Why implementing EHR systems still is fraught with risk

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The often-cited challenges to the implementation of electronic health record systems are not what healthcare providers say they are.

That’s the finding of researchers from Johns Hopkins University’s Bloomberg School of Public Health who analyzed data from the American Hospital Association (AHA) Annual Survey Information Technology Supplement.

“Many people were saying that the biggest challenges to EHR adoption were the purchase price and meeting the Meaningful Use requirements,” says Eric Ford, professor and associate department chair at the Bloomberg School of Public Health. “While those are the most common concerns, that doesn’t necessarily mean they’re the greatest concerns in terms of being actual challenges.”

Researchers used a novel analytic method—called item response theory (IRT)—to measure the magnitude of difficulty that particular challenges pose in implementing EHRs that meet Meaningful Use requirements.

According to Ford, IRT is a collection of modeling techniques for analyzing item-level data obtained to measure variation between respondents. “It’s a method for discriminating between items in a list,” he adds. “It’s able to put concepts into their order of difficulty.”

What IRT revealed from AHA’s Annual Survey were significantly different results from descriptive statistics in estimating the magnitude of specific EHR implementation challenges. Specifically, researchers discovered that “obtaining physician cooperation” and “ongoing costs of maintaining and upgrading systems” were the most challenging implementation issues for providers, rather than “upfront capital costs” and the “complexity of meeting Meaningful Use criteria within implementation timeline” cited by the survey.

Results of the study were published this week in the American Journal of Managed Care. AHA officials were not immediately available to comment on their survey results.

“Many surveys of hospital administrators have sought to identify barriers to the Meaningful Use of electronic health record technology. However, the surveys used often lack the precision to provide a list of barriers ordered from most difficult to least difficult. Instead, surveys tend to report the most common or well-known barriers to adoption,” states the article. “Although this approach is likely to capture how common an issue is among hospitals, it does not explicitly address how difficult a specific challenge is.”

Based on his team’s results, Ford contends that hospital administrators need to spend more time working with their clinical staffs to ensure that the EHRs meet their needs and that they are adequately trained to make the best use of the systems.

“A lot of health systems are not dedicating enough time and resources to system use by frontline employees,” he says.

When it comes to getting clinician buy-in, the researchers recommend that doctors and nurses should be brought in at the earliest stage possible of EHR implementation.

“In practice, they tend to be included after the decision to adopt the EHR has been made during vendor selection,” they state. “The importance of clinical staff engagement is an ongoing management challenge, as the degree of clinical functionality in the EHR and required care process documentation is ever-increasing.”

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Further, Ford believes the other challenge that has been widely underestimated is the ongoing cost of EHR ownership.

“While the upfront costs are significant, the fact of the matter is many organizations have had to hire more IT staff than they originally anticipated, and the efficiencies that they hoped to gain by using EHRs are not as great as anticipated,” he says.

Ford notes that the importance of managing ongoing ownership and operating costs for EHRs is often not fully understood by organizations until after they begin their implementations.

“Post-EHR implementation, health systems have to roll out additional functionalities to meet organizational needs and comply with ever-increasing regulations,” the researchers conclude. However, public policies that provide rewards for implementing more sophisticated EHR functionalities can be tailored to ameliorate these challenges, they argue.

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