Factors associated with difficult electronic health record implementation in office practice

Provider and patient satisfaction with the integration of ambulatory and hospital EHR systems

Objective

The installation of EHR systems can disrupt operations at clinical practice sites, but also lead to improvements in information availability. We examined how the installation of an ambulatory EHR at OB/GYN practices and its subsequent interface with an inpatient perinatal EHR affected providers' satisfaction with the transmission of clinical information and patients' ratings of their care experience.

Methods

We collected data on provider satisfaction through 4 survey rounds during the phased implementation of the EHR. Data on patient satisfaction were drawn from Press Ganey surveys issued by the healthcare network through a standard process. Using multivariable models, we determined how provider satisfaction with information transmission and patient satisfaction with their care experience changed as the EHR system allowed greater information flow between OB/GYN practices and the hospital.

Results

Outpatient OB/GYN providers became more satisfied with their access to information from the inpatient perinatal triage unit once system capabilities included automatic data flow from triage back to the OB/GYN offices. Yet physicians were generally less satisfied with how the EHR affected their work processes than other clinical and non-clinical staff. Patient satisfaction dropped after initial EHR installation, and we find no evidence of increased satisfaction linked to system integration.

Conclusions

Dissatisfaction of providers with an EHR system and difficulties incorporating EHR technology into patient care may negatively impact patient satisfaction. Care must be taken during EHR implementations to maintain good communication with patients while satisfying documentation requirements.

What to expect from electronic patient record system implementation: lessons learned from published evidence

Background

Numerous studies have examined factors related to success, failure and implications of electronic patient record (EPR) system implementations, but usually limited to specific aspects.

Objective

To review the published peer-reviewed literature and present findings regarding factors important in relation to successful EPR implementations and likely impact on subsequent clinical activity.

Method

Literature review.

Results

Three hundred and twelve potential articles were identified on initial search, of which 117 were relevant and included in the review. Several factors were related to implementation success, such as good leadership and management, infrastructure support, staff training and focus on workflows and usability. In general, EPR implementation is associated with improvements in documentation and screening performance and reduced prescribing errors, whereas there are minimal available data in other areas such as effects on clinical patient outcomes. The peer-reviewed literature appears to under-represent a range of technical factors important for EPR implementations, such as data migration from existing systems and impact of organisational readiness.

Conclusion

The findings presented here represent the synthesis of data from peer-reviewed literature in the field and should be of value to provide the evidence-base for organisations considering how best to implement an EPR system.

Psychometric validation of a new measurement instrument for time-oriented patient information in electronic medical records: A questionnaire survey of physicians

RATIONALE, AIMS, AND OBJECTIVES

Time is an important element in medical data. Physicians record and store information about patients' disease progress and treatment response in electronic medical records (EMRs). Because EMRs use timestamps, physicians can identify patterns over time regarding a patient's disease and treatment (eg, laboratory values and medications). However, analyses of physicians' use and satisfaction with EMRs have focused on functionality, storage, and system operation rather than the use of time-oriented information. This study aimed to understand physicians' needs regarding time-oriented patient information in EMRs in clinical practice.

METHODS

The reliability and validity of the items in the questionnaire were evaluated in 87 physicians at a national university hospital. Internal consistency was satisfactory (Cronbach alpha coefficient, 0.87).

RESULTS

Four dimensions were identified in exploratory factor analysis. Correlations between the 4 dimensions supported the construct validity of the items. Scores of time-oriented patients' medical history in the 4 dimensions showed a significant association with physician age. Based on confirmatory factor analysis, associations were significant and positive (P < .001). In terms of the needs of physicians regarding time-oriented patient information in EMRs, both time-oriented treatment results followed by time-oriented team information had significant positive associations.

CONCLUSION

Our study suggests that 4 specific time-oriented patient information factors in EMRs are needed by physicians. Exploring physicians' needs regarding patient-specific time-oriented information may provide a better understanding of the barriers facing the adoption and use of EMRs (eg, decision-making and practice safety concerns) and lead to better acceptance of EMRs in physicians' clinical practices.

A Literature Review of Electronic Health Records in Chiropractic Practice: Common Challenges and Solutions

OBJECTIVE

The purpose of this study was to review the literature on current challenges and propose solutions for the optimal utilization of the electronic health records (EHRs) in chiropractic practice.

METHODS

A search was performed in the PubMed, Index of Chiropractic Literature, and Current Index to Nursing and Allied Health Literature databases from November 2005 to February 2015. A combination of the following key words was used: electronic health records, electronic medical records, implementation, documentation, benefits, and challenges. Articles were categorized into common problems and solutions. These were filtered by application to chiropractic or educational institutions.

RESULTS

The search resulted in 45 papers, which included case reports of EHR implementation, governmental insurance reports, commentaries, controlled studies, narrative reviews of past experiences with conversion from paper systems, and the implementation of EHRs in small offices and chiropractic offices. Minimal literature was found that directly related to chiropractic EHRs. Improper utilization, incorrect use of the software, faulty implementation, workflow burdens, financial considerations, and insufficient training were found to negatively affect the quality of the record.

CONCLUSIONS

Documentation errors are often innate in the EHR software. Improper utilization, insufficient training, or difficulty in integration of the EHR into the clinical office setting results in poor implementation of the electronic version of the clinical record. Solutions that may decrease documentation errors include EHR training, continued financial incentives, and appropriate implementation process and utilization of available software features.

Electronic health records: current and future use

This paper provides an overview of the current state of the electronic medical record, including benefits and shortcomings, and presents key factors likely to drive development in the next decade and beyond. The current electronic medical record to a large extent represents a digital version of the traditional paper legal record, owned and maintained by the practitioner. The future electronic health record is expected to be a shared tool, engaging patients in decision making, wellness and disease management and providing data for individual decision support, population management and analytics. Many drivers will determine this path, including payment model reform, proliferation of mobile platforms, telemedicine, genomics and individualized medicine and advances in 'big data' technologies.

Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care

OBJECTIVE

Electronic health records (EHR) hold great promise for managing patient information in ways that improve healthcare delivery. Physicians differ, however, in their use of this health information technology (IT), and these differences are not well understood. The authors study the differences in individual physicians' EHR use patterns and identify perceptions of uncertainty as an important new variable in understanding EHR use.

DESIGN

Qualitative study using semi-structured interviews and direct observation of physicians (n=28) working in a multispecialty outpatient care organization.

MEASUREMENTS

We identified physicians' perceptions of uncertainty as an important variable in understanding differences in EHR use patterns. Drawing on theories from the medical and organizational literatures, we identified three categories of perceptions of uncertainty: reduction, absorption, and hybrid. We used an existing model of EHR use to categorize physician EHR use patterns as high, medium, and low based on degree of feature use, level of EHR-enabled communication, and frequency that EHR use patterns change.

RESULTS

Physicians' perceptions of uncertainty were distinctly associated with their EHR use patterns. Uncertainty reductionists tended to exhibit high levels of EHR use, uncertainty absorbers tended to exhibit low levels of EHR use, and physicians demonstrating both perspectives of uncertainty (hybrids) tended to exhibit medium levels of EHR use.

CONCLUSIONS

We find evidence linking physicians' perceptions of uncertainty with EHR use patterns. Study findings have implications for health IT research, practice, and policy, particularly in terms of impacting health IT design and implementation efforts in ways that consider differences in physicians' perceptions of uncertainty.

Predictors of success for electronic health record implementation in small physician practices

BACKGROUND

The federal government is promoting adoption of electronic health records (EHRs) through financial incentives for EHR use and implementation support provided by regional extension centers. Small practices have been slow to adopt EHRs.

OBJECTIVES

Our objective was to measure time to EHR implementation and identify factors associated with successful implementation in small practices receiving financial incentives and implementation support. This study is unique in exploiting quantitative implementation time data collected prospectively as part of routine project management.

METHODS

This mixed-methods study includes interviews of key informants and a cohort study of 544 practices that had worked with the Primary Care Information Project (PCIP), a publicly funded organization that since 2007 has subsidized EHRs and provided implementation support similar to that supplied by the new regional extension centers. Data from a project management database were used for a cohort study to assess time to implementation and predictors of implementation success.

RESULTS

Four hundred and thirty practices (79%) implemented EHRs within the analysis period, with a median project time of 24.7 weeks (95% CI: 23.3 - 26.4). Factors associated with implementation success were: fewer providers, practice sites, and patients; fewer Medicaid and uninsured patients; having previous experience with scheduling software; enrolling in 2010 rather than earlier; and selecting an integrated EHR plus practice management product rather than two products. Interviews identified positive attitude toward EHRs, resources, and centralized leadership as additional practice-level predictors of success.

CONCLUSIONS

A local initiative similar to current federal programs successfully implemented EHRs in primary care practices by offsetting software costs and providing implementation assistance. Nevertheless, implementation success was affected by practice size and other characteristics, suggesting that the federal programs can reduce barriers to EHR implementation but may not eliminate them.