Change management overlooked: physician perspectives on EHR implementation

Although Electronic Health Record (EHR) systems have recently achieved widespread adoption in the U.S., our understanding of their impact on care outcomes is still limited. Current literature has produced mixed results due to the use of non-standardized measurements and weak research designs. In this dissertation, 4 studies are conducted to develop a systematic methodology for detecting near real-time performance changes during EHR implementations. It also explores factors that can affect outcomes during a commercial EHR implementation. The first study assesses the current state of the literature on health IT adoption to identify the most commonly reported outcome measures and proposes a taxonomy to classify these measurements. The second study expands the first study by identifying additional measures through semistructured interviews with experienced clinical and administrative leaders from a large care delivery system. We also collect input from national informatics experts who suggested additional relevant measures. The third study is a robust longitudinal analysis including several measures from our larger inventory that were used for monitoring a large-scale commercial EHR implementation and detected patterns of impact and mixed time-sensitive effects across geographically dispersed settings from an integrated care delivery system. The fourth study is a qualitative analysis guided by the quantitative results of the third study. We identified several factors that may have contributed to performance changes detected by our methodology. In summary, this dissertation will help the broader medical and informatics communities by informing what and how to continuously monitor future similar implementations. First, it contributes to the identification of relevant outcomes likely impacted by health IT interventions. Second, it combines these outcome measures with a robust interrupted time-series design, producing a systematic methodology that allows earlier and potentially more precise detection of unexpected effects, and implementation of effective response to mitigate negative impacts. Last, the identification of factors that may impact outcomes during and following an EHR implementation and covariates to measure them will empower researchers in charge of future evaluations, hopefully increasing the understanding of the full impact of health IT interventions.

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders.

Context: This literature review mostly emphasizes on the challenges and barriers for acceptance and implementation of electronic health records (EHRs) in developing countries. Although the willingness of developing countries for acceptance and implementation of EHRs is rising, they will face some challenges and barriers which can slow down their progress due to the multidisciplinary and complexity characteristics of EHRs. Some of these challenges and barriers can be seen in the past and present histories of EHRs acceptance process in developed countries too. Familiarity with these challenges and barriers will help developing countries to have better understanding of these problems towards successful EHRs. The main goal of this survey is to study the challenges and barriers of acceptance and implementation of EHRs in the developing countries and how they can overcome such problems. Evidence Acquisition: Two databases, Pub-Med and Scopus with Combination of terms such as Electronic Health Records, Developing Countries, Barriers, Challenges, Acceptance, and Adoption were searched. Totally, 514 articles extracted. Some exclusive criteria such as date of publication (year 2000 and above) and having a close relation to the subject of the study (through abstract) were applied. The result was eight articles from Scopus and 12 articles from Pub-Med. Also, 7 articles were extracted by general search in internet. Also, 11 articles with the same search policies were selected from Journal of Health informatics for Developing Countries (JHIDC) with no exclusion criteria. Results: Developing countries must be fully aware of challenges and barriers in their way towards EHRs. They also need to study the experiences of countries which are successful in acceptance and implementation of EHRs. Developing countries also need to provide infrastructures needed for a successful implementation of EHRs. Conclusions: Despite the positive effects of EHRs in healthcare services, the acceptance rate of EHRs in developing countries and even developed countries is still low. The developing countries are facing many problems in their way toward implementing successful EHRs. Lack of infrastructures in information and communication technology, cost, and cultural resistance are considered as main barriers for developing countries in their approach to accept and implement EHRs.

Electronic health records implementation: An evaluation of information system impact and contingency factors

Nurses and physicians’ perceptions on the Electronic Health Record implementation

ABSTRACTEarly HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

To assess the impact of electronic health record (EHR) implementation on hospital finances. We analyzed the impact of EHR implementation on bond ratings and net income from service to patients (NISP) at 32 hospitals that recently implemented a new EHR and a set of controls. After implementing an EHR, 7 hospitals had a bond downgrade, 7 had a bond upgrade, and 18 had no changes. There was no difference in the likelihood of bond rating changes or in changes to NISP following EHR go-live when compared to control hospitals. Most hospitals in our analysis saw no change in bond ratings following EHR go-live, with no significant differences observed between EHR implementation and control hospitals. There was also no apparent difference in NISP. Implementation of an EHR did not appear to have an impact on bond ratings at the hospitals in our analysis.

The objective of this study was to examine end-user opinions on electronic health record (EHR) modifications related to social work documentation of psychosocial acuity and provision of social care. Content analysis was used to examine end-user opinions (n = 42; 20% of a social work department employed in a large, urban, pediatric hospital) about whether or not to integrate a metric of psychosocial acuity into the EHR and required documentation practices. Most (79%) participants were in favor of EHR integration. Content analysis revealed nine themes in favor and five against integration, with most pertaining to clinical care, the organizational context, process, and purpose. Given that health care providers may find EHR changes to be disruptive to workflow and an imposition to day-to-day activities, engaging end-users in decision-making processes surrounding forthcoming EHR changes may not only increase investment in them, but also prevent provider burnout.

The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives. Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation. The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support. Validation efforts included content validity assessment, a pilot study, and analysis of 606 nurse respondents. The revised tool was sent to randomly sampled EHR nurse-users in 11 acute care facilities. A total of 1,301 nurses responded (37%). Internal consistency of the survey tool was excellent (Cronbach's α = .892). Survey responses including 1,819 open comments were used to identify and prioritize improvement efforts in areas such as education, support, optimization of EHR functions, and vendor change requests. The Baylor EHR UX survey was a valid tool that can be useful for prioritizing improvement efforts in relation to EHR implementation.

Implementing a Common Data Model in Ophthalmology: Mapping Structured EHR Ophthalmic Exam Data to Standard Vocabularies

The intersection of electronic health records (EHR) and patient safety is complex. To examine the applicability of two previously developed conceptual models comprehensively to understand safety implications of EHR implementation in the English National Health Service (NHS). We conducted a secondary analysis of interview data from a 30-month longitudinal, prospective, case study-based evaluation of EHR implementation in 12 NHS hospitals. We used a framework analysis approach to apply conceptual models developed by Sittig and Singh to understand better EHR implementation and use: an eight-dimension sociotechnical model and a three-phase patient safety model (safe technology, safe use of technology, and use of technology to improve safety). The intersection of patient safety and EHR implementation and use was characterized by risks involving technology (hardware and software, clinical content, and human-computer interfaces), the interaction of technology with non-technological factors, and improper or unsafe use of technology. Our data support that patient safety improvement activities as well as patient safety hazards change as an organization evolves from concerns about safe EHR functionality, ensuring safe and appropriate EHR use, to using the EHR itself to provide ongoing surveillance and monitoring of patient safety. We demonstrate the face validity of two models for understanding the sociotechnical aspects of safe EHR implementation and the complex interactions of technology within a healthcare system evolving from paper to integrated EHR. Using sociotechnical models, including those presented in this paper, may be beneficial to help stakeholders understand, synthesize, and anticipate risks at the intersection of patient safety and health information technology.

Battling Intensivist Burnout: A Role for Workload Management

This study collects survey data (n = 345) from a healthcare organization in the early stages of electronic health record (EHR) implementation to understand how a series of organizational communication sources—managers, coworkers, IT personnel, and online organizational sources—impact healthcare employees’ (a) EHR resistance and (b) perceptions of EHR’s relative advantage. Regression results reveal that the levels of EHR information employees sought from coworkers did not predict EHR resistance or perceived relative advantage. Seeking information from managerial sources enhances EHR’s perceived relative advantage and decreases affective EHR resistance but is not related to behavioral or cognitive EHR resistance. Seeking information from IT staff decreased all types of EHR resistance and increased EHR’s perceived relative advantage. Finally, seeking information from online organizational sources increased EHR’s perceived relative advantage and decreased behavioral and cognitive resistance but is not related to affective EHR resistance. Study implications and limitations are offered.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Electronic Health Records: Privacy and Security Issues in a Comparative Perspective