Electronic Health Records (EHR) can be understood as an electronic version of patient’s medical records that contains patients’ information such as demographics, medical history, vital signs, immunization, clinical findings, laboratory and radiology reports and other relevant medical information (Mantas,2002). This information can be exchanged between various providers improving the communication (Walker et al., 2005). Digitized data also gets rid of the paper work and manual entry of medical information for a more efficient and automated system (Poissant, 2005). Additionally, it provides an easy access to the medical records and helps in better diagnosis (Blobelet al., 2004). Medical decisions aided by EHR tend to be less error prone and therefore reduce the risks of preventable mortality and morbidity risk of medical errors (Menachemi & Collum, 2011). The automated data collection can also reduce manual errors in data entry coding or billing and therefore provides a cost advantage. This can have an overall beneficial role on the health care outcome (Jensen et al., 2012). EHR access by patients can also keep the patient updated about his/her health and treatment status. This can improve patient’s experience and general satisfaction.
Even though Electronic Health Records have their own benefits in implementation, however, certain problems are also posed by it (Miller & Sim, 2004; Gamble, 2003). Here we try to identify the range of professionals who can utilize EHR. The importance of electronic health records has been recently recognized for improving healthcare quality by aiding decisions, and improved collaboration whilst providing critical information to providers. This have also enabled an increased accuracy, and lowered the rate of medical errors (Bates et al., 1999). EHR can also improve management of diseases and preventative care (Bates et al., 2003; Mitchell & Sullivan, 2001). Moreover, the removal of paper charts system, can also improve the efficiency (Bates et al., 2003). Interestingly, in spite of the advantages provided by EHR, the acceptance for EHR is not that good (Miller, 2004; Leatt et al., 2006).
Studies have been done to assess the impact of EHR on the efficiency of health care service, but more studies need to be done to assess the effect on the patients and working staff (Mitchell& Sullivan, 2001). A shortage of literature reviewing individual experiences of healthcare professionals working with EHR was identified (Leatt et al., 2006).
Three studies were conducted to understand the procurement, implementation and utilization of information technology by healthcare professionals as well as the associated difficulties and opportunities also studied the perspectives, ideas and experiences of the healthcare professionals while integrating the new technology in their work. The studies were independently undertaken, expecting to identify some common elements in the results. The objective of this report is to identify and highlight these themes, and how that can enable a successful EHR implementation and usage.
Participants:
9 physicians, 4 Staff Members, and 2 Consultants participated in Study #1 at a Family Practice Research Unit. For study #2, in depth interview with 2 healthcare informatics professionals were conducted, and used a focus group having four members from operations and project management team. For study #3, interviews with 39 healthcare professionals, 13 family physicians, 9 nurses and 7 staff, all of whom were using only recently using EHR, were interviewed, to study their experiences and expectations.
Participants from study #1 were experiencing the initial phase of EHR adoption, while those of study #2, the implementation phase, while participants from study #3 have experienced the complete transition to EHR system. All the studies were approved by the concerned authorities and Ethics committee.
Data Collection:
The studies involved face to face interviews to gather information, while study #2 also involved a focus group. Verbatim from the interviews were recorded and transcribed. In study #1interviews were aimed to understand the experience in the acquisition implementation and usage of EHR by health care professionals. In study #2 interviews were pointed towards studying the difficulties and their solutions.in EHR implementation. In study #3 the questions are aimed to understand the experiences and feelings of the staff related to EHR.
Data analysis
For studies #1 and #3 the findings were reviewed by two investigators to identify key elements from the information. The results were then compared to develop an agreed-upon theory. This theory was then utilized for the interviews and further analysis. This is called the Framework Approach (Ritchie & Spencer, 2002). Iterative and interpretive analysis has been done on the three studies. Integrity of the data was maintained by rigorous audit of the transcripts, detailed notes and de-briefing rounds.
Timeline
The initial analysis is a part of Phase 1 of the implementation process, that is aimed to assess current situation, in order to find potential challenges and possible remedies for those challenges. The phase 2 and 3 can therefore include feedbacks and key findings from phase 1.
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Month 1 |
Month 2 |
Month 3 |
Month 4 |
Month 5 |
Month 6 |
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PHASE #1 |
Analysis (complete) |
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PHASE #2 |
Training (pending) |
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PHASE- #3 |
Implementation (pending) |
Table above shows the timeline for the 6 month project, divided into 2 phases (phase 1-analysis of current scenario, phase 2 using the findings of phase 1 to implement changes in training, and faze 3 for implementation, followed by monitoring of effects. The three studies conducted, and subsequent data analysis is a part of phase 1.
Findings:
Four key elements were found from the three studies: Expectations from the new system, the requirement of training and time for EHR implementation, leadership and trouble-shooter for EHR and willingness of providers to adopt this new technology.
In the three studies the participants shared their expectations in the implementation and usage of the new system. In study#1 participants mentioned the importance of identifying the expectations from the new system. The interviewees suggested that it is important to identify the needs and the possible utilization of the system. Participants from study #2 highlighted a disbalance between the expectations of the providers with the new system and the quantity of effort anticipated in the adoption of the new system. Therefore, it is important to evaluate the pros and cons of the transition.
It is understandable if new users are not aware of the advantages of EHR. An interviewee from study#2 showed a complete unawareness of how EHR will completely restructure the flow of work, showing the importance of awareness of other change. However, for some participants (from study#3) the outcomes have exceeded expectations and have provided results better than that which was initially estimated. With an understanding of such insight it becomes meaningful to study the expectations of the staff/providers of the new system before initiating the transition to the new system.
It was pointed out by another interviewee from the focus group that a significant difficulty ensued when the initial expectations of EHR were not clarified which lead to the staff incorrectly or inefficiently using the system during the transition process. This also caused erroneous entry of data and invalid execution. This was only remedied after extensive backpacking of the incorrect entries and fixing them only after considerable wastage of time. This highlights why the expectations should be highlighted from the initial stage.
Another interviewee from study #1 mentioned that sometimes there are confusions and an overestimation of problems due to the new system. That is, the anticipation of a problem becomes more acute than the problems themselves, which can also prevent acceptability for a change. A misunderstanding of the functionalities and the expectations of the system can cause such confusions, and is a completely preventable form of problem. An effective and detained communication outlining the actions required by the new system should be considered.
In study #2, the time requirement was a significant difficulty in the implementation process of the new system. The amount of time required to implement EHR can last for weeks, stiff further support and training will be required to get the staff adept with it. One of the respondents expressed a concern over the overwhelming time requirement faced by the doctors. Another interviewee from study #1 explained that working in healthcare does not allow them with the time needed learn and get used to the new system. A respondent from study #3 suggested that a phasing in of the new system can be a more efficient method than a complete replacement. It was pointed out that in their case, only the appointment scheduling and demographics of the patients were used for digitization, followed by digitized billing, and after six months, all the medical records were digitized. This showed a very much workable model for our implication process.
Experiences from interviewees of study #1 highlighted how crucially important time is in the implementation of the new system, and suggested the time requirement not to be underestimated, mentioning that time always take much longer than we initially think it should. That then leads to a crisis situation. Ergo, plenty of time should be used. Interviewees from study #2 pointed out that since the primary responsibility of the physicians is the care of the patient, therefore taking additional time to get familiar with the new system, and change their workflow implementing the system in their practice is a luxury most can’t afford. They added that a lot of restructuration stemmed from this constant demand of time to learn the new system, and the hectic schedule of a healthcare professional. This was a major obstacle faced by other interviewees too. Additionally, the constant switching between different screens for different categories of information was found to be very confusing for many interviewees of study #3.
Participants from study #2 shared a common experience about a special training they received assisted them to overcome the common challenges they were facing while using the new system. They had access to both telephonic and on-site training, depending upon the necessity of the user. Additionally, special training sessions would be held once a week to address the technical challenges faced by the users. However, several interviewees also showed concern about the new remote form of teaching, saying that it was often much harder to learn and understand if the individual providing instruction was located in some off-location call centre, and hence such training was practically useless. Added to such a complication, arranging on-site training isn’t much feasible either due to time constraints.
A participant from study #3 suggested a possible remedy for this time challenge in the learning of the new system, considering their already busy schedules. It was pointed that during the first few days, treating a lesser number of patients, can be an effective way in keeping the work pressure low enough to provide time for training. However, it would be even more helpful, if a hands-on training was provided during that time. This will reduce the technical errors, as well as reduce the stress of adapting to the new system.
Another participant from study #3 also mentioned that it was very difficult to simultaneously learn to use the EHR and provide care for the patients, apart from being very distracting. It was also pointed that a major obstacle was if any errors occurred while using the system, which can lead to failure to move to the next screens. In such scenarios, a considerable amount of time gets wasted studying the cause of the error, and then rectifying it. This can be frustrating for physicians who need to treat a large number of patients. Such scenarios can also result in the healthcare professionals completely ignoring the use of the systematic avoid the wastage of time.
Thus, a common theme was found, related to the time required to get adapted to the new system, and utilizing them in their work, and the training required to achieve their technical skills for operating the new system. This is a significant challenge in the implementation of the system. It can therefore be implicated that an effective measure would be to start early, hands on training on the system, slowly phasing the EHR one department at a time.
Several interviewees unanimously highlighted the need for an effective leadership for the implementation project, for a successful implementation of EHR system. Such a leadership will be able to address the challenges faced during the transition process, and find effective solutions for it. Interviewees from study #1 explained that allowing members of the staff to champion the new technology can help to boost acceptability by the other members, and ease the training and implementation process. Selecting one staff (nurse or doctor) that has interest in the new system can be an effective method, and prevents employees from getting frustrated.
A member from the focus group of study #2 however cautioned that just assigning champion for the new system does not necessarily ensure success of the implementation process. It was argued that each physician are champions in their own rights, albeit adhering to different processes, but champions nonetheless. Hence care must be taken while setting up expectations while assigning a champion or leadership for the system.
It is often seen that after the implementation of new technologies, few of the basic users would simultaneously upgrade their knowledge and expertise on the new system, enough to be able to troubleshoot their and other’s problems. Such an individual will be able to tackle the innumerable daily challenges faced by other users. Members from study #3 shared a common experience that is was easier and more convenient to approach a known person (the problem solver) if he/she is a familiar person and co-worker, instead of an outside trainer. Many interviewees (from study #3) acknowledged that they felt more hesitation to ask questions and clarifying doubts when the trainer was an outsider, instead it was much easier to “talk it out” with the friendly co-worker and problem solver.
Thus, an effective champion for the new system can be a leader who has experience in problem solving and managerial skills or can be a trouble-shooter, selected from within the staff, with a certain amount of technical and problem-solving skills in the new system. Such a champion will be able to promote upgradation of skills and efficiency of the others apart from helping the transition process.
The willingness of the providers to adapt to the new system is related to their basic knowledge of computers, with the healthcare professions with a decent knowledge about computers showing more interest in the system than professionals who do not have the basic knowledge. In all the three studies, the interviewees have various degrees of computer knowledge and expertise. Participants from study #1 pointed out that if the staff had a previous experience in working with computers and windows system, then their training and transition could have been easier. However, learning computers from scratch is daunting and complicated for many who never used a computer before. Such people faced more challenges getting used to the new system and learning how to operate the software. Therefore, the existing technical knowledge of the providers was a key factor in determining their willingness to learn the new system, and therefore the success of the implementation process. An interviewee from study #2 reflected that the amount of beginner level knowledge in computers dictates how efficiently and smoothly the transition and implementation process will occur, and therefore the speed of the implementation process.
An interviewee from study #3 mentioned the necessity of extra time that needs to be put aside for learning and using the new system, especially for individuals while the least exposure to working with computers. Time will allow getting familiarized with the computer and its various terminologies, and the usage can only become easier with repeated usage. Additionally, repeated usage will also help to overcome a certain amount of technological “phobia” that is seen among individuals who rarely uses computers or technology.
It can therefore be inferred that an assessment of basic computer knowledge as an important aspect of the implementation process. This will allow to understand how much perceptible the staff will be for the change, and possibilities of challenges during training. It can also help to identify individuals who needs the most attention and help in the training process, and those who can be considered as champions to trouble-shooters for the project, apart from helping to assess their competencies to adapt to the new system.
An interviewee from study #2 also added that their problem solver was able to come up with new ways of involving the other staff in training each other, thereby helping them to increase their technical consistency, while a remark from an interviewee from study #1 showed that an effective leader can also perform as a trainer, and motivate the team to adapt to the new system, setting examples to follow, and recognizing key achievements in the process.
A member from the focus group mentioned that for a first-time computer user, who used to do all the previous work based on paper, just getting started on the application was difficult enough. And when added with dealing with a patient, simultaneously while adding the information in the system, in the correct order, did not make the job any easier.
Several difficulties are experienced by healthcare providers during the implementation of EHR in their professional practice. Many of these difficulties can be averted by assessing the factors that can promote and challenge the implementation process for EHR. Understanding such factors can help in the preparedness to possible complications in the ensue of the change. The three studies showed four important points that needs consideration:
Prior expectations on the new system was shown as a common theme in all the studies, showing a common challenge in the implementation of the new system, and supports the findings of previous studies. Similarly, the time needed to train the staff on the new system, and implementation adds to the list of challenges in implementation (Sruder, 2005). Training is a vital step of the implementation process, that will enable the staff to acquire knowledge and skill set to adapt to the new system. However, it must be noted that a uniform training module might not befit everyone, and hence should not be used. Instead a more hands on approach, based on individual competencies and existing basic computer operating skills can applied.
Even though previous studies have commonly shown that champions and trouble-shooters in information technology to play vital role in the overall efficiency of the operations, in our studies, the response towards the same subject was more nuanced (Leatt et al.,2006; Miller, Sim & Newman, 2007). It was explained that while certain physicians were acting as leaders, during the implementation of the new systems, it was the members from family practice team who stepped up for the change. Hence it shows that it is not necessary to select a champion from a pool of leaders, and instead keeping the option open for other staffs. Also considering that fact that leaders in healthcare profile are often very busy, and they can use the help of a trouble-shooter, such an individual ought to be selected from the general staff.
There are mixed opinions about the necessity of an initial analysis of basic computer knowledge of the staff (Aaronson et al., 2001; Dansky et al., 1999). Our studies were contrasted by a study on family medicine residents, that showed that the perceived satisfaction with the new system is not correlated with prior knowledge on computer (as evidenced by our studies) (Aaronson et al., 2001). Again, on the contrary, studies done in an American Ambulatory Service care setup showed a positive correlation between a prior knowledge in basic computer operations and the perception of the new system as well as with the willingness to adapt to the new system (Dansky et al.,1999). This supported our analysis that a basic knowledge on computers facilitates the willingness to adapt to the new system.
One of the primary limitation of the study was that all the results analysed in the paper are based upon interviews on a relatively small number of individuals involving healthcare providers and staff (N=42). The other limitation was time, since the study had to be conducted within a feasible amount of time, in order to facilitate the future transition process, the three studies were conducted within the set timeframe. A shortage of time also prevented the selection of more individuals or to analyse the data based on more researches. However, setting the limitations aside, we were able to examine the transition process during the implementation of EHR based on interviews, and identify some common themes that can act as important markers in our implementation project.
Conclusion:
Several studies exist that analyses the different challenges in the implementation of EHR, as well as factors that favour implementation. A limited study allows to analyse the role or organizational policies, broadly in the success of implementation projects for information technology, and specifically to analyse the personal experiences of individuals working with EHR. This study throws light upon several factors that can help the implementation of Electronic Health Record in a healthcare organization, and the possible challenges that might be faced during or after the transition. It also highlights a scope for further research on this transition process across other healthcare setups, so see if similar patterns of themes are emergent.
The following considerations must be kept in mind my any healthcare organization planning to implement EHR: expectations from the new system and the prerequisites of using the new system, willingness of the staff and providers in the adoption of the new system, an effective leader or champion or trouble-shooter, the basic computer knowledge and previous experience of the staff. Future research can also be done to understand further how such aspects play a role in the implementation process and figure effective solutions to those problems.
It should also be noted that an effective transition can occur by phasing in the new system starting with only a part of the patient data (dealt by a specific department) being digitized followed by gradual training and digitization of other departments transitioning into a complete digitization.
References:
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