In studies in both the inpatient and outpatient settings, the factors shown to be important for success tended to be environmental, organizational, personal, and technical.
Environmental trends, those that are putting pressure on hospitals and outpatient practices to implement EHRs, concern mainly financial and safety issues. On the financial side, both hospitals and physician practices are struggling, with practices perhaps doing worse. When hospitals make an investment in an EHR or CPOE and when the implementation is successful, they recover much of that investment, although the payers and purchasers also benefit. For outpatient practices, on the other hand, approximately 90% of the financial benefit accrues to payers and purchasers,8
though physicians must make the investment. This misalignment of incentives represents perhaps the single most important barrier to moving ahead and is especially problematic in the outpatient sector.
Health care safety has emerged as a major national concern and an important environmental force. Information technology has been touted widely as a tool that can improve the quality and safety of patient care.9
The forces of competition in health care may be providing pressure as well, as more patients become aware of the potential of health care information systems. Hospitals can improve their image by being on the cutting edge of technology, and this can be promoted through the media. The trend toward mergers of hospitals might have a negative influence if energy is shifted toward the organizational angst such mergers create. On the other hand, they may enable investment in EHRs by increasing purchasing power with vendors. Finally, there is a social trend toward patient empowerment, toward patients becoming more involved in their own care, and at the same time systems can assist them by allowing access to parts of their records. Most of these environmental trends are strong facilitating forces that should be capable of moving along the adoption rate and filling the adoption gap.
In addition, there are organizational trends that pose significant barriers. For the inpatient settings, the hospitals, the decision to purchase and implement an EHR with CPOE is a large and risky one. It may be the single biggest capital investment the hospital will make over a five-year period at a time when in a recent year approximately two thirds of U.S. hospitals lost money. The investment is great both initially and on an ongoing basis, and the return on investment case cannot always be made clearly. In addition to the financial risk, there are great social and behavioral risks. Once the organization adopts a system, the users need to adopt it. There have been several highly publicized failures of CPOE implementations in hospitals in which physicians refused to use CPOE for a variety of reasons reflecting underlying problems.
The organizational culture must be ready to support adoption by the individuals within it. There has been a period when clinicians have not experienced a sense of collaboration and trust between them and hospital administration. Consequently, if clinicians believe the administration wants to force them to use CPOE, for example, they may dig in their heels. They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there. On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level. One gauge of readiness is the extent to which certain categories of people hold positions within the organization. In particular, administrators at the highest level must offer both moral and financial support and demonstrate that they really believe in the patient care benefits of the systems. There must be clinical leaders, including a chief medical information officer if at all possible, who understand the fine points of implementation strategies, and opinion leaders among the clinical staff members. In addition, there need to be sufficiently skilled implementation, training, and support coordinators who understand both clinical and technical issues.
If systems are to be used by individual clinicians, a number of important personal issues must be considered. It must be understood that physicians are not resistant to technology; they have embraced many new medical technologies with no hesitation. They are embracing use of personal digital assistants (PDAs) for clinical purposes with amazing speed. In contrast, however, they are reluctant to adopt new ways of doing things that interfere with their workflow and that they perceive take time away from their patient care work. There is debate about whether CPOE is significantly slower than hand-writing orders, and indeed with some systems the time may be quite similar, but the widespread perception is that it is slower, and this is probably true, at least at first. In addition, an inferior CPOE system could even upset the workflow of clinicians to such a degree that it endangers patients, although we are not aware of published studies demonstrating that this has occurred. Overall, when clinicians have access to larger amounts of information with which to make decisions, and when the system fits their workflow, they tend to use it.
There are significant technical issues, both positive and negative. There are many definitions of CPOE and the EHR at numerous levels of sophistication and functionality. When one contemplates the highest levels, however, the ability of systems to interoperate with one another is paramount. CPOE should certainly interoperate with systems that are on the receiving end of ordering such as laboratory, pharmacy, and radiology systems. The EHR is a system of interoperating systems. Interoperability is a significant problem; many individual applications do not communicate with one another. In the outpatient setting, for example, most EHRs do not communicate well with practice management systems currently in use, and communication between inpatient and outpatient systems is also infrequent. At its most sophisticated or most infused level, the EHR becomes a hub of all activity, something that permeates every element of the workflow and of work life. It can be like an umbilical cord or spinal cord, depending on which analogy one likes best, but it can only achieve that level of importance if all systems work with one another. This level of “hubness” exists in a few places, and it indeed permeates organizational work life.
In the future, more organizations will hopefully share clinical data, dramatically increasing the level of interoperability. Issues related to interoperability and sharing from a technical vantage point are large and difficult. There is a sense that the clinical vocabulary issue is being addressed positively and with vigor, and a number of problems have been overcome, although there is still much work to be done. The issue of standards is also receiving increasing attention, and progress is being made. It stands to reason that there are business and political issues involved as well since it may not be in the best interest of vendors to develop systems that easily share data with those of other vendors. The standards issue was discussed in greater depth during the third ACMI discussion session.10
One overarching issue, perhaps outside the purview of the informatics community, is that of individual unique identifiers for each possible patient in the United States. There are arguments on the positive side for the ability to generate medical records so that everyone arriving in an emergency room, for example, could receive appropriate care based on adequate knowledge about them; in addition, the costs of implementing data interchange would be substantially lower. On the negative side, there are privacy issues of immense importance, and implementation of a unique patient identifier would be politically difficult.
In one important respect the technology offers clinicians something that facilitates patient care enormously—the ability to enter orders and review results remotely. In the inpatient setting, this means that the clinician can be anywhere in the hospital when writing orders. Even better, the clinician can do hospital work while in an office, at home, or while between locations. Some hospitals with EHRs have hesitated to offer remote access to physicians because of concerns about legal liability and privacy issues, but these concerns may not be warranted.
A study of outpatient EHR adoption done by the Massachusetts Medical Society in the spring of 2003 evaluated the attitudes of physicians toward their use and the use of information technology in general. The study has not been published in a peer reviewed journal and in fact the response rate was very low, but it was discussed at the retreat because the results are intriguing. The study found that the majority of respondents agreed that computers can significantly improve the quality of care and that doctors should computerize the writing of their prescriptions, yet almost half did not intend to do so.11
There is a large disconnect here between their belief in the value of EHRs and their intentions to use them themselves. Physicians believe the systems can make a difference, but they are not yet ready to make the commitment.
The reasons offered by respondents in this survey were first, that the systems are too expensive for them to purchase; second, that they take too much time; third, that they may not be secure; and fourth, that they are expensive to maintain. These concerns on the part of physicians are quite different from those seen in the inpatient setting. In hospitals, clinicians are not concerned about initial and ongoing costs because systems are purchased and maintained at the expense of the hospital and not the clinicians, and as noted earlier, the financial incentives are much better aligned. Physicians in hospitals are not as concerned about security either, since the information technology departments generally monitor that. For the individual physician in the inpatient setting, the paramount issue is physician time, and this is also very important outside the hospital.