chapter, prior the implementation of tablets. Most of the studies presented are statistical, quantitative studies. In this study, the focus was on seeking understanding of the subject. The focus of this thesis was on understanding of what the potential future users, i.e. doctors, consider about tablets and mobile technology in hospitals by giving examples and explaining their thoughts.

The first goal of this thesis was to understand how hospital doctors in Norway perceive the use of tablets instead of or as a complement to stationary computers, as a tool for improving their work performance? The respondents were asked the following questions:

− What do hospital doctors think and feel about tablets in general

− Do they own a private tablet

− Some hospitals have already implemented tablets. What are their thoughts on that

− If they believe that they (and doctors in general) would work more efficiently if they used tablets in hospital

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− If they think that tablets could improve their communication and interaction with their patients

− If they believe that tablets could make them better doctors

− If they believe that tablets could improve the quality of the healthcare Additionally, this thesis tried to identify what the potential future users need and wish, considering the use of the tablets in hospital setting. The respondents answered the following questions:

− In what work environments hospital doctors think that a tablet would be most helpful and useful

− What functions and applications are required in those settings

− What are their requirements about tablets physical appearance

− If they can see themselves carry the tablet with them while working

− If they are worried about information security

− If they feel that there is any need to bring a work tablet home.

An interview guide, presented in Appendix A, was prepared in advance, to be used during the interviews, with the potential end-users. Interview process itself was very flexible, focus was on what respondents considered important, as Bryman et al. (2011) stated.

3.2.2 Respondents and Interviews

The meetings with the interviewees were one-on-one meetings with one interviewer, the author of this study, and one interviewee, or the respondent, a hospital doctor. The duration of the meetings were between 30 and 50 minutes. All meetings were audio recorded with the consent of the respondent. The audio recordings were translated to English by the author of this study. The text was later coded, analysed and presented in the following chapter. All the respondents’ quotations, in the next chapter, are author’s own translation into the English language. Respondents were given pseudonyms.

The name of hospital they work at and their medical specialization was omitted on purpose.

There were totally three respondents participating in this study. All respondents participated voluntarily and they were selected since they were of both sexes and they had between 1 and 10 years of hospital experience.

Another important factor was their age. They were all 30 ± 5 years old, which increases the chance that they grew up with IT and that they are experienced users of modern IT technology.

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3.2.3 Sampling

The type of sampling in this study was a convenience sampling, which means that selected respondents were easily accessible and that is also one of the main reasons why they were selected.

3.3 Data Analysis

In qualitative studies it is not always simple to analyse the collected data because, as was mentioned before, the data is not numerical. Bryman et al., (2011) explains that thematic analysis is one of the most used techniques in qualitative data analysis.

King (2004) has developed a set of techniques called template analysis to be used for thematic analysis of texts. “The essence of template analysis is that researcher produces a list of codes (‘template’) representing themes identified in their textual data” (King 2004, p. 256).

Analysis of the interviews started with the definition of some priory themes.

“[…] template analysis normally starts with at least a few pre-defined codes which help guide analysis” (p. 259). King recommends using an interview guide as a base for development of initial template. With that in mind, priory themes used in this study were based on theory concepts, presented at the end of the previous chapter, and interview guide, attached in Appendix A. (King, 2004, Template analysis, 2012)

After the definition of priory themes the interviews were translated to the English language and written down. In the next step interviews were coded.

Template analysis is about the codes and templates. Codes are as labels that can be attached to a piece of text. They can be descriptive or interpretative.

Initial coding was done in the following way: parts of the interview that related to a research question was identified and a code from a priory theme was attached to it. If no priori theme existed a new theme was developed or an old one was modified. Figure 2 shows two examples that show how the coding was done. In template analysis codes are hierarchically organized in different levels. Codes with the higher-order represent general themes, while lower-order codes are more specific. (King, 2004, Template analysis, 2012)

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Figure 2 Coding example

King states: “Once an initial template is constructed, the researcher must work systematically through the full set of transcripts, identifying sections of text which are relevant to the project’s aims, and marking them with one or more appropriate code(s) from the initial template.” (p. 261). Inadequacies on the template were discovered and that is why the template needed to be modified by: insertion, deletion, changing scope and changing higher-order classification. The final version of the template was obtained when all text relevant to the research questions was coded. (King, 2004, Template analysis, 2012)

The finale template structure, presented in Appendix B, was used to interpret the interviews. The template analysis technique is illustrated in figure 3. It follows the process described by King, on his webpage:

http://hhs.hud.ac.uk/w2/research/template_analysis/technique/technique.

htm

Figure 3 Overview of the template analysis

Final template (analytical template) was used to interpret the findings. King pointed out that “template is not the end product of the analysis”. As was recommended by the King himself the final template was only used as a tool to produce an interpretation of the data. The section 4.2 “results & analysis”

was structured around the main themes as was recommended by King, it also seemed as a very logical structure. (Template analysis, 2012)

In section 4.3 the results were compared to the theoretical concepts presented in chapter 2 and in section 4.4 new findings were summed up.

Bryman et al. (2011) explains that in scientific research there are usually two different approaches, deductive and inductive approach. In deductive research approach, a hypothesis is deduced from the existing theory, then tested and confirmed or rejected. The inductive approach is opposite from deduction. To quote Bryman et al. (2011) “With an inductive stance, theory is the

Development of analytical template Template Analysis

Definition of priory themes

Interview

transcription Initial coding Producing initial template

Development of the finale template

Interpret findings

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outcome of the research.” (p. 13) In template analysis both deductive and inductive approaches were used. Saunders, Lewis & Thornhill (2007) clarified:

“… template analysis combines a deductive and an inductive approach to qualitative analysis in the sense that codes will be predetermined and then amended or added to as data are collected and analysed” (p. 496).

Results and analysis of the interviews are presented in the next chapter.

3.4 Method Evaluation 3.4.1 Reliability and Validity

In all qualitative studies it is highly essential to think about reliability and validity. Reliability and validity are important because they increase the quality of the study. According to Bryman et al. (2011) “reliability is concerned with the question of whether the results of a study are repeatable” (p. 41), while

“validity is concerned with the integrity of the conclusions that are generated from a piece of research” (p. 42).

This study explored the opinions and beliefs of doctors with 1 to 10 years of experience, because they belong to a generation that have grown up with computers and the Internet. They are used to new technology and not afraid of it.

The results of semi-structured interviews are hard to generalise because only three respondents were interviewed and they are not representative to the whole population of doctors neither in Norway nor in the world. However, all respondents were asked the same type of questions and in addition the interviews were made within the same week, which increases the reliability of this study.

The digital recordings of the interviews increase the validity of this study, because when interviews are recorded it is possible to go back and listen to what was said again.

3.4.2 Limitations

There are some limitations concerning convenience sampling. For example one of the problems is that the sample is not representative for the whole population of young doctors. However, Bryman et al. (2011) explains that when opportunity to gather information presents itself the researcher should do the study with convenience sampling. Although, the results of the study cannot be generated to a whole population of young doctors, the results can be used as “springboard for further research or allow links to be forged with existing findings in an area” (p. 190).

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The language is another limitation factor in this study, because in qualitative study the understanding is very important. The answers from respondents were translated from Norwegian to English language, which is another limitation that is worth remarking.

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4 Findings: Results & Analysis

This chapter presents the case study findings. It starts with a general presentation of the respondents, following by presentation of the results and analysis. Moreover, this chapter compares the findings with the theoretical concepts and it also sums up new findings at the end of the chapter. The results are analysed using template analysis, which is explained in detail in the previous chapter.

4.1 Respondents

Three respondents were interviewed in this case study. This chapter starts with a very short and general presentation of them. The respondents are one female and two male doctors, who have different working experiences, personalities and perspectives. All respondents have worked in other hospitals in Norway or abroad, which means that they had experience with IT systems in other hospitals as well.

4.1.1 Respondent A: Dr. Erik G.

Erik is 34 years old and has 7 years of experience as a hospital doctor. In addition to an iPhone and a laptop he also owns a private iPad 2, which he uses every day. Erik does not bring his tablet to his work at hospital. The only work-related tasks he uses it for is for reading medical books and other medical related literature, and for keeping himself updated on his medical field.

4.1.2 Respondent B: Dr. Anna C.

Anna is 31 years old resident doctor and has 3 years of hospital experience.

She is not particularly interested in newest technology, although she owns a private Smartphone, a Samsung Galaxy tablet and a laptop. She commutes to work every day by train. On the train she uses her Smartphone to read medical books and other work-related literature. That is how she prepares herself for the patients that she will meet during that day.

4.1.3 Respondent C: Dr. Robert S.

Robert is 29 years old resident doctor and has 2 years of hospital experience.

He does not own a private tablet, but he owns a Smartphone in addition to a laptop. His Smartphone has a somewhat larger screen and he uses it all the time. In his private time he reads a lot. Robert enjoys reading real books and books in digital format are of no interest to him.

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4.2 Results and Analysis

All three respondents that were interviewed for this study work as hospital doctors at the same hospital in Norway. They have 2, 3 and 7 years of work experience. Three out of three respondents own a private Smartphone, which they use a lot, and two out of three own a private tablet.

Analysis of the interviews was done using thematic analysis approach, which is described in detail in the previous chapter. The results of the analysis are presented here in this chapter.

This chapter presents the findings of this study and it is structured around the main themes that were identified during the thematic analysis. Those main themes are: doctors at work, patient contact, education, personal, physical appearance of a tablet, thoughts on tablets and issues.

4.2.1 Doctors at Work

Doctors interviewed in this study, seem generally very positive towards the idea of implementation of tablets in hospital settings. They believe that it is positive that some hospitals around the world are already providing their employees with tablets, mainly because they see tablets as very practical and helpful devices.

The reason why respondents think that tablets would be practical and helpful tool if they were used in their working environment is mainly due to its mobility and easier information access. On different days the respondents work in different departments: on the ward, in the ER at the polyclinic etc.

They move a lot around hospital while computers are located in specific spots that are not always easy to access. Some days the respondents work at hospital ward. Here is what one of the respondents says about it:

“During the ward rounds, for instance, we have a computer at the on call room. There we go through everything and then we go and see the patient. I write down everything I need to remember. But if I was a patient I would like to see for example my x-ray images after the surgery. And today it is not possible because the patient lies

in bed and we have a computer in on call room.”

At polyclinic the situation seems to be completely different.

“At polyclinic a tablet would not make any difference because there I sit in my office and have a computer with me, which I am already logged on when a patient visits”

Which means that a tablet would not be of any use for doctors when they work at the polyclinic.

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At the emergency room (ER), where they sometimes also work, computers and patients are not in the same room. In addition, when they are on call they often have to work all-around hospital.

“When I am on call I think a tablet would be very practical to have. […] In the ER we have computers but we have to look for them and find an available one. They are not

by the patient’s side. So I have to leave the patient look at blood results and then go back to the patient. So, when I am on call or at the ER I believe that a tablet would be very helpful. Sometimes they call me from the ward and ask me to just check on some blood results. It would be helpful to just check it on the tablet instead of looking for a

computer and then look it up there.”

Surgeons very often spend their working days in operating rooms, but they think that a tablet would be absolutely unnecessary there, because in the OR, computers are easy to access. Sterility is of also of high importance in the operating room. That is why it would feel very unsafe to take a tablet in and out.

Respondents in this study also believe that a tablet would be very helpful to them during meetings with their colleagues and seniors. They have meetings with their colleagues at the start and the end of the day.

“At meetings when I am reporting about my patients, if there is much information I write it down. Just some words. But if there is much information, then I print out the

notes to have with me when presenting. But if I had a tablet then it would not be necessary.”

To summarise, respondents interviewed in this study believed that the need of tablets depends on their particular work environment and above all on their mobility. In some work environments, for instance when they are working on the ward, in the ER and when they are on call, i.e. when they are mobile, tablets would be more practical to use than stationary computers. In those settings tablets could be used as a complement to computers. Whilst, they believe that tablets would be of no use, or of very little use, at polyclinic or in the operating room, because there they have access to all information on a computer next to them.

Digital devices used in this hospital, already facilitate the work of all healthcare personnel, including doctors. For instance, the respondents use computers to get access to most of the information they need. Pagers are another type of device that is used frequently, and digital voice recorders are used for recording information about patients in the EHR. It appears that although stationary computers make the doctors’ job a lot easier, there are some issues with them as well.

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“There are plenty of computers in hospital so one can always find a free one. But sometimes one needs a computer in a quiet area, where one can concentrate better. I

have a computer at my office, but sometimes it is at the other end of the building. It would take a lot of time to get there.”

“One uses a lot of time every day just to log in and out, in and out, in and out [on the computer].”

“I am sure it takes sometimes 2 minutes from when I sit down at the computer until I am logged in on the system.”

As understood from the answers, respondents find it sometimes difficult to find an available computer. Other times they leave their patient to go and find the patient-related information on a computer. Two out of three respondents explained that they very well understand why it is important to have a good and secure login technology, but that the login technology they use today is too slow and inefficient.

Generally, respondents find computers very useful when they already have access to them, when they have time to sit down and look for the information and when they are already logged in under a longer period of time, like for instance when they are working at the polyclinic. They also believe that computers are more useful than tablets when one does some more demanding tasks that take longer time, like for instance writing letters of referral, reporting patient sick and writing prescriptions. Respondents feel that computers are easier to write on because they have physical keyboards.

They have larger screens, which are positive and in some situations important. In addition, one can run many programs at the same time on the computer, which is certainly of advantage.

Tablets, however, have the advantage of being mobile and in many situations easier and more practical to use than computers. Respondents also pointed out that if tablets are to be a success then they had to have a faster and easier login technology that would not compromise the information security.

Pagers are another type of digital device that doctors interviewed in this study use. Here are some of their thoughts about them:

“It was a change for me, in [old work place] I had my own telephone. With a number only I had. It was not like having a pager, someone calls you and you have to find a phone. There every doctor had his or her own wireless phone. One loses a lot of

time when one looks for a phone and calls people back.”

“Suddenly all phones are taken and you have to look for a phone elsewhere and people do not hang up their phones or you call them back and they are not there. That is why

I think that a mobile phone would be a better alternative.”

Doctors and Tablet Computers: A Case Study

BACHELOR THESIS