Implementing a new EHR system is complex especially at academic institutions that have many diverse ambulatory care practices each with varying electronic capabilities. At 1 institution, we found that ambulatory leaders had a wide range of priorities ranging from concerns about adequate workstations and technical support to insuring confidentiality and privacy for patients. Using qualitative analysis of interviews with leaders in paper- and EHR-based practices, we found that both had similar concerns regarding practitioner productivity and training. We also found differences. Leaders of paper-based systems prioritized the following: sufficient workstations and printers, a physician IT champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and IT support staff. In contrast, leaders of EHR-based systems prioritized: open recognition of physician resistance especially for those who were loyal to the legacy EHR, improved technical training, ongoing technical support, and sufficient protection of patient privacy.
Resistance to change is always a crucial challenge for the success of any innovation. Research has found that physician resistance is a challenge in the implementation of a new EHR system when switching from a paper-based practice.7,8,11,15
One might expect that resistance would decrease after a practitioner began using an EHR thereby facilitating the transition to a new system. However, our study findings indicate otherwise. An important finding of this research is that leaders of EHR-based systems believed that resistance toward implementation of a different EHR system was a formidable challenge to overcome. Practitioners may be reluctant to adopt new ways of doing things that interfere with their workflow, taking time away from patient care.16
One previous case study in the inpatient setting explored the transition from 1 EHR system to another. Medical directors unexpectedly encountered high levels of practitioner resistance that ultimately led to its failure.17
An important lesson learned from this experience was that during the early stages of the transition, a cooperative environment, which was conducive to minimizing initial resistance later, became an impediment: “At times [it] exacerbated implementation challenges or encouraged passive resistance.” Building a cooperative culture is important, especially when selecting an EHR product; however, during the implementation process, a directive leadership style may be necessary for success.
Another important finding of our study is that although both paper- and EHR-based system leaders had important concerns about decreased productivity, it appeared that paper-based leaders were more apprehensive. This is understandable, as implementation of an EHR system causes disruption to the office practice, requiring changes at all levels (e.g., acquiring new and expensive equipment, redesigning workflow patterns, and re-educating practitioners). Although this apprehension may be reasonable, it is important for senior leadership to address to optimize for success. We suggest that senior management provides practice leaders with IT training and also have them visit EHR-based practices. In this way, leaders can observe a paperless practice in operation, gain deeper understanding about adaptations that will have to be made and alleviate undue concerns.
Information sharing can be a great incentive for adoption of an EHR system, but it also creates challenges for maintaining patient privacy and confidentiality.18,19
We found that leaders of paper- and EHR-based practices had different perceptions about the effects an EHR system has on patient privacy. Leaders of paper-based systems expected that the EHR would increase patient privacy, whereas leaders of EHR-based systems were concerned that the EHR may be less secure, a view supported by at least 1 published report.20
Privacy is of concern to patients and practitioners and is a known barrier to adoption.21,22
The Department of Health and Human Services has invested significant resources to develop a comprehensive strategy for protecting health information, including the creation of an American Health Information Community’s Confidentiality, Privacy, and Security workgroup comprised of privacy, security, clinical, and technology experts.23
Unlike ours, many studies have found that costs are an important challenge to overcome.7,8,15
The high costs of implementing an EHR system are often prohibitive. Costs are often an adoption challenge to office practices and an implementation challenge to individual practitioners whose salaries are dependent on productivity. This was not true for the participants in our study because the larger hospital network had made the financial investments necessary to purchase and implement the new EHR system and the vast majority of staff practitioners were salaried, buffering their personal income against an expected decrease in patient volume.
Our study has several limitations. First, this is a qualitative study, generating hypotheses that need further investigation. Second, although we conducted interviews at 12 diverse ambulatory practices located in Manhattan, all respondents were faculty associated with 2 academic-based institutions affiliated with 1 hospital, thereby limiting our ability to generalize. Third, although we interviewed important leaders at each practice site, we did not obtain the perspectives of staff practitioners, support staff, or patients potentially limiting our view of the barriers and facilitators of implementation. Lastly, implementing an EHR is a dynamic process; this was a preimplementation study assessing anticipated challenges at only 1 point in time.
Implementation of a new EHR requires consideration of an ambulatory practice’s baseline system, paper or EHR based, because each has its own unique advantages and challenges. Previous studies have shown that the implementation of an EHR system if done prudently can improve quality of care24
but if done ineffectively can increase risks to patients.2
Because adoption of EHRs has been slow, with notable failures, efforts to understand and overcome the challenges to implementation are vitally important not only for paper-based practices but also for those changing from a legacy system to a new EHR.