Final ReportLessons from the Literature on Electronic HealthRecord ImplementationA study funded by the Office of the National Coordinator for Health InformationTechnology of the U.S. Department of Health and Human ServicesAugust 1, 2013Prepared by Fredric Blavin, Christal Ramos, Arnav Shah, and Kelly DeversSubmitted to:Emily Jones, Ph.D.U.S. Department of Health & Human ServicesOffice of the National Coordinatorfor Health ITTel: 202-669-9107Email: [email protected] by:Fredric Blavin, Ph.D.The Urban InstituteHealth Policy CenterTel: 202-261-5866Fax: 202-223-1149Email: [email protected]

ContentsExecutive Summary. 3Introduction/Background . 6Framework . 7Methods . 9Results . 10Categorization of Articles .10Common Themes and Lessons Learned: Planning and Vendor Selection .11Common Themes and Lessons Learned: Design of Workflows and Software Customization .19Common Themes and Lessons Learned: Training and User Support .23Common Themes and Lessons Learned: Optimization and Modification .24Discussion. 29Conclusion . 32Tables and Figures . 34Figure 1. Framework . 34Table 1. List of Literature Review Search Terms . 35Figure 2. Article Selection Flow Chart . 36Table 2. Classification of Articles by Study Design, Organizational Setting and Health ITType/Function . 37Table 3. Number of Articles by Perspective and Stage . 38Table 4. Themes by Stage and Perspective . 39Citations . 402

Executive SummaryDespite the potential benefits, health care providers were initially slow to adopt electronic healthrecords (EHRs). To promote the widespread adoption and use of health IT, Congress passed TheHealth Information Technology for Economic and Clinical Health (HITECH) provisions of theAmerican Recovery and Reinvestment Act of 2009, with the ultimate aim of improving quality,safety, and efficiency of the U.S. health care system. These provisions includes incentivepayment programs and technical assistance for eligible health professionals and hospitals toadopt, implement, or upgrade certified electronic health records (EHRs) and to achieve theMeaningful Use (MU) of health information technology (IT). 1,2To achieve the ultimate aims of HITECH, health care organizations must not only successfullyimplement but also optimally and meaningfully use EHRs, a process that involves significantinvestment, technical complexity, changes in workflow, and numerous other challenges. Thepurpose of this literature review is to provide examples of how organizations are implementingand optimizing EHRs, and summarize “lessons learned” from peer-reviewed publications and thegray literature.Common Themes and Lessons LearnedThis paper is organized around different stages of the EHR implementation process (planningand vendor selection, workflow and software design, training and user support, and optimizationand modification) and explores each stage through multiple perspectives (organizational,professional, and technical perspectives).Planning and Vendor SelectionThe literature suggests the planning stage of EHR implementation is critical to whether or notimplementation will ultimately be successful. Selection of systems that will best meet theorganization’s needs, obtaining staff buy-in, defining the implementation strategy, anddetermining the pace at which implementation will occur are key issues during this stage. Theliterature suggests that from the start, it is important for organizations to consider their technicalneeds, the perspectives of staff from all levels of the organization, and the organizational cultureand environment in which the system will be implemented. In addition to relationships withvendors and consultants, partnerships with external stakeholders are also important in order toshare and exchange patient information. 3 Smaller organizations with fewer resources have alsoentered into networks or partnerships to “piggy back” off a larger organization’s system.However, some smaller organizations have found the systems of larger hospitals to be toocomplex for their needs.3

Design of Workflows and Software CustomizationPlanning for changes in user workflow is one of the first and most important tasks fororganizations implementing an EHR system. However, a major consensus in the literature is thatin general, EHRs are often poorly designed for clinical purposes and need to be continuouslycustomized to meet the needs of the organization. Organizations must address various barriersrelated to hardware and infrastructure, software customization and usability, and workflowthroughout the implementation and optimization process. Several studies found thatcomputerized physician order entry (CPOE) presented greater implementation, customization,and usability barriers relative to other healthcare technologies and remains a major barrier to thereceipt of MU incentive payments. 4 Similarly, several studies cited inadequate designs and poorusability of clinical decision support (CDS) systems as major barriers to EHR implementation, orconversely, proper CDS designs and ease of use were cited as facilitators of successfulimplementation. 5Training and User SupportThe literature describes training as affecting all professional groups involved, ranging fromprogram planning and strategizing among managers to end-user implementation andparticipation. Several studies emphasize the importance of investing heavily in and requiringupfront training for all staff members to avoid negative impacts on workflow, costly setbacks,and productivity losses. 6 Some articles also note that post-implementation support is oftenlimited and organizations would benefit from a lengthy post “go-live” period in which hands-onsupport is available. 7 Training best practices include obtaining organizational commitment toinvest in training, assessing users' skills and training needs, selecting appropriate training staff,matching training to users' needs, using multiple training approaches, leveraging the skills of rolemodels (clinical leaders, champions, super-users, training coordinators), providing trainingsupport throughout the implementation process, and retraining to optimize use of the EHR. 8,9Optimization and ModificationThe literature highlights that organizations must continually modify EHR technology to help meet their institution’sperformance goals. After the system is installed, there are needs for software updates, equipment upgrades andreplacement, as well as ongoing maintenance – all of which need to be included in the budget when estimatingimplementation costs.10Resources also need to be devoted to provide ongoing hand-on support long after new11technology is initially implemented. Organizations must also continually engage clinicians around using newtechnology to keep up with changes in the health care system, such as the development of new drugs, devices,procedures and treatments, evidence-based guidelines, and billing and documentation requirements. In addition,organizations have found it important to engage quality improvement (QI) leaders in developing and updating EHRsto facilitate the ability to aggregate data for performance reporting,1312as well as to develop metrics to track theoutcomes associated with QI initiatives utilizing health IT. While evidence to date around the QI movement inhealth care suggests the effects are positive yet modest, the potential for EHRs and other health IT to enhancequality and provide more comprehensive and timely data for QI may help strengthen the nation’s QI capacity.414

ConclusionTo promote the EHR implementation and optimization process, planning and modifications arecontinually needed to address technological, professional, and organizational perspectives. Whilethis review included optimization as a step in the implementation process, one important lessonis that optimization is an ongoing process that needs to be incorporated into each organization’sstructure and culture. Practically, organizations that successfully implemented EHRs did anumber of things early on, such as: Engage staff at all levelsInvest in workflow analysis and careful redesign in order to customize and effectivelyintegrate new technology among usersDesign systems for quality improvement and implementation and information exchangeAllocate resources for ongoing maintenance and technical support of the system, systemadjustments, and continual staff training and engagementThe Institute of Medicine views EHRs as an essential part of a “learning health care system,” ora system that is designed to both generate and apply evidence to promote innovation, quality,safety and efficiency in health care. 15 Many also believe that EHRs are critical to the success ofpayment and delivery system reforms such as patient centered medical homes and accountablecare organizations. In order for EHRs to reach their full potential, it will be important to considerhow to encourage and support organizations to continually modify and optimize their systems tomeet the needs of their organization, their staff, and ultimately their patients.5

Introduction/BackgroundSeveral evidence-based reviews conclude that some types of health information technology (IT),particularly electronic health records (EHRs) with advanced functionalities, have reducedmedication errors and improved care processes, adherence to evidence-based guidelines, patientengagement, and patient satisfaction. 1 Despite these potential benefits, health care providerswere initially slow to adopt EHRs. In 2008, approximately 1.5 percent of non-federal acute carehospitals reported having a comprehensive EHR system and 7.6 percent had a basic EHRsystem. 2 Similarly, approximately 17 percent of office-based physicians used an EHR that metthe criteria of a basic system in 2008. 3To promote the widespread adoption and use of health IT, Congress passed the HealthInformation Technology for Economic and Clinical Health (HITECH) provisions of theAmerican Recovery and Reinvestment Act (ARRA) of 2009, with the ultimate aim of improvingquality, safety, and efficiency of the U.S. health care system. Through the Medicare andMedicaid EHR Incentive Programs, HITECH makes available an estimated 27 billion toeligible health professionals and hospitals to adopt, implement, or upgrade certified EHRtechnology and to achieve the Meaningful Use (MU) of health IT. 4,5 HITECH also includes othermajor programs and activities to support greater provider adoption of EHRs, including thecreation of Regional Extension Centers (RECs) to provide local technical assistance to highpriority providers to adopt certified EHRs and meet MU requirements, and the State HealthInformation Exchange Cooperative Agreement Program to facilitate health informationexchange.These ARRA HITECH programs appear to be associated with a rise in the adoption of EHRs. In2012, 16.9 percent non-federal acute care hospitals reported having a comprehensive EHRsystem and 27.6 reported having a basic system, representing increases of 15 and 20 percentagepoints compared to 2008, respectively. 6 Similarly, 39.6 percent of office-based physiciansreported using an EHR that met the criteria of a basic system in 2012, more than twice the shareof physicians with a basic system in 2008. 7To achieve the ultimate aims of HITECH, health care organizations must not only successfullyimplement but also optimally and meaningfully use EHRs, a process that involves significantinvestment, technical complexity, changes in workflow, and numerous other challenges. Eventhough EHR adoption is increasing among providers, little is known about the facilitators of andmost promising practices associated with successful EHR implementation and optimizationprocesses. For example, the most recent systematic review that focuses on the effects of healthIT concludes that additional research related to technical, human, and organizational factors isneeded to fully understand how organizations can implement and effectively use health IT. 8 Thistype of information is largely absent from other prior reviews as well, although general socialand technical barriers are often cited as preventing some providers from realizing the full6

potential of health IT, while the “human element” (i.e., managerial and/or clinical leadership and“buy-in”) is cited as critical to successful health IT implementation. 9The purpose of this literature review is to provide examples of how organizations areimplementing and optimizing the use of health IT/EHRs from peer-reviewed publications and thegray literature by examining the context and organization specific factors, barriers andfacilitators, and “lessons learned” associated with the successful implementation and optimal useof EHR systems. HITECH states that the “The [Office of the] National Coordinator [ONC] shallprepare a report that identifies lessons learned from major public and private health care systemsin their implementation of health information technology, including information on whether thetechnologies and practices developed by such systems may be applicable to and usable in wholeor in part by other health care providers.” This this literature review aims to contribute to thisreport and help answer the following research questions: What are the practices that major public and private health care systems use inimplementing and meaningfully using health IT?How are public and private health care systems implementing health IT and optimizingthe use of these technologies? For instance, what are the common barriers toimplementation and MU and the best practices to overcome them?What are the “lessons learned”? In other words, what can other organizations learn fromthe strategies and organizational characteristics that have been able to facilitate successfulimplementation of health IT?In this paper, we first briefly present and describe the conceptual framework used to structurethis analysis and the presentation of relevant findings. Second, we describe the methodologicalapproach to this literature review, covering such key issues as what databases and search termswere used to identify relevant articles, inclusion and exclusion criteria, and the process fordetermining the final list of papers for review. Third, we discuss the findings, including thecommon themes and lessons learned related to these three research questions. Finally, wesummarize key results and conclusions and highlight topics that were not sufficiently covered inthe existing literature, since these gaps indicate where further research is needed.FrameworkWe modified and refined an existing conceptual framework to guide this review of selectedpublished and gray literatures around the implementation and optimization of EHRs (see Figure1). Specifically, we combined the Multiple Perspectives model 10, a systems-based theoreticalframework for understanding complex organizational systems, with a hospital-focusedframework 11 on the stages associated with EHR implementation and use. This framework isintended to incorporate different perspectives throughout the implementation process,particularly different levels of decision-making and types of users and can serve as a practicaltool for major private and public health systems that are in various stages of the EHR7

implementation process. We selected a hospital-focused framework as the starting point becausehospitals play a major role in local markets and organized delivery systems, and can beinfluential in shaping the choices of other providers.The four rectangles representing implementation stages in Figure 1 were adopted from AmericanHospital Association (2010). 12 This figure highlights how EHR implementation is a multi-stage,continuous process: The initial phase is planning and vendor selection. The key components of this stageinclude identifying the potential uses and benefits of the system, analyzing costs andfinancial metrics, communicating with staff and articulating goals, conducting vendor andsystem research, choosing a vendor/system and negotiating a contract, and obtaining thecommitment from the staff.The second stage, workflow and software design, and third stage, training and usersupport, are highly interrelated. These stages involve developing new workflows,customizing the system where necessary, installing and testing the system, convertingpaper charts, informing patients, and training staff.The final stage, optimization and modifications, is a continuous process. During the earlystages of this process, hospitals will need to troubleshoot their system and find solutions.To optimize the use of the EHR system, the hospital will need to continuously customizeand update the system to meet user and patient needs, train staff on an ongoing basis,compare projected and actual costs, and use the system to meet organizational goals andimprove outcomes (e.g., utilize a dashboard).The arrows running through the implementation stages represent the organizational, professionalgroup, and technological perspectives that must be considered at each successive stage ofimplementation. This element of the framework is borrowed from the Multiple Perspectivesmodel as adopted by Ash et al. (2012). 13 These perspectives or factors are: Organizational factors, including organizational type (e.g., academic hospital, ruralhospital, physician practice, organized delivery system, accountable care organization,etc ), policies and procedures of the organization, and organizational vision, goals,politics, and culture (e.g., leadership).Professional group perspectives, which include the thoughts and behaviors of individualusers from different professional groups (e.g., physicians, nurses, administrative staff,informatics team, etc ), teams or departments, as well as management.The technical perspective, representing aspects of the EHR system or technology typethemselves.The research team classified and summarized studies using this framework while conducting theliterature review. This model is particularly useful, as it covers key organizational dynamics andprovides the flexibility to categorize and describe various interrelated factors grounded in8

organizational behavior and management theories related to implementation, change, andongoing learning or optimization. This framework may also be a useful tool to identify areas forfuture research.MethodsWe made several assumptions to guide the literature review process. First, we focus on thedynamics within major hospitals and organized delivery systems, including the providerexperience of health IT adoption and optimization. We define “major public and private healthcare systems” as individual hospitals or hospital systems that may include owned or affiliatedmedical groups, managed care plans that own and operate their own hospitals, or other facilities(e.g., accountable care organizations and organized delivery systems ranging from centralizedhealth care systems to independent hospital networks). Second, we emphasize recent experiencesin health IT adoption and optimization since the HITECH Act was passed, focusing on the peerreviewed and grey literature published from 2010 to 2013. Finally, we focus on U.S. health caresystems and only evaluate health IT implementation experiences that are ‘related or similar to’MU, for example, comprehensive adoption of an EHR or adoption of specific EHR functions thatare part of the MU criteria.The final search terms incorporate phrases used in prior health IT literature reviews and expertopinion from Urban Institute and ONC staff members (Table 1). We searched the online journaldatabase Web of Knowledge for the period spanning January 1, 2010 to March 20, 2013. Web ofKnowledge is a research platform and search engine provided by Thomson Reuters that coversthe sciences and medicine, arts and humanities, along with the social sciences (e.g.,organizational management), providing a slight advantage over other search engines such asPubMed which only primarily focus on medicine and health. We also searched additional greyliterature for relevant articles, incorporating publications from a list of government agencies,foundations, academic and research organizations, advocacy groups, and accreditation vendorscompiled by ONC project officers.Figure 2 illustrates how the research team selected the final articles for review. Based on thesearch term criteria, we identified 1,397 articles for potential review. We then screened the titlesand abstracts of each paper to determine if they should be included in the final list of articles. Weeliminated all but 104 articles during this phase, keeping those that had a primary focus onimplementation and optimization issues and dropping out-of-scope studies (e.g., those that didnot meet our assumptions outlined above) along with studies that focus solely on the predictorsof adoption or the effects of health IT on specific outcomes. Most of the excluded studies did notfocus on implementation and optimization process or did not include sufficient detail onorganizational context. We then conducted a full text review of remaining articles and excludedadditional papers that were deemed out-of-scope upon further review (e.g. duplicate articles,9

studies with international setting, and editorials). This left 75 articles that met our inclusioncriteria, 50 of which were peer-reviewed articles and 25 were grey literature articles.We summarize all of the final articles based on article purpose, setting or context (public vs.private systems, type of provider or organized delivery system, etc ), health IT function(“What”), implementation practices (“How”), implementation barriers and facilitators, and keyfindings and lessons learned that are applicable to and useable by other providers (“Spread”).Each article was characterized by key themes, which we organized around the frameworkdomains using NVivo software for qualitative data analysis. 14 The discussion of the resultscenters on these categories (planning and vendor selection, workflow and software design,training and user support, and optimization and modifications), while emphasizing keydifferences across organizational, professional group, and technical perspectives.ResultsCategorization of ArticlesWe categorized the final 75 articles by study design, theoretical/conceptual framework,organizational setting, health IT type or function, and study perspective and implementationstage.We found that the research articles used a wide range of study designs, including literaturereviews, quantitative, qualitative, and mixed methods, including case studies or profiles of singleand multiple organizations, and cross-sectional rather than longitudinal data and analyses (Table2). We differentiated between case studies and profiles of organizations by classifying articlesthat had more rigorous study design (with a stated methods or framework, for example) as casestudies, and those that did not as profiles. More than half of our final 75 articles were either casestudies of multiple organizations (20) or single organizations (11), or profiles of singleorganizations (nine). We also found that 15 articles used a mixed methods approach, 10 usedquantitative cross-sectional methods (such as descriptive and multivariate analyses), and fivewere literature reviews. Finally, five articles used other types of study designs that did not fit intoour specified categorizations, including an application of a theoretical model (one articlediscussed theories of influence in the context of two organizations where health ITimplementation failed 15), reviews or guides to health IT design and workflow decisions, anannual report, and a workgroup discussion white paper.The majority of the articles (65) included in our final analysis did not include a formal theoreticalor conceptual framework, although they may have been guided by one. The formal frameworkswe identified include organizational management theory, institutional theory, Plan-Do-Study-Act(PDSA) model which is a particular quality or process improvement technique, social cognitivetheory, diffusion of innovation, technology use mediation, Multiple Perspectives model, sociotechnical theory, and implementation stage framework.10

Table 2 also shows the various organizational settings of the articles included in the finalanalysis. We found that 16 articles were cross-sections of multiple public or private hospitals(using qualitative, quantitative, or mixed methods analysis), 13 were set in individual private,not-for-profit or for-profit hospital systems, five were in rural or Critical Access Hospitals(CAHs), and two took place in a Veterans Affairs (VA) medical center. Three articles focused onhospital issues, but were not institution-specific and did not make a distinction betweenpublic/private ownership,14 articles focused on ambulatory settings, and 11 had mixedorganizational settings (hospital and ambulatory). Three articles did not indicate a particularorganizational setting, and were labeled “N/A”. One article focused on a nursing home.As part of our organizational setting categorization, we identified seven articles that focused onthe experience of various “health IT leaders” or health care organizations (hospitals, healthsystems, ambulatory practices, and community health centers) that were early adopters of healthIT, as classified by the authors. These health IT leaders include a variety of organizations such asa children’s hospital in Houston (Texas Children’s Hospital), a gynecology practice in Florida(Palm Beach Obstetrics and Gynecology), a network of community health centers in the Bronx(Urban Health Plan, Inc.), and a national managed care consortium (Kaiser Permanente).In terms of the type(s) of health IT functionality discussed in each article, Table 2 shows that amajority of the articles (48) discussed the implementation or of EHRs with multiple functions orhealth IT systems in general. Nine articles specifically targeted clinical decision support (CDS)technology and six focused on computerized provider order entry (CPOE). Two articles werespecifically about the MU criteria and one article focused e-prescribing. The final nine articlesfocused on other specific EHR or health IT functions, including secure messaging, diagnostickiosk, electronic lab order entry management, barcode medication administration, mobiletechnology, and patient web portals.Finally, articles covered multiple perspectives and stages of the implementation process (Table3). For example, 48 papers included information related to EHR technical perspectives, 65papers included information on professional perspectives, and 25 covered organizationalperspectives. Similarly, the studies in this review covered all of the EHR implementation stages,with more papers falling into the planning and vendor selection (46) and workflow design andsoftware design (52) stages compared to the training and user support (37) and optimization andmodification (30) stages. The numbers in Table 3 do not add up to 75 because many articles areincluded in more than one category.Common Themes and Lessons Learned: Planning and Vendor SelectionThe literature suggests the planning stage of EHR implementation is critical to whether or notimplementation will ultimately be successful. Selection of systems that will best meet theorganization’s needs, obtaining staff buy-in, defining the implementation strategy, anddetermining the speed or pace at which implementation will occur are key issues during this11

stage. The literature suggests that from the start, it is important for organizations to consider notonly their technical needs, but the perspectives of staff from all levels of the organization and theorganizational culture and environment in which the system will be implemented.Technical PerspectiveA number of articles addressed considerations made during the EHR/health IT selection process,as well as strategies for how this technology would be acquired and integrated into existingsystems. These choices also take into account important partnerships that provider

Aug 01, 2013 · Lessons from the Literature on Electronic Health Record Implementation A study funded by the Office of the National Coordinator for Health Information Technology of the U.S. Department of Health and Human Services . August 1, 2013 . Prepared by Fredric Blavin, Christal Ramos, Arnav