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1.  Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review 
BMC Medicine  2011;9:46.
Background
Electronic health record (EHR) implementation is currently underway in Canada, as in many other countries. These ambitious projects involve many stakeholders with unique perceptions of the implementation process. EHR users have an important role to play as they must integrate the EHR system into their work environments and use it in their everyday activities. Users hold valuable, first-hand knowledge of what can limit or contribute to the success of EHR implementation projects. A comprehensive synthesis of EHR users' perceptions is key to successful future implementation. This systematic literature review was aimed to synthesize current knowledge of the barriers and facilitators influencing shared EHR implementation among its various users.
Methods
Covering a period from 1999 to 2009, a literature search was conducted on nine electronic databases. Studies were included if they reported on users' perceived barriers and facilitators to shared EHR implementation, in healthcare settings comparable to Canada. Studies in all languages with an empirical study design were included. Quality and relevance of the studies were assessed. Four EHR user groups were targeted: physicians, other health care professionals, managers, and patients/public. Content analysis was performed independently by two authors using a validated extraction grid with pre-established categorization of barriers and facilitators for each group of EHR users.
Results
Of a total of 5,695 potentially relevant publications identified, 117 full text publications were obtained after screening titles and abstracts. After review of the full articles, 60 publications, corresponding to 52 studies, met the inclusion criteria. The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities.
Conclusions
This systematic review presents innovative research on the barriers and facilitators to EHR implementation. While important similarities between user groups are highlighted, differences between them demonstrate that each user group also has a unique perspective of the implementation process that should be taken into account.
doi:10.1186/1741-7015-9-46
PMCID: PMC3103434  PMID: 21524315
2.  Users' perspectives of barriers and facilitators to implementing EHR in Canada: A study protocol 
Background
In Canada, federal, provincial, and territorial governments are developing an ambitious project to implement an interoperable electronic health record (EHR). Benefits for patients, healthcare professionals, organizations, and the public in general are expected. However, adoption of an interoperable EHR remains an important issue because many previous EHR projects have failed due to the lack of integration into practices and organizations. Furthermore, perceptions of the EHR vary between end-user groups, adding to the complexity of implementing this technology. Our aim is to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators influencing the adoption of an interoperable EHR among its various users and beneficiaries.
Methods
First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to the implementation of the EHR. Standardized literature search and data extraction methods will be used. Studies' quality and relevance to inform decisions on EHR implementation will be assessed. For each group of EHR users identified, barriers and facilitators will be categorized and compiled using narrative synthesis and meta-analytical techniques. The principal factors identified for each group of EHR users will then be validated for its applicability to various Canadian contexts through a two-round Delphi study, involving representatives from each end-user groups. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the implementation of EHR in the Canadian healthcare system.
Discussion
Given the imminence of an interoperable EHR in Canada, knowledge and evidence are urgently needed to prepare this major shift in our healthcare system and to oversee the factors that could affect its adoption and integration by all its potential users. This synthesis will be the first to systematically summarize the barriers and facilitators to EHR adoption perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. This comprehensive and rigorous strategy could be replicated in other settings.
doi:10.1186/1748-5908-4-20
PMCID: PMC2673204  PMID: 19358739
3.  A Comparison of Physician Pre-Adoption and Adoption Views on Electronic Health Records in Canadian Medical Practices 
Background
There is a major campaign involving large expenditures of public money to increase the adoption rate of electronic health record (EHR) systems in Canada. To maximize the chances of success in this effort, physician views on EHRs must be addressed, since user perceptions are key to successful implementation of technology innovations.
Objective
We propose a theoretical model comprising behavioral factors either favoring or against EHR adoption and use in Canadian medical practices, from the physicians’ point of view. EHR perceptions of physicians already using EHR systems are compared with those not using one, through the lens of this model.
Methods
We conducted an online cross-sectional survey in both English and French among medical practitioners across Canada. Data were collected both from physicians using EHRs and those not using EHRs, and analyzed with structural equation modeling (SEM) techniques.
Results
We collected 119 responses from EHR users and 100 from nonusers, resulting in 2 valid samples of 102 and 83 participants, respectively. The theoretical adoption model explained 55.8% of the variance in behavioral intention to continue using EHRs for physicians already using them, and 66.8% of the variance in nonuser intention to adopt such systems. Perception of ease of use was found to be the strongest motivator for EHR users (total effect .525), while perceptions of usefulness and of ease of use were the key determinants for nonusers (total effect .538 and .519, respectively) to adopt the system. Users see perceived overall risk associated with EHR adoption as a major obstacle (total effect –.371), while nonusers perceive risk only as a weak indirect demotivator. Of the 13 paths of the SEM model, 5 showed significant differences between the 2 samples (at the .05 level): general doubts about using the system (P = .02), the necessity for the system to be relevant for their job (P < .001), and the necessity for the system to be useful (P = .049) are more important for EHR nonusers than for users, while perceptions of overall obstacles to adoption (P = .03) and system ease of use (P = .042) count more for EHR users than for nonusers.
Conclusions
Relatively few differences in perceptions about EHR system adoption and use exist between physicians already using such systems and those not yet using the systems. To maximize the chances of success for new EHR implementations from a behavioral point of view, general doubts about the rationale for such systems must be mitigated through improving design, stressing how EHRs are relevant to physician jobs, and providing substantiating evidence that EHRs are easier to use and more effective than nonusers might expect.
doi:10.2196/jmir.1726
PMCID: PMC3222163  PMID: 21840835
Electronic health record; information technology; medical practice; Canada
4.  Multi-level analysis of electronic health record adoption by health care professionals: A study protocol 
Background
The electronic health record (EHR) is an important application of information and communication technologies to the healthcare sector. EHR implementation is expected to produce benefits for patients, professionals, organisations, and the population as a whole. These benefits cannot be achieved without the adoption of EHR by healthcare professionals. Nevertheless, the influence of individual and organisational factors in determining EHR adoption is still unclear. This study aims to assess the unique contribution of individual and organisational factors on EHR adoption in healthcare settings, as well as possible interrelations between these factors.
Methods
A prospective study will be conducted. A stratified random sampling method will be used to select 50 healthcare organisations in the Quebec City Health Region (Canada). At the individual level, a sample of 15 to 30 health professionals will be chosen within each organisation depending on its size. A semi-structured questionnaire will be administered to two key informants in each organisation to collect organisational data. A composite adoption score of EHR adoption will be developed based on a Delphi process and will be used as the outcome variable. Twelve to eighteen months after the first contact, depending on the pace of EHR implementation, key informants and clinicians will be contacted once again to monitor the evolution of EHR adoption. A multilevel regression model will be applied to identify the organisational and individual determinants of EHR adoption in clinical settings. Alternative analytical models would be applied if necessary.
Results
The study will assess the contribution of organisational and individual factors, as well as their interactions, to the implementation of EHR in clinical settings.
Conclusions
These results will be very relevant for decision makers and managers who are facing the challenge of implementing EHR in the healthcare system. In addition, this research constitutes a major contribution to the field of knowledge transfer and implementation science.
doi:10.1186/1748-5908-5-30
PMCID: PMC2873301  PMID: 20416054
5.  Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? 
Background
Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction.
Methods
Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction.
Results
30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001).
Conclusions
Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.
doi:10.1136/amiajnl-2011-000544
PMCID: PMC3384111  PMID: 22199017
Electronic medical records; medical errors; hospital information systems; unintended consequences; physician satisfaction; electronic health record; developing/using computerized provider order entry; knowledge representations; classical experimental and quasi-experimental study methods (lab and field); designing usable (responsive) resources and systems; statistical analysis of large datasets; health information technology; quality of care; electronic health records; veterans; primary care; patient safety; decision support; data exchange
6.  Factors associated with difficult electronic health record implementation in office practice 
Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.
doi:10.1136/amiajnl-2011-000689
PMCID: PMC3384124  PMID: 22249965
Data exchange; decision support; electronic health records; group practice; health information technology; implementation; ownership; patient safety; practice management; primary care; quality of care; veterans
7.  EHR Acceptance Factors in Ambulatory Care: A Survey of Physician Perceptions 
With the U.S. government calling for electronic health records (EHRs) for all Americans by the year 2014, adoption of an interoperable EHR is imminent in America's future. However, recent estimates for EHR implementation in the ambulatory care environment are just over 10 percent. This second part of a two-part study examines EHR acceptance factors in an academic-based healthcare system. Innovation diffusion theory and the Technology Acceptance Model provide a combined theoretical framework for this case study. An online questionnaire was administered to 802 faculty, fellow, and resident physicians to explore the factors affecting attitudes toward EHR adoption. In this study, age, years in practice, clinical specialty, health system relationship, and prior computer experience were not predictors of EHR acceptance. In order to facilitate successful adoption of health information systems, social and behavioral factors must be addressed during the EHR planning phase.
PMCID: PMC2805555  PMID: 20697466
electronic health records; barriers; user adoption; physicians; attitudes; technology acceptance; health information systems; ambulatory care; diffusion of innovations; perceptions
8.  Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting 
Journal of Oncology Practice  2011;7(4):233-237.
EHR/CPOE systems improve completeness of medical record and chemotherapy order documentation, as well as user satisfaction with the medical record system.
Purpose:
Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites.
Methods:
This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems.
Results:
The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system.
Conclusion:
Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety.
doi:10.1200/JOP.2011.000261
PMCID: PMC3140445  PMID: 22043187
9.  Enabling Cross-Platform Clinical Decision Support through Web-Based Decision Support in Commercial Electronic Health Record Systems: Proposal and Evaluation of Initial Prototype Implementations 
AMIA Annual Symposium Proceedings  2013;2013:1558-1567.
Enabling clinical decision support (CDS) across multiple electronic health record (EHR) systems has been a desired but largely unattained aim of clinical informatics, especially in commercial EHR systems. A potential opportunity for enabling such scalable CDS is to leverage vendor-supported, Web-based CDS development platforms along with vendor-supported application programming interfaces (APIs). Here, we propose a potential staged approach for enabling such scalable CDS, starting with the use of custom EHR APIs and moving towards standardized EHR APIs to facilitate interoperability. We analyzed three commercial EHR systems for their capabilities to support the proposed approach, and we implemented prototypes in all three systems. Based on these analyses and prototype implementations, we conclude that the approach proposed is feasible, already supported by several major commercial EHR vendors, and potentially capable of enabling cross-platform CDS at scale.
PMCID: PMC3900165  PMID: 24551426
10.  Physician Satisfaction Following Electronic Health Record Adoption in Three Massachusetts Communities 
Background
Despite mandates and incentives for electronic health record (EHR) adoption, little is known about factors predicting physicians’ satisfaction following EHR implementation.
Objective
To measure predictors of physician satisfaction following EHR adoption.
Methods
A total of 163 physicians completed a mailed survey before and after EHR implementation through a statewide pilot project in Massachusetts. Multivariable logistic regression identified predictors of physician satisfaction with their current practice situation in 2009 and generalized estimating equations accounted for clustering.
Results
The response rate was 77% in 2005 and 68% in 2009. In 2005, prior to EHR adoption, 28% of physicians were very satisfied with their current practice situation compared to 25% in 2009, following EHR adoption (P < .001). In multivariate analysis, physician satisfaction following EHR adoption was correlated with self-reported ease of EHR implementation (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16), resources for practice improvement (adjusted OR = 2.6, 95% CI 1.2 - 6.1), pre-intervention satisfaction (adjusted OR = 4.8, 95% CI 1.5 - 15), and stress (adjusted OR = 5.3, 95% CI 1.1 - 25). Male physicians reported lower satisfaction following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6).
Conclusions
Interventions to expand EHR use should consider additional support for practices with fewer resources for improvement and ensure ease of EHR implementation. EHR adoption may be a factor in alleviating physicians’ stress. Addressing physicians’ satisfaction prior to practice transformation and anticipating greater dissatisfaction among male physicians will be essential to retaining the physician workforce and ensuring the quality of care they deliver.
doi:10.2196/ijmr.2064
PMCID: PMC3626123  PMID: 23611987
electronic health record; physician satisfaction; implementation; Massachusetts eHealth collaborative
11.  Perceptions Regarding Electronic Health Record Implementation among Health Information Management Professionals in Alabama: A Statewide Survey and Analysis 
Moving from paper records to electronic health records (EHRs) has been a challenge for many Alabama hospitals. Implementation of this innovative technology will assist in providing better patient care by allowing for and providing more accurate and available patient information. The purposes of this study were to assess the status of implementation of EHRs among Alabama hospitals;the factors that are associated with EHR implementation; andthe benefits of, barriers to, and risks of EHR implementation.
A self-completed survey was mailed to 131 directors in the health information management (HIM) department of Alabama hospitals. Of 91 responding hospitals (69 percent response rate), only 12.0 percent have completed implementation of EHRs. The key factor driving electronic health record (EHR) implementation was to improve clinical processes or workflow efficiency. Lack of adequate funding and resources was the major barrier to EHR implementation. Rural hospitals were less likely to implement EHRs when compared with urban hospitals (p = .07). Adoption of EHRs should be evaluated in depth for hospitals, and particularly for rural hospitals. Ways to seek appropriate funding and provide adequate resources should be explored.
PMCID: PMC2394577  PMID: 18504505
Electronic health records; barriers; benefits; implementation; rural hospitals
12.  Is Canada ready for patient accessible electronic health records? A national scan 
Background
Access to personal health information through the electronic health record (EHR) is an innovative means to enable people to be active participants in their own health care. Currently this is not an available option for consumers of health. The absence of a key technology, the EHR, is a significant obstacle to providing patient accessible electronic records. To assess the readiness for the implementation and adoption of EHRs in Canada, a national scan was conducted to determine organizational readiness and willingness for patient accessible electronic records.
Methods
A survey was conducted of Chief Executive Officers (CEOs) of Canadian public and acute care hospitals.
Results
Two hundred thirteen emails were sent to CEOs of Canadian general and acute care hospitals, with a 39% response rate. Over half (54.2%) of hospitals had some sort of EHR, but few had a record that was predominately electronic. Financial resources were identified as the most important barrier to providing patients access to their EHR and there was a divergence in perceptions from healthcare providers and what they thought patients would want in terms of access to the EHR, with providers being less willing to provide access and patients desire for greater access to the full record.
Conclusion
As the use of EHRs becomes more commonplace, organizations should explore the possibility of responding to patient needs for clinical information by providing access to their EHR. The best way to achieve this is still being debated.
doi:10.1186/1472-6947-8-33
PMCID: PMC2532996  PMID: 18652695
13.  EHR Safety: The Way Forward to Safe and Effective Systems 
Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.
doi:10.1197/jamia.M2618
PMCID: PMC2409999  PMID: 18308981
14.  Predefined headings in a multiprofessional electronic health record system 
Background
Applying multiprofessional electronic health records (EHRs) is expected to improve the quality of patient care and patient safety. Both EHR systems and system users depend on semantic interoperability to function efficiently. A shared clinical terminology comprising unambiguous terms is required for semantic interoperability. Empirical studies of clinical terminology, such as predefined headings, in EHR systems are scarce and limited to one profession or one clinical specialty.
Objective
To study predefined headings applied by users in a Swedish multiprofessional EHR system.
Materials and methods
This was a descriptive study of predefined headings (n=3596) applied by 5509 users in a Swedish multiprofessional EHR system. The predefined headings were classified into four term and word categories.
Results
Less than half of the predefined headings were shared by two or more professional groups. All eight professionals groups shared 1.7% of the predefined headings. The distribution of predefined headings across categories yielded two-thirds “terms for special purposes” and “specialist terms” and one-third “common words” and “unclassified headings”.
Discussion
The indicated presence of profession-specific predefined headings and the conflict between ambiguity and comprehension of terms and words used as headings are discussed.
Conclusions
The predefined headings in the multiprofessional EHR system studied did not constitute a joint language for specific purposes. The improvement of the quality and usability of multiprofessional EHR systems requires attention.
doi:10.1136/amiajnl-2012-000855
PMCID: PMC3534463  PMID: 22744962
Medical records; health occupations; terminology; documentation; EHR; disability; ICF; early intervention
15.  An Analysis of Clinical Queries in an Electronic Health Record Search Utility 
Purpose
While search engines have become nearly ubiquitous on the Web, electronic health records (EHRs) generally lack search functionality; furthermore, there is no knowledge on how and what healthcare providers search while using an EHR-based search utility. In this study, we sought to understand user needs as captured by their search queries.
Methods
This post-implementation study analyzed user search log files for 6 months from an EHR-based, free-text search utility at our large academic institution. The search logs were de-identified and then analyzed in two steps. First, two investigators classified all the unique queries as navigational, transactional, or informational searches. Second, three physician reviewers categorized a random sample of 357 informational searches into high-level semantic types derived from the Unified Medical Language System (UMLS). The reviewers were given overlapping data sets, such that two physicians reviewed each query.
Results
We analyzed 2,207 queries performed by 436 unique users over a 6-month period. Of the 2,207 queries, 980 were unique queries. Users of the search utility included clinicians, researchers and administrative staff. Across the whole user population, approximately 14.5% of the user searches were navigational searches and 85.1% were informational. Within informational searches, we found that users predominantly searched for laboratory results and specific diseases.
Conclusions
A variety of user types, ranging from clinicians to administrative staff, took advantage of the EHR-based search utility. Though these users' search behavior differed, they predominantly performed informational searches related to laboratory results and specific diseases. Additionally, a number of queries were part of words, implying the need for a free-text module to be included in any future concept-based search algorithm.
doi:10.1016/j.ijmedinf.2010.03.004
PMCID: PMC2881186  PMID: 20418155
Information Storage and Retrieval; Medical Informatics; Medical Informatics Applications; Medical Records Systems; Computerized
16.  ICU nurses' acceptance of electronic health records 
Objective
To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.
Design
The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.
Measurements
Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.
Results
On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.
Conclusion
As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.
doi:10.1136/amiajnl-2010-000018
PMCID: PMC3197984  PMID: 21697291
Human factors; EHR; Geisinger
17.  Importance of Testing for Usability When Selecting and Implementing an Electronic Health or Medical Record System 
Journal of Oncology Practice  2010;6(3):120-124.
The role of usability testing in the evaluation of an electronic health record system could improve chances that the design is integrated with existing workflow and business processes in a clear, efficient way.
Purpose:
An oncology electronic health record (EHR) was implemented without prior usability testing. Before expanding the system to new clinics, this study was initiated to examine the role of usability testing in the evaluation of an EHR product and whether novice users could identify issues with usability that resonated with more experienced users of the system. In addition, our study evaluated whether usability issues with an already implemented system affect efficiency and satisfaction of users.
Methods:
A general usability guide was developed by a group of five informaticists. Using this guide, four novice users evaluated an EHR product and identified issues. A panel of five experts reviewed the identified issues to determine agreement with and applicability to the already implemented system. A survey of 42 experienced users of the previously implemented EHR was also performed to assess efficiency and general satisfaction.
Results:
The novice users identified 110 usability issues. Our expert panel agreed with 90% of the issues and recommendations for correction identified by the novice users. Our survey had a 54% response rate. The majority of the experienced users of the previously implemented system, which did not benefit from upfront usability testing, had a high degree of dissatisfaction with efficiency and general functionality but higher overall satisfaction than expected.
Conclusion:
In addition to reviewing features and content of an EHR system, usability testing could improve the chances that the EHR design is integrated with existing workflow and business processes in a clear and efficient way.
doi:10.1200/JOP.200017
PMCID: PMC2868635  PMID: 20808553
18.  Archetype Model-Driven Development Framework for EHR Web System 
Healthcare Informatics Research  2013;19(4):271-277.
Objectives
This article describes the Web application framework for Electronic Health Records (EHRs) we have developed to reduce construction costs for EHR sytems.
Methods
The openEHR project has developed clinical model driven architecture for future-proof interoperable EHR systems. This project provides the specifications to standardize clinical domain model implementations, upon which the ISO/CEN 13606 standards are based. The reference implementation has been formally described in Eiffel. Moreover C# and Java implementations have been developed as reference. While scripting languages had been more popular because of their higher efficiency and faster development in recent years, they had not been involved in the openEHR implementations. From 2007, we have used the Ruby language and Ruby on Rails (RoR) as an agile development platform to implement EHR systems, which is in conformity with the openEHR specifications.
Results
We implemented almost all of the specifications, the Archetype Definition Language parser, and RoR scaffold generator from archetype. Although some problems have emerged, most of them have been resolved.
Conclusions
We have provided an agile EHR Web framework, which can build up Web systems from archetype models using RoR. The feasibility of the archetype model to provide semantic interoperability of EHRs has been demonstrated and we have verified that that it is suitable for the construction of EHR systems.
doi:10.4258/hir.2013.19.4.271
PMCID: PMC3920039  PMID: 24523991
Electronic Health Records; Internet; Computing Methodologies; Automatic Data Processing
19.  Developing public health clinical decision support systems (CDSS) for the outpatient community in New York City: our experience 
BMC Public Health  2011;11:753.
Background
Developing a clinically relevant set of quality measures that can be effectively used by an electronic health record (EHR) is difficult. Whether it is achieving internal consensus on relevant priority quality measures, communicating to EHR vendors' whose programmers generally lack clinical contextual knowledge, or encouraging implementation of EHR that meaningfully impacts health outcomes, the path is challenging. However, greater transparency of population health, better accountability, and ultimately improved health outcomes is the goal and EHRs afford us a realistic chance of reaching it in a scalable way.
Method
In this article, we summarize our experience as a public health government agency with developing measures for a public health oriented EHR in New York City in partnership with a commercial EHR vendor.
Results
From our experience, there are six key lessons that we share in this article that we believe will dramatically increase the chance of success. First, define the scope and build consensus. Second, get support from executive leadership. Third, find an enthusiastic and competent software partner. Fourth, implement a transparent operational strategy. Fifth, create and test the EHR system with real life scenarios. Last, seek help when you need it.
Conclusions
Despite the challenges, we encourage public health agencies looking to build a similarly focused public health EHR to create one both for improved individual patient as well as the larger population health.
doi:10.1186/1471-2458-11-753
PMCID: PMC3198707  PMID: 21962009
20.  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.
doi:10.1136/amiajnl-2012-001377
PMCID: PMC3912724  PMID: 23698256
electronic health record use; physician perceptions of uncertainty; complexity science; uncertainty management; ambulatory care
21.  Predictors of Success for Electronic Health Record Implementation in Small Physician Practices 
Applied Clinical Informatics  2013;4(1):12-24.
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.
doi:10.4338/ACI-2012-09-RA-0033
PMCID: PMC3644811  PMID: 23650484
Electronic health records; ambulatory care/primary care; implementation and deployment; facilitators and barriers; quantitative methods; mixed methods
22.  Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors 
Background
Electronic health records (EHR) have the potential to improve patient care through efficient access to complete patient health information. This potential may not be reached because many of the most important determinants of health outcome are rarely included. Successful health promotion and disease prevention requires patient-reported data reflecting health behaviors and psychosocial issues. Furthermore, there is a need to harmonize this information across different EHR systems.
Methods
To fill this gap a three-phased process was used to conceptualize, identify and recommend patient-reported data elements on health behaviors and psychosocial factors for the EHR. Expert panels (n=13) identified candidate measures (phase 1) that were reviewed and rated by a wide range of health professionals (n=93) using the grid-enabled measures wiki social media platform (phase 2). Recommendations were finalized through a town hall meeting with key stakeholders including patients, providers, researchers, policy makers, and representatives from healthcare settings (phase 3).
Results
Nine key elements from three areas emerged as the initial critical patient-reported elements to incorporate systematically into EHR—health behaviors (eg, exercise), psychosocial issues (eg, distress), and patient-centered factors (eg, demographics). Recommendations were also made regarding the frequency of collection ranging from a single assessment (eg, demographic characteristics), to annual assessment (eg, health behaviors), or more frequent (eg, patient goals).
Conclusions
There was strong stakeholder support for this initiative reflecting the perceived value of incorporating patient-reported elements into EHR. The next steps will include testing the feasibility of incorporating these elements into the EHR across diverse primary care settings.
doi:10.1136/amiajnl-2011-000576
PMCID: PMC3384114  PMID: 22511015
Common data elements; electronic health record; health behavior; meaningful use; measurement; measures; patient-centered; patient report; patient reported outcomes; primary care; prevention
23.  Bridging Informatics and Implementation Science: Evaluating a Framework to Assess Electronic Health Record Implementations in Community Settings 
Effective electronic health record (EHR) implementations in community settings are critical to promoting safe and reliable EHR use as well as mitigating provider dissatisfaction that often results. The implementation challenge is compounded given the scale and scope of EHR installations that are occurring and will continue to occur over the next five years. However, when compared to EHR evaluations relatively few biomedical informatics researchers have published on evaluating EHR implementations. Fewer still have evaluated EHR implementations in community settings. We report on the methods we used to achieve a novel application of an implementation science framework in informatics to qualitatively evaluate community-based EHR implementations. We briefly provide an overview of the implementation science framework, our methods for adapting it to informatics, the effects the framework had on our qualitative methods of inquiry and analysis, and discuss its potential value for informatics research.
PMCID: PMC3540540  PMID: 23304351
24.  Facilitating Ambulatory Electronic Health Record System Implementation: Evidence from a Qualitative Study 
BioMed Research International  2013;2013:629574.
Background. Ambulatory care practices have increasing interest in leveraging the capabilities of electronic health record (EHR) systems, but little information is available documenting how organizations have successfully implemented these systems. Objective. To characterize elements of successful electronic health record (EHR) system implementation and to synthesize the key informants' perspectives about successful implementation practices. Methods. Key informant interviews and focus groups were conducted with a purposive sample of individuals from US healthcare organizations identified for their success with ambulatory EHR implementation. Rigorous qualitative data analyses used both deductive and inductive methods. Results. Participants identified personal and system-related barriers, at both the individual and organization levels, including poor computer skills, productivity losses, resistance to change, and EHR system failure. Implementation success was reportedly facilitated by careful planning and consistent communication throughout distinct stages of the implementation process. A significant element of successful implementation was an emphasis on optimization, both during “go-live” and, subsequently, when users had more experience with the system. Conclusion. Successful EHR implementation requires both detailed planning and clear mechanisms to deal with unforeseen or unintended consequences. Focusing on user buy-in early and including plans for optimization can facilitate greater success.
doi:10.1155/2013/629574
PMCID: PMC3817798  PMID: 24228257
25.  Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department 
Implementing electronic health records (EHR) in healthcare settings incurs challenges, none more important than maintaining efficiency and safety during rollout. This report quantifies the impact of offloading low-acuity visits to an alternative care site from the emergency department (ED) during EHR implementation. In addition, the report evaluated the effect of EHR implementation on overall patient length of stay (LOS), time to medical provider, and provider productivity during implementation of the EHR. Overall LOS and time to doctor increased during EHR implementation. On average, admitted patients' LOS was 6–20% longer. For discharged patients, LOS was 12–22% longer. Attempts to reduce patient volumes by diverting patients to another clinic were not effective in minimizing delays in care during this EHR implementation. Delays in ED throughput during EHR implementation are real and significant despite additional providers in the ED, and in this setting resolved by 3 months post-implementation.
doi:10.1136/amiajnl-2011-000462
PMCID: PMC3341791  PMID: 22052897
Electronic health record; implementation; pediatrics; provider efficiency

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