Barriers to Electronic Health Record
Implementation
TEXAS WOMAN’S UNIVERSITY
School of Management
HSM 5003 - Management of Health Service Organizations
Dr. Pat Driscoll
Linda Brown
Charlie C Costa
Elizabeth Gardner
Rashi Jayswal
D’Les Jones
July 20, 2009
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Barriers 2
Introduction
Paperless healthcare, deemed critical to healthcare reform, has been talked about for
several years and yet few hospitals have completely transitioned to Electronic Health Records
(EHR). President Obama, in a recent speech to the American Medical Association, quoted Newt
Gingrich, former speaker of the house, when he said, “We do a better job tracking a FedEx
package in this country than we do tracking patient’s health records.” He further added, “As jobs
change and as insurance coverage changes, you should not have to tell every new doctor what
your medical history has been and what medications you are taking. Instead, information should
be stored securely in a private health record that is inclusive of your entire medical history.”
Lower administrative costs are needed to maintain electronic records and should result in
significant savings for the federal government as well as the individual taxpayer. Various
functions of the EHR include; but are not limited to: health information, data storage and access,
management of results, patient support and administrative functions (Sprague, 2004). A review
of the literature determines the EHR should allow physicians greater access to patient
information whenever and wherever the caregiver needs it. It should facilitate the physician
workflow, daily tasks of prescribing and refilling medications, ordering tests, viewing results and
documenting patient encounters. However, physician’s use and acceptance of the EHR remains
an issue. Heir, Rothschild, LeMaistre and Keeler (2005) report that physicians thought computer
speed, lack of terminals, confusing interface, lack of understanding of system features and lack
of computer skills were the greatest barriers to successful implementation of the EHR.
Hospitals are now faced with intervening and finding ways to manage these issues as a
full conversion to electronic records will now be mandatory. President Obama recently passed
the American Recovery and Reinvestment Act of 2009. Contained in the legislation is a mandate
Barriers 3
that all healthcare providers convert to EHR’s by 2015. The current stimulus package allows for
incentive payments for those hospitals and physicians who begin conversion by 2011. Medicare
providers that cannot demonstrate meaningful use of the EHR by 2015 will be penalized through
lower payments.
The purpose of this research is to explore physician perceptions of the EHR and barriers
to their acceptance and use in the hospital settings in which they practice. Also noted, will be the
hospital’s perception of physician’s issues and management’s steps to intervene. Research will
be gathered through survey, statistical analysis, discussion and observation. Study sites will
include Baylor Healthcare System, Children’s Medical Center, Parkland and U.T. Southwestern.
Results of this research will culminate with best practices of those institutions that have
demonstrated successful implementation of the EHR.
Literature Review
The U.S. healthcare system faces challenges on multiple fronts, including rising costs and
inconsistent quality (Jha, et al., 2009). According to one recent report, total healthcare spending
is expected to increase nearly seven percent per year over the next decade, reaching $4.3 trillion
in 2017– fully 20 percent of the U.S. gross domestic product (Wurster, Lichtenstein, &
Hogeboom, May/June 2009). Health information technology, especially the electronic health
record, has the potential to improve the efficiency and effectiveness of healthcare providers (Jha,
et al., 2009). However, only 1.5 percent of U.S. hospitals have a comprehensive electronic
health records system and an additional 7.6 percent have a basic system. Larger hospitals, those
located in urban areas, and teaching hospitals were more likely to have electronic health records
system (Jha, et al., 2009). Electronic health records systems were more prevalent among
Barriers 4
physicians who were younger as compared to with other physicians (Blumenthal, 2009). The
Institute of Medicine has developed a comprehensive list of the potential functionalities of an
inpatient electronic health record but there is no consensus on what functionalities constitute the
essential elements necessary to define an electronic health record in the hospital setting (Jha, et
al., 2009).
Barriers to Electronic Health Record Adoption
Among hospitals without electronic health records systems, the most commonly cited
barriers were inadequate capital purchase, concerns about maintenance costs, resistance on the
part of physicians (high initial physician time costs (Miller & Sim, 2004)), unclear return on
investment, interoperability, and lack of availability of staff with adequate expertise in
information technology (Jha, et al., 2009). There are legal barriers to EHR namely, paper-era
state regulations that may not permit EHRs, the Anti-kickback Statute, the Stark anti-referral
rules, concerns about enhanced malpractice exposure, HIPAA’s privacy and security regulations,
and in some contexts, the anti-trust laws (Shay,n.d.). Nebecker, Hoffman, Weir, Bennet and
Hurdle (2005) report that computerized physician order entry (CPOE) systems caused a high rate
of adverse drug effects. This finding was verified by Koppel, Metlay, Cohen, Abaluck, Localio,
Kimmel and Strom. (2005). This concern could increase physician hesitancy to implement EHR.
Poissant, Pereira, Tamblyn and Kawasumi (2005), citing six studies, state that “increased time
for documentation is one of the most commonly stated barriers to successful implementation of
an EHR.”
Facilitators of Electronic Health Record Adoption
Barriers 5
Most hospitals that adopted electronic health records systems identified financial factors
as having a major positive effect on the likelihood of adoption: additional reimbursement for
electronic health record use and financial incentives for adoption (Jha, et al., 2009). Meaningful
use of electronic health records in 2011 will earn hospitals a one-time bonus payment of $2
million plus an add-on to the Medicare fee based on the diagnosis-related group (DRG)
(Blumenthal, 2009).
Physicians who use electronic health records believe such systems improve the quality of
care (clinical decisions, communication with other providers and patients, prescription refills,
timely access to medical records, and avoidance of medication errors) and are generally satisfied
with the systems (DesRoches, et al., 2008).
Methodology
The physician survey was developed by adapting a written survey instrument created by
Heir, et al. (2005). No information is available about the reliability or validity of this tool. Two
studies had raised concerns about the EHR increasing the possibility of medication errors. (Nebecker,et
al. (2005) and Koppel,et al. 2005).)Therefore, a question was developed to specifically address this
issue. A 5-point Likert-like scale was used with 1 indicating strong disagreement to 5 indicating
strong agreement with survey statements.
The initial survey consisted of 22 questions. Two questions collected information about
years in medical practice and amount of time using the EHR . Twenty questions surveyed
attitudes towards and satisfaction with the EHR. The survey was modified in attempt to increase
response rate after objections were raised regarding its length. The final survey had 23
questions.
Barriers 6
Sample Characteristics
A convenience sample was used. Data was collected from medical residents at Parkland
Hospital and physicians from Integra Rehabilitation hospital, Presbyterian Hospital (Plano), and
Baylor Medical Center (Plano).
Data Collection
Data was collected by three methods: a) permission was obtained from Parkland Hospital
administration to survey medical residents. The survey was submitted to the administration, who
sent it via group e-mail to all Parkland Hospital medical residents. b.) Parkland medical residents
were asked to complete a paper survey by medical records personel. c.) Community physicians
from the hospitals listed in above were contacted by researchers and asked to complete a paper
survey.
Results
The total sample size was 36. There were no responses to email survey (0%).
Community physician response was 30/40 (75%). Medical residents completed nine surveys.
Their refusal rate was not captured. Of these, three surveys were discarded because of change in
survey questions. In total, 30/36 (83.3 %) were community physician responses and 6/36 (16.6
%) of responses were from medical residents. One non-contributory demographic question was
discarded in final analysis. Data was analyzed using SPSS statistical software, version 17.
There were 35 complete data sets and one data set with one missing response. Frequencies and
percentages of responses to each question were calculated.
Barriers 7
Demographics: Forty-two percent of respondents had been in medical practice for one to
nine years, with another 40% having practiced between ten and thirty years (See Figure 1).
Figure 2 shows that 38.9 % had used EHR for three to four years, 22.2% for five to six years.
Figure 1. Years of Physician Practice.(N=36).
Figure 2. Years of Physician Use of EHR.(N=36).
Responses were placed into three categories: Strongly disagree/disagree, neutral, agree/strongly
agree. Responses were as follows: 86 %: EHR provided timely access to medical records; 69.5
%: improvement of communications with other providers; 75%: easier to order prescriptions, lab
,radiology, and to view imaging results; 72.2%: easy to view lab results; 61.1% responded as
preferring EHR over paper based charts, felt it saved time documenting care, and enjoyed using
EHR (Table 1.). Sixty three point nine percent disagreed with the statement that EHR increases
chances of medication errors (Table 2). Response was neutral to “not enough computers
available”: (77.1%) (Table 3). Table 4 lists responses with no clear trend, although it should be
Barriers 8
noted that 52.8 % responded neutrally to statement that EHR prevents patient care errors; 57.7%:
EHR allowed them to spend more time with patients; 52.8 % : EHR is easy to use; 55.6% :
computer interface is confusing ; 50% EHR makes workload more efficient. Thirty six point four
percent of respondents disagreed with the statement “I understand the EHR features,” while
38.9% agreed.
Discussion
Finding are weakly consistent or non- consistent with previous research. The findings
that medication errors were increased with use of the EHR are not supported; 63.9% of
responses were negative. In a related question, “EHR increases patient care errors,” 52.8% of
responses were positive. Seventy-seven percent of respondents felt neutral about lack of
computers, and only 55.6% felt the computer interface was confusing. Lack of understanding of
the EHR was equivocal. The findings that more than half the respondents had been using EHR
for three to six years and perceived that the EHR saved time documenting patient care has
possible implications. With time and experience, EHR may save time documenting patient care.
Study Limitations
Sample size was small and convenient. Parkland medical residents were underrepresented. The survey tool had no reliability or validity data. Statistical probability was not
calculated..The survey was edited after data collection started; therefore, there is no data
available for comparing perceptions of computer speed and lack of computer skills with previous
studies. The initial survey had been edited for length. The result had one more question than the
original. Response rate may have improved due to more attractive formatting. There were no
responses to the electronic survey sent to the medical residents. It’s unclear if this was due to
Barriers 9
lack of interest or malfunction of the electronic survey: its postulated that the surveys’ hyperlink
was not active.
Findings
Table 1. Positive Responses (N=36)
Questions
Percent responses “agree “ or
“highly agree”
1. The EHR provides timely access to medical records.
80.6 (29)
2. The EHR improves communication with other providers
69.5 (25)
and patients.
3. The EHR makes it easy to order prescriptions
75.0 (27)
4. The EHR makes it easy to order lab tests.
75.0 (27)
5. The EHR makes it easy to order radiology tests.
75.0 (27)
6. The EHR makes it easy to view lab results.
72.2 (26)
7. The EHR makes it easy to view imaging results.
75.0 (27)
8. I prefer using the EHR over paper –based charts.
61.1 (22)
9. The EHR saves time documenting care.
61.1 (22)
10. I enjoy using the EHR.
61.1 (22)
Notes: Number in parenthesis= number of respondents.
Barriers 10
Table 2
Question
Percent disagree
63.9 (23)
1. The EHR increases chances of medication errors.
Table3.
Question
1.
Percent neutral
Not enough computers are available
77.1 (27)
Table 4
Questions
Percent
Percent
Percent agree or
neutral
disagree or
strongly agree
strongly
disagree
1. The EHR prevents patient care errors.
52.8 (19)
27.7 (10)
19.4 (7)
2. The EHR increases record security.
44.4 (16)
33.3 (12)
22.2 (8)
3. Computer training was sufficient.
19.4 (7)
44.2 (16)
36.1 (13)
4. I understand the EHR features.
25.0 (9)
36.4 (13)
38.9 (14)
5. The EHR allows me to spend more time
30.6 (11)
16.6 (9)
57.7(19)
6. The EHR is easy to use.
25.0 (9)
22.2 (8)
52.8 (19)
7. The computer interface is confusing.
22.2 (8)
22.2 (8)
55.6 (20)
with patients.
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8. The EHR makes the workload more
19.4 (11)
33.3 (12)
50.0 (18)
efficient.
Administrator’s Experience with the Implementation of EHR.
Organizations reviewed- Non Profit, Large (greater than 250 beds)
Parkland- Successfully implemented EHR for inpatients.
Transition phase
An understanding of the modules being implemented.

Knowledge of the present environment.

Reanalyze and develop new process workflows for both the HIM and the provider based
processes( physicians/nursing, ancillaries)

Decision whether to include legal medical records for the hospital and the need for any
documentation.
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Determine the new workflows for HIM data, considering the provison of data to external
reviewers, research, ROI, Transcription.

Involvement of IT during all the phases.
The physicians were actively involved during the transition and the training which was
created by IT team.
Administrators observe that the major advantage of an EHR is the instant availability of the
data.
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The drawbacks appeared when there were communication lapses between the IT and the
HIM. An active involvement of both the teams while designing the EHR is essential to the
successful transition for paper based system to EHR.
Conclusion
The objective for this study was to determine physician’s perception of the EHR as well
as factors negatively affecting their use and acceptance of the tool. Additionally, steps taken by
hospitals to intervene and facilitate use of the EHR were gathered for evaluation and rate of
success. This section summarizes findings and presents recommended best practices that have
aided a smooth transition to better health records.
Study results did prove sufficient evidence to corroborate the literary review plus
revealed information valuable to hospitals in their efforts to ensure implementation success.
Physician’s initial perceptions were consistent with purported barriers. However, with training
and continued use, physicians believed the EHR did improve quality of care are generally
satisfied with the tool. Physicians have long resented any perceived change to their practice of
medicine and constraint or limitation on the physician’s ability to make patient care decisions
remains an issue. At the forefront, are the potential repercussions from added transparency
brought about by the EHR. Patients, hospitals, and physicians share in this concern. For
physicians, this could mean a change in payment methodology from a fee for service basis to a
pay for performance basis. However, most physicians support the need for change in the
nation’s healthcare system. They want to practice medicine effectively and at a level of quality
that results in the best outcomes for their patients. The electronic health record is a necessary
step towards healthcare reform that benefits patient and provider.
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There are steps that hospitals can take to facilitate a smooth transition. Obtaining
physician involvement in the planning process seems to have the greatest impact on physician’s
attitudes toward the EHR. Soliciting input from users supports their needs and aids in workflow.
Additionally, allocating sufficient dollars in the way of capital needs, extensive and accessible
training, and adequate staffing shows the hospital’s support of the users and the hospital’s
investment in the overall success of the conversion. Taking steps to facilitate slower users such
as providing follow-up training and making nurse practitioners available to shadow and scribe
for the physician can foster better attitudes towards acceptance of change.
In conclusion, the EHR is no longer just a good idea. Recent legislation has mandated
that healthcare in the United States must fully transition to electronic records by 2015. Despite
the availability of federal incentives, the implementation will come at a cost. However,
improvement to quality, reduction in patient care errors and fiscal savings are necessary to
improve our nation’s health system and sustain access to affordable care for every citizen.
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References
Blumenthal, D. (2009). Stimulating the Adoption of Health Information Technology. The New
England Journal of Medicine , 1477 - 1479.
DesRoches, C. M., Campbell, E. G., Rao, S. R., Donelan, K., Ferris, T. G., Jha, A., et al. (2008).
Electronic Health Records in Ambulatory Care – A National Survey of Physicians . The
New England Journal of Medicine , 50 - 60.
Jha, A. K., DesRoches, C. M., Campbell, E. G., Donelan, K., Rao, S. R., Ferris, T. G., et al.
(2009). Use of Electronic Health Records in U.S. Hospitals. The New England Journal of
Medicine , 1628-1638.
Miller, R. H., & Sim, I. (March/April 2004). Physicians' Use Of Electronic Medical Records:
Barriers And Solutions. Hope/Health Affairs , 116 - 126.
Shay, E. F. (n.d.). Legal Barriers to Electronic Health Records. Retrieved July 10, 2009, from
Texas Medical Association: http://www.texmed.org/Template.aspx?id=3956
Wurster, C. J., Lichtenstein, B. B., & Hogeboom, T. (May/June 2009). Strategic, Political, and
Cultural Aspects of IT Implementation: Improving the Efficacy og an IT System in a
Large Hospital. Journal of Healthcare Management , 192.
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SURVEY
How many years have you been practicing medicine?
<1
1-9
 10 - 19
 20 - 29
 > 30
For how long have you been using the Electronic Health Record/Electronic Medical Record?
 < 1 year
1–2
Medical Specialty:
3–4
5–6
 Primary Care
Rate the following questions:
Availability:
The EHR provides timely access to
medical records.
Communication:
The EHR improves communications
with other providers and patients.
The EHR makes it easy to order:
Prescriptions
Laboratory Tests
Radiology Tests
Medication Errors:
The EHR increases the chance of
medication errors.
The EHR makes it easy to view:
Laboratory results
Imaging results
Ease of use:
The EHR is easy to use
Time with patient
The EHR allows me to spend more
time with patients.
Prefer EHR
I prefer using the EHR over the paperbased charts.
Efficient workload:
The EHR makes the workload more
efficient.
7–8
 9 – 10
 > 10 years
 Not primary care
1
2
3
4
5
Strongly Disagree Neutral Agree Strongly
Disagree
Agree
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Agree
Barriers 16
Patient care Errors
The EHR prevents patient care errors.
Saves time
The EHR saves time documenting
care.
Record Security
The EHR increases record security.
Computer Lack:
Not enough computers are available.
Training
Computer training was sufficient.
Computer Interface
The computer interface is confusing.
Understand features
I understand the EHR features.
Enjoy EHR:
I enjoy using the EHR.
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Are the any concerns or comments you have about the EHR?
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Thank you for completing this survey.