Electronic Health Record Adoption: Perceived Barriers and Facilitators

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1 Electronic Health Record Adoption: Perceived Barriers and Facilitators A Literature Review April 2010

2 Centre for Military and Veterans Health University of Queensland Node Electronic Health Record Adoption: Perceived Barriers and Facilitators A Literature Review April 2010 Cristina Cotea, Research Coordination Unit, CMVH Centre for Military and Veterans Health 2010 Centre for Military and Veterans' Health The University of Queensland Mayne Medical School Herston Road, Herston QLD 4006 Phone Fax

3 EHR Adoption: Perceived Barriers and Facilitators 1 Table of Contents 2 Abbreviations Executive Summary Introduction Methods Results Perceived Barriers to EHR Adoption Personal Barriers Organisational Barriers Perceived Facilitators of EHR Adoption EHR Adoption Predictors Attitudes towards EHRs by Stakeholder Type Primary Care Physicians Multispecialty Physicians Nurses Patients Other Stakeholders Addressing Barriers: Recommendations from the Literature Appendix A: Summary of Included Studies References

4 EHR Adoption: Perceived Barriers and Facilitators 2 Abbreviations CPOE EHR EPR GP HIT HP IT Computerised Provider Order Entry Electronic Health Record Electronic Personal Record General Practitioner Health Information Technology Health Practitioner Information Technology 4

5 EHR Adoption: Perceived Barriers and Facilitators 3 Executive Summary The Centre for Military and Veterans Health has conducted a literature review to identify the current knowledge related to perceived barriers and facilitators to the adoption of electronic health records (EHRs). While EHRs promise to improve healthcare delivery, efficiency, quality and safety, these improvements will occur only if health practitioners have access to the key functions they expect, and use them regularly. To guarantee the success of an EHR system implementation, it is therefore essential to have a good understanding of the factors that contribute to stakeholders adoption of EHRs. This report presents an overview of these factors as perceived by the stakeholders involved in EHR implementations, from an international perspective, in various clinical settings. While not all findings can be generalisable to the Australian context, they can be used as an inventory of commonly reported factors affecting EHR adoption to be considered when exploring change management strategies designed to increase EHR adoption. KEY FINDINGS A total of 51 studies measuring perceptions of factors affecting EHR adoption were included in the review. Of these, 43 studies focused on health practitioners and other healthcare staff perceptions 1-43, while the other 7 focused on patients perceptions The majority of studies (82%) were conducted in the US, while the remaining studies were from Australia, Austria, Canada, Hong Kong, New Zealand, Sweden and the UK. This suggests that some findings presented in this report could be specific to the US healthcare context, that doesn t rely extensively on general practitioners (GPs) to deliver a broad range of services, as opposed to the other countries. The US context also differs from other countries in the way primary care doctors are paid and in the fact that a high percentage of the population is uninsured. In spite of these differences, the findings suggest that most of the common themes reported in the US studies were present in studies from other countries. The common themes for factors affecting EHR adoption have been summarised below. They include nine personal perceived barriers to EHR adoption, five organisational barriers, seven perceived facilitators and ten EHR adoption predictors. Perceived Personal Barriers to EHR Adoption 1. Disruption of clinical workflow; 2. Lack of understanding of benefits; 3. Confidentiality, privacy and security issues; 4. Usability and flexibility issues; 5. Lack of time for training and re-designing workflows; 6. Lack of computers skills; 7. Negative impact on interactions between health practitioners and patients; 8. Patient resistance; 9. De-skilling. 5

6 EHR Adoption: Perceived Barriers and Facilitators Perceived Organisational Barriers to EHR Adoption 1. Financial costs; 2. Lack of adequate IT resources; 3. Implementation complications; 4. Software design and testing issues; 5. Lack of standardisation and interoperability. Perceived Facilitators to EHR Adoption 1. Motivation and incentives of the users; 2. Conservation of physician time; 3. Complementary changes in clinical workflow; 4. Facilitated selection of suitable EHR system; 5. Demonstrated utility of EHRs; 6. Adequate IT resources; 7. Reassurance regarding confidentiality and security issues. EHR Adoption Predictors 1. Practice size and type; 2. Understanding of benefits; 3. Technology readiness; 4. Physician specialty; 5. Age; 6. Experience; 7. Practice location; 8. Patient / provider ratio; 9. Financial resources; 10. Cooperative organisational culture. Attitudes towards EHRs were also summarised by stakeholder type: primary care physicians, multispecialty physicians, nurses, patients and other stakeholders. This presentation of the findings may be useful for devising EHR adoption strategies tailored to the needs of each stakeholder. The following concerns were found to be common among each stakeholder group: Physicians in Primary Care Disruption of clinical workflow resulting in loss of productivity; Usability and flexibility issues; Negative impact on interactions between HPs and patients; Physicians of all Specialties Financial costs associated with EHR implementation and maintenance; Technical organisational issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Disruption of workflow resulting in loss of productivity. 6

7 EHR Adoption: Perceived Barriers and Facilitators Nurses Lack of adequate IT resources such as computers, training, technical support; Lack of technical skills and time available for training; Disruption of clinical workflow resulting in decreased time spent with patients. Patients Privacy and data security issues; Unauthorised sharing of their personal health information stored in their EHR; Inability to access and control access to their EHR; Other Stakeholders involved in EHR Implementation Financial costs associated with EHR implementation; Technical issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Physician resistance. A summary of recommendations from the literature for addressing the perceived barriers has also been included at the end of this report. These recommendations were grouped under four themes: Strong leadership, that results from: (i) the presence of an EHR champion, Senior user or problem solver at each practice that has received extensive technical training and has acquired a deep understanding of the benefits associated with EHR implementation; and (ii) the use of different styles of leadership depending on the EHR implementation stage. Strong project management techniques, to ensure that: (i) the EHR vision is shared and understood by all and clinical input is included in the IT planning process; (ii) adequate support is available to reduce perceived barriers such as redesigning the clinical workflow to accommodate the EHR system; and (iii) EHR adoption strategies are tailored to the needs of each stakeholder type. Personalised, effective training and education, to ensure that: (i) all clinicians have a good understanding of the benefits to be realised by adopting EHRs, regardless of their respective roles in the clinical practice; (ii) adequate training is offered to users based on their needs; (iii) training is delivered without affecting clinicians productivity levels; and (iv) extensive, responsive technical support is available during early stages of implementation. Establishment of standards, that will reduce issues related to lack of standardisation and interoperability. In summary, the literature findings suggest that EHR adoption is affected by a combination of barriers, facilitators and adoption predictors. Hence, change management strategies and interventions designed to increase EHR adoption need to follow a holistic approach, addressing the multitude of personal and organisational factors applicable to the specific stakeholder type and healthcare setting. 7

8 EHR Adoption: Perceived Barriers and Facilitators 4 Introduction Electronic health records promise to improve healthcare delivery, efficiency, quality and safety. However, these improvements will occur only if health practitioners have access to the key functions they expect, and use them regularly. To guarantee the success of an EHR system implementation, it is therefore essential to have a good understanding of the factors that contribute to stakeholders adoption of EHRs. The purpose of this literature review was to: (i) identify the current knowledge related to attitudes towards electronic health records from different stakeholder perspectives, with a focus on the Australian context; and (ii) identify recommendations from the literature on successful change management strategies that could be implemented through the EHR design and implementation stages to increase adoption of the system. The research question for this literature review was: What are the perceived barriers and facilitators to electronic health record adoption? 5 Methods A comprehensive literature review of peer reviewed literature was undertaken to identify the current state of knowledge related to factors affecting EHR adoption, as perceived by the different groups of stakeholders involved in EHR system implementations. The bibliographic database Ovid Medline was searched in January 2010 articles published since 2000 using a combination of the MeSH terms Medical Records Systems, Computerized, attitude, attitude of health personnel, attitude to computers, and the keywords electronic health record, accept*, adopt*, attitud*, perception*. The resulting 97 articles were limited to the English language and studies on humans, yielding 91 articles. An additional 58 articles were retrieved following a Google Scholar search and a review of references from the included Medline articles. Inclusion Criteria Each title and abstract was reviewed and designated for inclusion, exclusion or further examination. Inclusion was based on the following criteria: The study reported attitudes towards EHRs from stakeholders involved in EHR implementation and use, focused on perceived barriers or facilitators to EHR adoption based on self-report data, or adoption predictors were inferred from self-report data; The study reported other attitudes towards patient-accessible EHRs (including perceived benefits of EHRs or satisfaction levels); The article reported final results of studies that measured attitudes towards EHRs (e.g. original research or review of several studies); Systematic reviews and comprehensive literature reviews were included. 8

9 EHR Adoption: Perceived Barriers and Facilitators Exclusion Criteria Research articles were excluded if they: Did not report perceived barriers, facilitators or adoption predictors of EHRs or other attitudes towards patient-accessible EHRs. Reported preliminary results of studies related to attitudes towards EHRs (e.g. conference proceedings, poster); Provided anecdotal information (i.e. not measured); Were duplicates. A total of 51 studies measuring attitudes towards EHRs were included in this literature review. Of these, 43 studies reported on health practitioner or healthcare staff attitudes towards EHRs 1-43, while the other 7 reported on patient attitudes towards EHRs In addition, two relevant systematic reviews were identified: one was focused on EHR adoption in the US, and the other was focused on lessons learned from EHR implementation experiences in 52, 53 seven countries. While these reviews did not focus on the perceptions of stakeholders involved in EHR implementations, they were useful for guiding the direction of the recommendations provided at the end of this report. The 51 studies identified were further categorised from several perspectives to gain insight into the review: Healthcare setting (community physician offices, hospitals, mixed); Study subjects (primary care physicians, specialists, nurses, patients, other stakeholders involved in EHR implementation and use); Country (Australia, Austria, Canada, Hong Kong, New Zealand, Sweden, UK, US); Study method (survey, questionnaire, interview, focus group, observations; study conducted pre- or/and post-implementation); Measurements (perceived barriers, perceived facilitators, adoption predictors, other attitudes). A summary of these studies by category is included in Table 1 on the next page, and a structured summary of each study has been included in Appendix A. 9

10 EHR Adoption: Perceived Barriers and Facilitators Table 1: Summary of Papers included in the Literature Review Articles reviewed (title and abstract) 146 Included after review: studies measuring attitudes towards EHRs 51 Health practitioners (and other healthcare staff) By healthcare setting: 1, 4, 14, 20, 22-26, 30, 40 Community Physician Offices Study Subjects: 1, 4, 14, 20, 22-26, 30, 40 Primary care physicians - Medical students 30 4, 31 Primary care nurses Other stakeholders: Managers / administrators / senior clinicians Administrative staff 40 Country: UK 4 1, 14, 20, 22-26, 30, US Method: Interview 4, 25, 26 1, 14, 20, 22-24, Survey Measurements: Predictors 1, 14, 20, , 14, 25, 26, 30, Barriers, 25, Facilitators 26 14, 30, Other attitudes Implementation stage: pre- and post- 1, 14 4, 25, 26, 30, post- 7, 10, 12, 21, 27, 38, 42 Hospitals Study Subjects: 7, 10, 27 Physicians 10, 27 - Residents 7, 16 Nurses Pharmacists 7 Other stakeholders: Managers / administrators / senior clinicians Country: Australia 7, Canada 38 10, 12, 16, 21, 27, 42, US Method: Focus groups 7, Interviews 7, 42 10, 16, 21, 27, 38, Survey Measurements: Predictors 12, 21 7, 10, 12, 16, 38, 42, Barriers, 10, Facilitators 12 10, 16, 27, 42, Other attitudes Implementation stage: pre- and post- 10, 12, 42, pre- 7, 38 16, 27, post- 4, 25, 26 7, 12, 21, 38, 42 3, 5, 6, 8, 9, 11, 13, 15, 17-19, 28, 29, 31-37, 39, 41 Mixed (Community offices and hospitals) Study Subjects: 15, 18, 19, 29, 31, 33, 37, 39 Primary care physicians 3, 5, 6, 8, 9, 11, 13, 15, 17, 31, Mixed physicians (primary care and specialists) - Emergency physicians 3 - Residents 31 3, 31, 33, 37 Nurses Other stakeholders: Managers / administrators / senior clinicians / project 28, 32, 37, 41 management team / technical staff Administrative staff 37 Country: Austria 8, Canada 37, Hong Kong 17, New Zealand 15, Sweden 9, 3, 5, 6, 11, 13, 18, 19, 28, 29, 31-36, 39, 41 US Method: Focus groups 41, Interviews 6, 8, 28, 32, Observation 31, Site Visits 5, 3, 5, 6, 9, 11, 13, 15, 17-19, 29, 33, 39 Survey Measurements: Predictors 3, 5, 6, 13, 17, , 6, 8, 11, 13, 15, 17-19, 28, 29, 31-36, 39, 41, Barriers, 5, 17, 31, Facilitators , 11, Other attitudes 6, 11, 13, 19, 28, 29, 32, 34-36, 39 Implementation stage: pre- and post, 3, 5, 9, 15, 18, 31, 33, 37, post- 41, pre Patients Country: Australia 50, Canada 44, 46, New Zealand 49, 51, UK 47, US 45, 48,

11 EHR Adoption: Perceived Barriers and Facilitators 6 Results A review of the literature has identified several common themes for factors affecting EHR adoption, as perceived by stakeholders. They include several perceived barriers to EHR adoption at the personal and organisational level, perceived facilitators and EHR adoption predictors. A summary of attitudes towards EHRs by stakeholder type (primary care physicians, multispecialty physicians, nurses, patients and other stakeholders) was also included to provide an overview of the main concerns among these different groups. 6.1 Perceived Barriers to EHR Adoption Common themes surrounding personal and organisational barriers to EHR adoption were reported in the literature, from studies measuring stakeholders perceptions. The resistance to change or EHR adoption by stakeholders can be attributed to these perceived negative effects of EHRs at the personal and organisational levels Personal Barriers Personal barriers to EHR adoption are related to professional and psychosocial factors that influence attitudes towards EHRs, primarily of those stakeholders that are using the EHR system. Nine key personal barriers to EHR adoption emerged as persistent themes from the literature review: (1) Disruption of Clinical Workflow. Health practitioners may be reluctant to adopt the EHR system if they believe that it will interfere with their workflow, productivity and efficiency, and take time away from patient care. Some HPs even reported concerns that this disruption of clinical workflow could lead to dissatisfaction with practice situation, 6-8, 10, 11, 14, 17, 18, 22, 25, 28, 31-34, 37, 39, 42 and decreased revenues. (2) Lack of Understanding of Benefits. Difficulty perceiving usefulness of EHRs such as improvement in quality of care can lead to HP resistance to change. Some HPs reported uncertainty about return on investment, and concerns over the introduction of clinical 5, 8, 10, 12-14, 17, 19, 21, 25, 31, 32, 39 errors. (3) Confidentiality, Privacy and Security Issues. Some stakeholders are concerned about unauthorised access to patient data due to hackers or identity theft and corruption or 7, 8, 10, 14, 21, 22, 35, 39, 42 alteration of the data. (4) Usability and Flexibility Issues. Most HPs are concerned that the EHR system could be too difficult to use or it could lead to redundant data entry. For example, data entry and coding can be too difficult in the fast pace of a primary care practice and free text could be preferred in certain cases. Other concerns were reported regarding the lack of flexibility of EHR due to inapplicability of certain features or unavailability of appropriate 4, 8, 15, 18-20, 22, 25, 31 options. (5) Lack of Time. Some HPs believe they lack the time required to acquire knowledge about 7, 11, 17, 22, 31, 33, 37, 42 systems through training and redesign clinical workflows. (6) Lack of Computer Skills. Some HPs feel that their inability to type quickly enough and 6, 7, 14, 18, 22, 35, 42 general lack of comfort with IT could act as a barrier to EHR adoption. 11

12 EHR Adoption: Perceived Barriers and Facilitators (7) Negative Impact on Interactions between Health Practitioners and Patients. Concerns have been expressed around the negative impact of EHRs on HPs interaction with patients and other HPs. Some HPs are concerned that EHRs will create a shift in the physician-patient relationship which will result in a loss of HP control and a shift in work 7, 8, 14, responsibilities which will result in HPs becoming an expensive order entry clerk. 18, 30, 31, 33 (8) Patient Resistance. HPs are concerned that patients will be opposed to their use of the EHR. Some HPs have also expressed concerns about EHRs affecting their communication with patients such as loss of eye contact, which is against the social norm for physicians to avoid using the computer while with the patient. 22 (9) De-skilling. Some HPs were concerned of becoming dependent on the EHR system. Nurses thought that the EHR could limit their critical thinking and charting accuracy if they relied too heavily on the system. More experienced HPs feel that this could cause a serious concern for younger HPs that could become reliant on the decision support 7, 16 available within the EHR Organisational Barriers Organisational barriers to EHR adoption are related to financial and technical factors affecting attitudes towards EHRs, primarily of those stakeholders involved in implementing EHR systems. Five key organisational barriers to EHR adoption emerged as important themes in the literature: (1) Financial Costs. The most common organisational concern reported was around financial costs associated with all stages of the EHR implementation such as planning, consulting services, start-up, purchasing of hardware and software, and ongoing costs for training and 5-8, 11-14, 17, 19-22, 25, 28, 35, 39, 54 maintenance. (2) Lack of Adequate IT resources. Concerns have been reported regarding the availability of 6, 7, 10-13, 17, 33, 35, 42 workstations, printers, internet connections, training and technical support. (3) Implementation Complications. There is a concern that the organisation will be unable to select an EHR system that meets the needs of HPs due to an overwhelming number of EHR vendors, most of them transient or volatile. Concerns were also reported surrounding conflicting priorities between the organisation as a whole and individual clinicians during the selection process of the EHR system and differences over software development priorities. 5-8, 14, 22, 25, 32, 33, 35, 38 (4) Software Design and Testing issues. Concerns were reported regarding the technical limitations of computers such as slow systems, system downtime and software design problems not indentified during early testing. Another concern from HPs was around system designers misunderstanding of clinical processes resulting in usability and flexibility issues. Clinicians working on template design felt that not have access to a working prototype had a 7, 10, 14, 16, 18, 33 negative impact the EHR system design. (5) Lack of Standardisation and Interoperability. The challenges associated with using these non-interoperable EHR systems such as inadequate electronic data exchange may negatively impact workflow and productivity, which in turn contribute to clinicians resistance to adopt 5, 12-14, 25, 28, 35, 39 these systems. 12

13 EHR Adoption: Perceived Barriers and Facilitators 6.2 Perceived Facilitators of EHR Adoption Facilitators are initiatives or actions from healthcare organisations or governments related to EHR system implementation that could lead to increased adoption of EHRs. Several key perceived facilitators have been reported in the literature: (1) Motivation and Incentives of the Users. Health practitioners believe that financial incentives for EHR implementation and quality performance have the potential to influence EHR 5, 12, 17 adoption. (2) Conservation of Physician Time. HPs believe that healthcare organisations implementing EHRs need to address workstation availability and system speed issues and minimise time required by HPs to document care. For example, it was suggested that in the case of clinical decision support features such as reminders, limiting the number of reminders following review by a committee can facilitate their effective use and eliminate reminder burden. Another example is the strategic placement of the computer workstations to facilitate the effective use of clinical reminders and patient-physician communication during patient 10, 31 visits. (3) Complementary Changes in Clinical Workflow. HPs suggest that healthcare organisations must take steps to ensure that they understand physician workflow and build EHR systems that facilitate this workflow. Examples of complementary changes in clinical workflow include entering data from patient paper charts into the EHR, creating customised templates for the record, creating documentation shortcuts, obtaining adequate technical support and consultation, reorganising workflow in the examination room and in the practice to accommodate EHRs and integration of clinical reminders in the workflow. In addition, programs and interventions intended to increase adoption should help HPs modify their 31, 40 workflow to accommodate EHRs and to get the most out of the system. (4) Facilitated Selection of Suitable EHR System. The availability of certified products that guarantee a minimum level of EHR functionality is believed to contribute to increased adoption of EHRs. Other suggestions include educational programs to inform HPs about the EHR system selection process and provide them with a list of standardised questions to ask EHR vendors. HPs also believe that the EHR system selection should be participatory, involving local leaders and clinicians, to allow staff to provide input into the decision and feel that their input has been noted. Finally, extensive software testing is required to avoid users frustration with software problems which can quickly escalate to the entire EHR system and 12, 40 result in resistance to implementation. (5) Demonstrated Utility of EHRs. HPs need to be presented with evidence of the utility of EHRs to HPs. A targeted, educational effort to show the advantages of EHRs that includes demonstrations of a system prototype may be useful for improving acceptance of the system. Evidence-based protocols and data collected post-implementation could document the utility of EHRs. 17 (6) Adequate IT Resources. Technical support provided during implementation and a problem reporting system that allows HPs to document problems and receive prompt feedback are believed to increase EHR adoption. Other IT facilitators include flat-screen monitors on mobile arms, convenient availability of computers at numerous locations in the medical 12, 31, 40 office, in the hospital and at the homes of on-call physicians. (7) Reassurance Regarding Confidentiality and Security Issues. HPs believe that healthcare organisations need to pay more attention to confidentiality and security issues in order to convince HPs that these issues have been addressed. Another suggestion consists of protecting practitioners from personal liability for record tampering by external parties. 5 13

14 EHR Adoption: Perceived Barriers and Facilitators 6.3 EHR Adoption Predictors Most of the studies also reported EHR adoption levels in the clinical settings studied. The following list includes key factors that were associated with a higher level of EHR adoption with health practitioners: (1) Practice Size and Type. HPs practising in larger groups, being based at hospitals or medical centres seem to be driving EHR adoption. It was suggested that this reflects the greater availability of the financial resources required to acquire an EHR system at these sites. Physicians located in areas with higher physician concentration and more competition were 1, 5, 6, 12-14, 17, 19, 28, 29, 34, 35, 52 found to be more likely to adopt EHRs. (2) Understanding of Benefits. HPs that had a good understanding of the quality of care improvements resulting from EHR use or those involved in IT planning were more likely to be high users of EHRs. Organisational engagement in quality improvement is also a predictor of 3, 13, 17, 21, EHR adoption. (3) Technology Readiness. Positive attitudes about the influence of computers on health care and experience with existing system positively influences EHR adoption. Those HPs who are already using online scheduling and billing systems show less resistance to technologyrelated changes. Placement of strategic importance on IT by the organisation was likely to 1, 3, 13, 21, 22, 34 result in higher EHR adoption. (4) Physician Specialty. The higher the level of technology dependency in a specialty, the more likely HPs will be comfortable accepting technology related changes in their workplace. Some studies have reported that primary care physicians were less likely to adopt EHRs compared to specialists. In addition, general paediatricians were significantly slower to incorporate EHRs into their office practice than other physicians, while imminent adopters were more likely to be practising family medicine or obstetrics/gynaecology. This could also be explained by the observed marked differences in attitudes towards EHRs between GPs 15, 20, 22, and specialists. (5) Age. Younger HPs are generally more likely to adopt EHRs. However, a study reported that 1, they are less likely to become high users of EHRs once adopted. (6) Experience. Studies have shown that residents and recent graduates have more positive attitudes towards EHRs and practices that teach medical students or residents were more 10, 30, 35 likely to have an EHR. (7) Practice Location. HPs practising in urban setting were more likely to adopt EHRs, suggesting that the introduction of EHRs is likely to widen the digital divide between rural and urban HPs. 23 (8) Patient / Provider Ratio. HPs seeing fewer patients were more likely to have adopted EHRs, suggesting that HPs working in busy offices or hospitals may be more resistant to EHR implementation. (9) Financial Resources. HPs with an increased number of patients on Medicare were significantly more likely to adopt EHRs than those with low volume of Medicare patient panels. Different financial considerations exist in HP s private office or in a governmentfunded hospital. Initial and ongoing maintenance cost is a big issue that physicians do not have to deal with if they are working in a hospital. 14

15 EHR Adoption: Perceived Barriers and Facilitators (10) Cooperative Organisational Culture. A cooperative culture within the HP practice can minimise active resistance to EHRs. However, it can also inhibit criticism before and during implementation, thus depriving decision makers of important feedback. 32 An understanding of the impact of the above predictors on EHR adoption may assist healthcare organisations as they work to increase EHR adoption rates. 6.4 Attitudes towards EHRs by Stakeholder Type This section summarises the literature findings for each group of stakeholders involved in EHR implementation and use, such as primary care physicians, multispecialty physicians, nurses and patients. A comparison of specific attitudes towards EHRs reported for each stakeholder group provides a more robust estimate of the barriers to EHR adoption and could be useful in devising strategies tailored to these groups based on their perceived barriers and needs Primary Care Physicians 1, 4, 14, 15, 18 studies of primary care physicians attitudes towards EHRs were reported in the literature 18-20, 22-26, 29-31, 33, 37, 39, 40 1, 4, 14, 20,. Nine of these studies were conducted in community physician offices 22-26, 30, 40, while the other eight were conducted in a mixed healthcare setting consisting of both community offices and hospitals 15, 18, 19, 29, 31, 33, 37, 39. One of these 18 studies examined medical students attitudes towards EHRs. 30 KEY FINDINGS Major concerns among primary care physicians: Disruption of clinical workflow resulting in loss of productivity; Usability and flexibility issues; Negative impact on interactions between HPs and patients EHR Adopters vs. Non-adopters Studies comparing attitudes among EHR adopters and non-adopters in primary care suggest that the two groups perceive EHRs differently. This information can be useful for determining the most important barriers to EHR adoption, as perceived by non-adopters. A US study compared perceived barriers among general paediatricians with and without an EHR in their practice. 14 The perceived barriers common among both groups included the cost of implementing and maintaining the EHRs, increased physician workload and physician resistance. Those without an EHR mentioned other barriers such as being unable to select an EHR system that meets their paediatric-specific requirements, concerns regarding system downtime and a lack of understanding of benefits resulting from EHR implementation. Perceived benefits of EHRs included improved practice operation, long-term savings and improved quality of care. An interesting finding 15

16 EHR Adoption: Perceived Barriers and Facilitators of this study was that paediatricians without an EHR were less likely to believe in benefits resulting from EHR system implementation. Another US study reported that there were large differences in GPs perceptions of barriers to EHR adoption between users and non-users of EHRs. 19 Overall, the perceived barriers to EHR adoption reported by non-users were a lack of understanding of the benefits resulting from EHR implementation, usability issues, cost, and confidentiality and security issues. A large US study identified several perceived barriers to EHR adoption among GPs who had not adopted EHRs. The main perceived barriers to EHR adoption among non-adopters were concerns about financial costs, workflow barriers and loss of productivity, implementation complications and 39 security and privacy issues. The authors also reported that more than 264 unique types of EHR/EMR software implementations were found. This low rate of standardisation was also considered a major barrier to EHR proliferation, as it results in a great devaluation of existing implementations. Several US studies of primary care physicians revealed that the practice size has an impact on physicians attitudes towards EHRs. The results suggest that primary care physicians practicing in 1, 20, 22-24, larger groups are more likely to be interested in utilising EHRs. 29 In addition, technology readiness was found to be the strongest predictor of EHR adoption in this primary care setting Post-implementation Attitudes The most common theme among studies of primary care stakeholders perceptions following the implementation of an EHR system is around the negative impact of EHRs on the clinical workflow and overall productivity. A US study reported the perceptions of primary care physicians, nurses and physician assistants serving minority populations, following the implementation of a large-scale EHR system based on VistA (the EHR system used by the US Veterans Health Administration). The perceived barriers reported by this group were clinical productivity loss, technical limitations of computers and availability of technical support. 33 Adoption predictors included increasing years since completion of clinical training and positive attitudes towards EHRs improving quality of care. The study suggests that clinicians support the use of IT to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential, due to limited use of key functions within the EHR. Interviews with a group of primary care physicians and managers following implementation of an EHR system suggests that a successful re-design of clinical workflow to accommodate the EHR and 25, 26 more intensive EHR use are associated with greater quality of care and financial benefits. Perceived barriers reported by this group were financial costs, disruption of clinical workflow, usability issues, lack of time and support to re-design clinical workflow, and lack of standardisation and interoperability. An observational study of the use of clinical decision support by GPs and nurses at Veterans Administration medical centres in the US has confirmed some of the perceived barriers listed above. 31 The researchers observed how a failure to redesign the practice workflow resulted in a lack of coordination between nurses and providers, redundant documentation and the use of paperbased workarounds. During patient visits, GPs were less likely than nurses to use the computer 16

17 EHR Adoption: Perceived Barriers and Facilitators resulting in impaired data acquisition and implementation of recommended actions. This barrier was attributed to the belief by GPs in the social norm to avoid using the computer while with the patient. GPs complained about usability and flexibility issues with the clinical decision support module of the EHR system, such as being unable to provide the answers required by the system and having to make something up, and the inapplicability of the CRs to some clinical scenarios. Finally, GPs reported that slow processing speed or computer crashes can be paralysing as the clinicians are required to use the system for virtually all clinical functions. The researchers suggest that further attention to these factors when redesigning clinical workflows to accommodate the EHR can contribute to effective use of the EHR system. Two other common themes among studies of primary care stakeholders perceptions following the implementation of an EHR system are around usability issues and the negative impact of EHRs on the physician-patient interaction. The usability issue that has been commonly reported in the literature is related to the recording of structured information in the EHR, also referred to as coding. Interviews with a small group of GPs in the UK suggest that the recording of structured information in the EHR is perceived as a usability issue due to too many detailed options in the classification and the lack of definite meaning for each code. 4 The study findings suggest that the barriers to recording of structured data in the EHR by GPs are socio-cultural, mainly associated with the negative impact coding could have on the physician-patient relationship. Although they accept that coding is necessary for demonstrating evidence-based care, they believe it is inappropriate for documenting the complex social interaction in primary care and its associated diagnostic uncertainty. For GPs, free-text is a vital constituent of the EHR as it provides a more powerful reminder of the individual human encounter. A New Zealand study also reported that GPs and specialists found it difficult to code diagnoses in the EHR, and objected to coding being done primarily for administration, financial or statistical purposes, 15 rather than for individual patient care. The study respondents also felt that there was considerable delay in the flow of diagnostic information from the hospital to general practices, and favoured an electronic transfer of information. However, marked differences in the attitudes of GPs and hospital specialists were reported: most GPs embraced computers and diagnostic coding, whereas few hospital consultants did so. This difference was attributed to the fact that GPs have more investment in their EHR systems, while hospital specialists have the systems imposed by their hospital administration, with no facility for hospital doctors to add codes to the EHR. The study suggests that attitudinal differences between GPs and hospital specialists will need to be addressed to facilitate the flow of information between hospitals and general practices. GPs also feel that there are several social, workflow, technical and professional barriers to EHR use during patient visits. A US study reported that some of these concerns include loss of eye contact with patient, loss of efficiency and productivity, slow EHR system and inability to type quickly enough. 18 GPs also indicated a preference towards writing long prose notes and reported that using the computer in front of the patient was considered unprofessional. The authors suggest that these barriers need to be addressed to ensure EHRs are used in the presence of patients, which will in turn realise the full potential of in-office clinical support. 17

18 EHR Adoption: Perceived Barriers and Facilitators Medical students at US primary care clinics were also concerned that the EHR system will have a negative impact on the doctor-patient encounter, such as loss of eye contact and loss of communication with the patient. 30 Perceived benefits reported included improved organisation of information, and improved documentation and decision support. A US study investigated in more detail the effect of the EHR system on the physician-patient encounter, by conducting interviews, focus groups and observations in primary care offices. They identified 14 perceived facilitators grouped under four themes: spatial, relational, educational and 40 structural. Perceived spatial facilitators during patient visits included using flat-screen monitors on mobile arms (as opposed to large, fixed monitors located in the corner of the examination room), having computers conveniently available at numerous locations in the medical office, in the hospital and at the homes of on-call physicians to create seamless communication over time and location, and ensuring that patient records are reviewed by physicians prior to patient visits to minimise the impact of EHR use on the flow of the encounter. Perceived relational facilitators included the availability of flexible EHR templates to accommodate the complex social interaction in primary care, ensuring the physician s style when alternating between computer use and patient communication does not have a negative impact on the interaction, and ensuring physicians see the benefits of collaboration with patients and are willing to share the EHR screen with their patients. Perceived educational facilitators included advanced computer skills for all physicians using the EHRs, a training plan that addresses topics related to best-practices for EHR use during patient visits, educating the patient to ensure they have a good understanding of how the EHR is used in primary care. Perceived structural facilitators included availability of financial resources necessary for continuing technical updates, being able to record narrated notes in the EHR, organisational culture supportive of the EHR, and acceptance by physicians and patients that the EHR is a newly introduced technology that is still in its embryonic stages of development. A synthesis of the findings from three qualitative studies of Canadian family physicians and primary health care staff reported that perceived facilitators among this group were for: (i) the EHR implementation team to understand the needs and expectations of users, and baseline levels of computer knowledge, (ii) to dedicate time specifically for EHR training that will not impact on physicians productivity and (iii) to ensure an EHR champion or problem solver is available at the 37 practice site. 18

19 EHR Adoption: Perceived Barriers and Facilitators Multispecialty Physicians 17 studies of physicians from all specialties were reported in literature. 3, 5-11, 13, 15, 17, 27, 28, Two of these studies were conducted in hospitals 7, 10, while the other 15 were conducted in mixed healthcare settings (community offices and hospitals) 3, 5, 6, 8, 9, 11, 15, 17, 28, Two of these 17 studies 10, 27 examined residents attitudes towards EHRs. KEY FINDINGS - Major concerns among physicians of all specialties: Financial costs associated with EHR implementation; Technical issues such as lack of adequate IT resources, implementation complications and lack of standardisation and interoperability; Disruption of workflow resulting in loss of productivity EHR Adopters vs. Non-adopters Similarly to the primary care setting, studies comparing attitudes among EHR adopters and nonadopters from all physician specialties suggest that the two groups perceive EHRs differently. A national survey in the US of physicians practicing in groups of three or more reported that the most important perceived barriers to EHR adoption were: (1) lack of support from practice physicians; (2) lack of capital resources to invest in an EHR; (3) concern about physicians ability to input into the EHR; (4) concern about loss of productivity during transition to EHRs; and (4) inability to easily input historic medical record data into the EHR. Another finding of this study was that larger practices were more likely to have adopted EHRs than smaller practices. Several studies reported findings from a recent survey of a large group of US physicians from all 11, specialties. Perceived barriers to EHR adoption were financial costs, training and productivity loss, lack of time to acquire knowledge about the EHR system, lack of uniform standards and a lack of computer technical support. Physicians also reported being generally satisfied with the EHR due to improved access to up-to-date knowledge, improved interactions with the healthcare team, reduction of medication, and improved efficiency and quality of care. The authors reported considerable variability in the functions available in the EHRs and the extent to which physicians use them, suggesting that the availability of EHR functions does not always translate to regular use in day-to-day practice. The study findings suggest that physicians most likely to be EHR adopters were from larger practices, other than primary care, affiliated with hospitals especially teaching hospitals, had more experience and had been practicing for a longer time and had a better understanding of EHR benefits. Incentives for quality of care were reported to facilitate EHR adoption. A state-wide survey in the US reported that important perceived barriers to EHR adoption were: (1) lack of technical support; (2) lack of industry standards; (3) interoperability concerns; (4) high upfront costs; and (4) physician scepticism. The researchers also established a profile of imminent adopters based on the findings. Imminent adopters were more likely to be younger, from practices 19

20 EHR Adoption: Perceived Barriers and Facilitators with multiple physicians, more experienced with technology and more often in practices engaged in quality improvement. A large study with Hong Kong physicians representative of the general physician population reported that the major perceived barriers were time costs associated with planning, purchasing, training and maintenance activities related to the EHR, large capital investments and maintenance costs, lack of technical support and lack of knowledge and perceived difficulty in learning new technology. The study findings also reported that an understanding of benefits and government financial incentives were perceived as facilitators to EHR adoption by the respondents Pre-implementation Attitudes A recent (2009) study conducted in a large Australian teaching hospital preparing to implement an electronic medication management system has confirmed the above findings are applicable to Australian health professionals. 7 The authors identified the following areas of concern: (1) change in workflow; (2) lack of adequate IT resources; (3) software issues; (4) negative impact on the patientphysician relationship; (5) lack of time to acquire knowledge about systems through training; (6) lack of computer skills; (7) de-skilling; (8) confidentiality, privacy and security concerns; (9) financial concerns; and (10) implementation complications. Similar findings were reported by a recent study in Austria exploring how change-barriers and resistance of GPs and specialists in private practice to the introduction of a nationwide EHR were 8 motivated by negative emotions. This fear and anxiety was related to uncertainty regarding the implementation, lack of knowledge, change of accustomed workflows, concerns of an increase in workload and cost, and concerns of confidentiality, privacy and security issues introduced by EHRs. To improve the physicians acceptance of the nationwide EHRs, the authors recommend the publication of documents outlining the benefits of the EHRs to physicians, and the introduction of information campaigns. The EHR system has to be made transparent to physicians to allow an informed discussion around the facts to take place, that will in turn address some of the concerns Post-implementation Attitudes A recent study of clinician perceptions of an EHR system during the first year of implementation in emergency services reported that EHR adoption was strongly associated with positive perceptions of training and support, and belief in usefulness of EHRs. 3 Many perceptions of the EHR system at launch persisted through the first months of use, suggesting that early positive impressions of training, support, and belief in EHR usefulness can maximise EHR adoption. A large nationwide survey of US physicians from all specialties, with a 50% representation from primary care, suggests that the most important perceived barriers among this group were: (1) financial issues; (2) concerns about findings a system that meets their needs; (3) uncertainty about their return on investment; and (4) concern that the system would become obsolete. Perceived facilitators were: (1) financial incentive for the purchase; (2) payment for use of EHR; and (3) protecting physicians from personal liability for personal record tampering by external parties. The authors also suggested that based on the findings, primary care physicians, and those practicing in larger groups, in hospitals or medical centres were more likely to use EHRs. 20

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