Implementation Of Electronic Health Record System Research Articles

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography.

To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. Observation was conducted for 300hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.

Value co-creation dimensions and challenges in EHR systems

ABSTRACT Electronic Health Record (EHR) systems are the cornerstone of the healthcare industry. Looking through the combined theoretical lens of value co-creation (VCC) and the relational view, this article uses the qualitative case study methodology to get an in-depth understanding of value co-creation in EHR systems. The spirit of this study is discovery. Value co-creation perspectives of different business-unit heads within an extensive hospital system were gathered to identify: (1) the key values reciprocally co-created and recognized in a multi-unit EHR environment, and (2) critical challenges facing the implementation of EHR systems in such multi-unit environments. Based on the study results, a conceptual framework is proposed highlighting five VCC dimensions of EHR in multi-unit environments: systems & data, information, processes, relationships, and regulations.

An Evaluation of System End-User Support during Implementation of an Electronic Health Record Using the Model for Improvement Framework.

Electronic health record (EHR) system implementation is complex. Strong support for clinicians and other end-users during the initial phase of implementation requires dedicated resources and commitment to ensure a smooth transition, reduce frustration, and assist in adoption. Evaluate end-user support processes and personnel employed during the initial phase of EHR implementation at an academic medical center and identify facilitators of success, challenges, and lessons learned. Using the model for improvement framework, this case report describes the activities that follow the concepts of planning, doing, studying, and acting (PDSA) when providing on-site support to system end users during an EHR implementation in a complex health care system. Strengths included engaged and supportive leadership, use of internal support personnel, use of zone leaders, daily huddles for effective dissemination of information, and an evaluation survey tool to provide data supporting rapid changes in support personnel allocation. Challenges primarily surrounded the management of over 1,000 external support personnel which included limited EHR system knowledge, scheduling, and transportation logistics. Implementation of EHR systems continues. Supporting end users is one aspect of these complex projects that require dedicated resources to manage effectively. Organizations taking a more proactive approach, based on learning from experiences, as well as from other health care organizations, can improve their ability to take on this challenge armed with best practices and lessons learned.

Implementation of electronic health records systems in surgical units and its impact on performance.

Electronic health records (EHR) systems have been utilized in New South Wales for more than a decade; however, there is no agreement as to what clinical benefits they provide. This study aims at determining whether the introduction of EHR systems resulted in changes in documentation quality and other markers of clinical performance such as post-operative length of stay (PO LOS), use of imaging modality, rates of readmission and morbidity. A before and after study was conducted utilizing both written and electronic patient documentation in a single surgical ward. Patients who underwent appendicectomy at Blacktown Hospital had inpatient documentation collated at three distinct time-points. Documentation was then assessed against the QNOTE assessment criteria. Other markers of clinical performance assessed included PO LOS, ultrasound use, computed tomography use, rate of readmission, rate of morbidity and rate of positive histological findings. There was a significant (P = 0.001) improvement in QNOTE score between group 1 (6 months prior to the implementation of EHR) and group 3 (12 months after the implementation of EHR) of 9 points. PO LOS was reduced following the implementation of EHR from 1.94 to 1.37 days (P = 0.001). This study demonstrated that following the implementation of EHR system in an inpatient surgical ward, notation quality improved. It was also found that the implementation of EHR was associated with a decrease in PO LOS.

Association of Surgical Setting and Deployment of a New Electronic Health Record With Ophthalmic Operative Times

Determining the association of surgical setting and implementation of a new electronic health record (EHR) system with ophthalmic operative times is important for surgical planning and resource allocation. To assess the associations of surgical setting and EHR system replacement with operative times for ophthalmic surgery. This case series included ophthalmic surgeries from July 2015 to November 2016 in 2 ambulatory surgical centers and 1 hospital outpatient department in a single academic eye institute. Operative times from consecutive surgical cases performed by board-certified ophthalmologists were extracted from 2 EHR systems. Those performed after replacement EHR system implementation were divided into three 50-day time categories (immediate posttransition, intermediate posttransition, and late posttransition periods). Multivariable regression analyses assessed the associations of surgical setting (hospital outpatient department vs ambulatory surgical center) with total operating room times for comparable surgeons performing cataract surgery and deployment of a new EHR system in the OR on several operative time measures. Data were evaluated from November 2016 to March 2018. Room duration, procedure duration, turnaround time, and total OR time. A total of 11 064 cases performed by 76 surgeons were included in this analysis. The mean total OR time was 2.9 (95% CI, 0.5-5.4; P = .02) minutes longer in the immediate posttransition period and 1.2 (95% CI, 0.1-2.2; P = .04) minutes longer in the intermediate posttransition period relative to surgeries performed before EHR system replacement. No difference in the total OR time was found between the late posttransition and pretransition periods. Relative to ambulatory surgical centers, the mean total OR time was 15.9 (95% CI, 14.7-17.0) minutes longer, and the mean turnaround time was 5.1 (95% CI, 4.3-6.0) minutes longer at the hospital outpatient department for comparable surgeons performing cataract surgery (P < .001 for both). The mean total OR time per case lengthened after the replacement of an EHR system in the OR, but this increase was small (shorter than 3 minutes) and limited to surgeries performed during the first 100 days after the EHR system transition. Modeling to assess surgical setting demonstrated all operative time measures were longer for cataract cases performed at the hospital outpatient department relative to those at ambulatory surgical centers. These data have implications for the fiscal and logistical management of ophthalmic surgery.

The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: A tale of two countries

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders.

Impact of EHR Technology Implementation on Physicians' Job Satisfaction

The concept of an electronic health record (EHR) has been the solicitous subject of researchers’ discussion in recent times. The impact that a successful implementation of EHRs can have on physicians cannot be overstated. Factors which are critical to successful implementation of EHR systems are commonly known as crucial technology implementation factors (CTIFs). The present study investigates the CTIFs of EHR systems and also their impact on physicians’ job satisfaction and characteristics in North Indian multispecialty hospitals. The questionnaire has been distributed to physicians of 12 hospitals that have been using EHR technology. It has been concluded that five CTIFs—organizational support, training, software attributes, acceptance to change, and computer knowledge—play a more important role than that played by other factors. The factors have not been considered separately on the basis of preimplementation scenario and postimplementation phase. The study attempts to analyze the impact of EHR systems on job operational performance of physicians.

Medical Student Use of Electronic and Paper Health Records During Inpatient Clinical Clerkships: Results of a National Longitudinal Study.

An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

Drivers, enablers and resistors of electronic health record system implementation in India

Technology enabled healthcare is transforming the healthcare sector by altering the way health services are delivered. An electronic health record system is one such intervention that has integrated technology with healthcare to improve the quality of care. Implementing an electronic health record system is a complex process involving multiple stakeholders. Research has shown that a substantial amount of projects fail, or are scrapped, leading to a loss in terms of finances effort and resources. It is, therefore, vital to identify the drivers, enablers and resistors of the electronic health record system implementation in order to gain a better understanding of the process. The majority of research on electronic health record initiatives has been undertaken in developed countries. However, there is a significant difference in infrastructure, regulatory policies, demographics and context between the developed and the developing countries, and the research from the developed countries cannot be wholeheartedly replicated in an emerging market. This article explores the drivers, enablers and resistors of the electronic health record system implementation. in a public hospital, in an emerging economy focusing on case based-evidence from India. The results are reflected in light of existing theories of change implementation and diffusion.

Implementation of a nationwide electronic health record (EHR)

PurposeThe purpose of this paper is to identify the best practices applied during the implementation process of a national electronic health record (EHR) system. Furthermore, the main goal is to explore the knowledge gained by experts from leading countries in the field of nationwide EHR system implementation, focusing on some of the main success factors and difficulties, or failures, of the various implementation approaches.Design/methodology/approachTo gather the necessary information, an international survey has been conducted with expert participants from 13 countries (Denmark, Austria, Sweden, Norway, the UK, Germany, the Netherlands, Switzerland, Canada, the USA, Israel, New Zealand and South Korea), who had been playing varying key roles during the implementation process. Taking into consideration that each system is unique, with each own (different) characteristics and many stakeholders, the methodological approach followed was not oriented to offer the basis for comparing the implementation process, but rather, to allow us better understand some of the pros and cons of each option.FindingsTaking into account the heterogeneity of each country’s financing mechanism and health system, the predominant EHR system implementation option is the middle-out approach. The main reasons which are responsible for adopting a specific implementation approach are usually political. Furthermore, it is revealed that the most significant success factor of a nationwide EHR system implementation process is the commitment and involvement of all stakeholders. On the other hand, the lack of support and the negative reaction to any change from the medical, nursing and administrative community is considered as the most critical failure factor.Originality/valueA strong point of the current research is the inclusion of experts from several countries (13) spanning in four continents, identifying some common barriers, success factors and best practices stemming from the experience obtained from these countries, with a sense of unification. An issue that should never be overlooked or underestimated is the alignment between the functionality of the new EHR system and users’ requirements.

Perceived critical success factors of electronic health record system implementation in a dental clinic context: An organisational management perspective

BackgroundElectronic health records (EHR) make health care more efficient. They improve the quality of care by making patients’ medical history more accessible. However, little is known about the factors contributing to the successful EHR implementation in dental clinics. ObjectivesThis article aims to identify the perceived critical success factors of EHR system implementation in a dental clinic context. MethodsWe used Grounded Theory to analyse data collected in the context of Brunei’s national EHR − the Healthcare Information and Management System (Bru-HIMS). Data analysis followed the stages of open, axial and selective coding. ResultsSix perceived critical success factors emerged: usability of the system, emergent behaviours, requirements analysis, training, change management, and project organisation. The study identified a mismatch between end-users and product owner/vendor perspectives. DiscussionWorkflow changes were significant challenges to clinicians’ confident use, particularly as the system offered limited modularity and configurability. Recommendations are made for all the parties involved in healthcare information systems implementation to manage the change process by agreeing system goals and functionalities through wider consensual debate, and participated supporting strategies realised through common commitment.

Pre and Post Hoc Analysis of Electronic Health Record Implementation on Emergency Department Metrics

Longitudinal time-based emergency department (ED) performance measures were quantified 12 months before and 12 months after (March 2012–February 2014) implementation of a Meditech 6.0® electronic health record (EHR) at a single urban academic ED. Data assessed were length of stay from door to door, door to admission, door to bed, bed to provider, provider to disposition, and disposition to admission, as well as number of patients leaving against medical advice and number of patients leaving without being seen. Analysis of variance was used to compare levels before and after EHR implementation for each variable, with adjustments made for the number of admissions, transfers, and month. No difference was seen in monthly volume, admissions, or transfers. Implementation of an EHR resulted in a sustained increase in ED time metrics for mean length of stay and times from door to door, door to admission, door to bed, and provider to disposition. Decreased ED time metrics were seen in bed-to-provider and disposition-to-admit times. The number of patients who left against medical advice increased after implementation, but the number of patients who left without being seen was not significantly different. Thus, EHR implementation was associated with an increase in time with most performance metrics. Although general times trended back to near preimplementation baselines, most ED time metrics remained elevated beyond the study length of 12 months. Understanding the impact of EHR system implementation on the overall performance of an ED can help departments prepare for potential adverse effects of such systems on overall efficiency.

Barriers to Electronic Health Record System Implementation and Information Systems Resources: A Structured Review

Electronic health record systems have the potential to improve the quality of health services primarily through the availability of health information. Implementing EHR systems in healthcare facilities has been met with an alarming rate of failure. This paper reviews the literature identifying barriers to implement an EHR system. Identifying the barriers will be a precursor to assessing readiness for such a system. A structured literature review was done in accord with the PRISMA guidelines. The barriers identified were categorized into the information systems resources. The review suggests that people resource (user resistance and lack of skills) and procedure resource (concern for return on investment and lack of administrative and policy support) are the primary barriers to overcome. Further studies are directed to examine the barriers in detail and recognize how to address said barriers.

Communication Patterns in the Perioperative Environment During Epic Electronic Health Record System Implementation.

In April 2016, Massachusetts General Hospital (MGH) went live with the Epic electronic health records (EHR) system, replacing a variety of EHRs that previously existed in different departments throughout the hospital. At the time of implementation, the Vocera® Badge Communication System, a wireless hands-free communication device distributed to perioperative team members, had increased perioperative communication flow and efficiency. As a quality improvement effort to better understand communication patterns during an EHR go-live, we monitored our Vocera call volume and user volume before, during and after our go-live. We noticed that call volume and user volume significantly increased during our immediate go-live period and quickly returned to baseline levels. We also noticed that call volume increased during periods of unplanned EHR downtime long after our immediate go-live period. When planning the implementation of a new EHR, leadership must plan for and support this critical communication need at the time of the go-live and must also be aware of these needs during unplanned downtime.

Nurses’ Experiences of an Initial and Reimplemented Electronic Health Record Use

The electronic health record is a key component of healthcare information systems. Currently, numerous hospitals have adopted electronic health records to replace paper-based records to document care processes and improve care quality. Integrating healthcare information system into traditional nursing daily operations requires time and effort for nurses to become familiarized with this new technology. In the stages of electronic health record implementation, smooth adoption can streamline clinical nursing activities. In order to explore the adoption process, a descriptive qualitative study design and focus group interviews were conducted 3 months after and 2 years after electronic health record system implementation (system aborted 1 year in between) in one hospital located in southern Taiwan. Content analysis was performed to analyze the interview data, and six main themes were derived, in the first stage: (1) liability, work stress, and anticipation for electronic health record; (2) slow network speed, user-unfriendly design for learning process; (3) insufficient information technology/organization support; on the second stage: (4) getting used to electronic health record and further system requirements, (5) benefits of electronic health record in time saving and documentation, (6) unrealistic information technology competence expectation and future use. It concluded that user-friendly design and support by informatics technology and manpower backup would facilitate this adoption process as well.

A systematic literature review on security and privacy of electronic health record systems: technical perspectives.

Even though many safeguards and policies for electronic health record (EHR) security have been implemented, barriers to the privacy and security protection of EHR systems persist. This article presents the results of a systematic literature review regarding frequently adopted security and privacy technical features of EHR systems. Our inclusion criteria were full articles that dealt with the security and privacy of technical implementations of EHR systems published in English in peer-reviewed journals and conference proceedings between 1998 and 2013; 55 selected studies were reviewed in detail. We analysed the review results using two International Organization for Standardization (ISO) standards (29100 and 27002) in order to consolidate the study findings. Using this process, we identified 13 features that are essential to security and privacy in EHRs. These included system and application access control, compliance with security requirements, interoperability, integration and sharing, consent and choice mechanism, policies and regulation, applicability and scalability and cryptography techniques. This review highlights the importance of technical features, including mandated access control policies and consent mechanisms, to provide patients' consent, scalability through proper architecture and frameworks, and interoperability of health information systems, to EHR security and privacy requirements.

Application of Transition-Phase Management Model for an Electronic Health Record System Implementation: A Case Study

The implementation of an electronic health record (EHR) system requires changes in processes, which in turn requires management of the transition phase to EHR systems. EHR system implementations are composed of various subsystems that manage medical, clerical, administrative, and billing data. The complexity of an EHR implementation in each of these subsystems is affected by current organizational capabilities, the number of places it is deployed, and whether the deployments will be in series or in parallel, among other factors. This begs the question of how to determine the objective function and related strategy to conduct an EHR implementation. In this article, an evaluation of the previously-proposed transition-phase management model is presented through three different EHR process change case studies. Analysis of the adequacy and accuracy of the model is provided, and guidelines for interpretation and implementation are suggested.

The Practice Impact of Electronic Health Record System Implementation Within a Large Multispecialty Ophthalmic Practice.

Given the lack of previous reports examining the impact of electronic health record (EHR) system migration in ophthalmology, a study evaluating the practice and economic effect of implementing an EHR into an ophthalmic practice is warranted. To examine the clinical and economic impact of EHR system implementation into a large multispecialty ophthalmic practice. A retrospective case-control study was conducted comparing the pre-EHR and post-EHR time periods at the Cole Eye Institute, Cleveland, Ohio. Eight months were spent prior to implementation personalizing and customizing the system to enable advanced charting functions (July 1, 2011, to March 1, 2012). The periods were compared regarding total revenue, total visit volume, revenue per visit, coding volumes, and the number of diagnostic tests and procedures performed. In addition, the total costs of the EHR implementation and the expected return in EHR incentive payments were evaluated. Data analysis was performed from April 1, 2011, through April 5, 2013. Net revenue, patient volume, revenue to volume ratio, diagnostic and procedure volume, capital and implementation costs, EHR incentive payments received, and coding volumes (including eye and evaluation and management [E/M] codes). A total of 28,161 patient encounters were identified (13,969 in the pre-EHR period and 14,191 in the post-EHR period). No significant change was identified with total net fiscal revenue between the periods (median, -$44,372 per month; 25th to 75th interquartile range [IQR], -$103,850 to $83,126; P = .42). No significant change in patient volume (median, +217.0; IQR, -511.5 to 812.0; P = .57) or revenue per visit volume (median, -$7; IQR, -$9 to -$1; P = .20) was identified. The volume of diagnostic tests and procedures billed was unchanged after conversion (median, +93; IQR, -20 to 235; P = .13). Overall use of eye codes declined (-15.7%) and use of E/M codes increased (14.7%) following EHR implementation (P < .001). The composition of eye codes showed a 2% change toward comprehensive codes over intermediate codes after implementation, but only the composition of new E/M codes increased (42.6%) (P < .001 for both values). Total capital costs amounted to $1,571,864, and personnel costs amounted to $1,514,334. A cumulative amount of $983,103 from meaningful use attestation is expected by 2016. The analyses conducted in this study did not identify significant differences in revenue or productivity following EHR conversion in this clinical setting. The EHR incentive payments did not offset costs of implementation.

A process model leading to successful implementation of electronic health record systems

The implementation of electronic health record (EHR) systems presents a number of difficult challenges for practitioners. Until now, no study in the Information Systems discipline has rigorously examined these challenges. This paper proposes a process model of the factors leading to successful implementation of EHR systems. The process is composed of three stages: pre-implementation, implementation, and post-implementation. Each stage involves specific factors which are based on the system development life cycle theory, the general systems theory, and the contingency model. These theories are also used to validate the model. A quantitative tool based on the maximised expected payoffs is used to assess the model and demonstrate its usefulness for best practices. The implications for both researchers and practitioners are discussed.

Patient experiences with electronic medical records: lessons learned.

PurposeTo describe the lived experience of patients communicating with their nurse practitioners and physicians while using paper health records (PHRs) and electronic health records (EHRs) in the examination rooms. The significance of the study lies in the salience of communication between the patient and provider in promoting optimal clinical outcomes and the highest level of patient satisfaction.Data sourcesThe study used a qualitative, phenomenological design. Audio-taped focus group interviews were conducted with 21 patients from a diabetes clinic in Baltimore, Maryland. Patients had visits with the provider before and after implementation of EHRs in the clinic.ConclusionsThe four themes that emerged from the three focus groups included communication issues, patient preferences for electronic records, safety and security concerns, and transition problems with implementation of EHRs.Implications for practicePotential benefits for nurse practitioners implementing the recommendations in this study include enhanced communication between patients and providers while using EHRs, increased patient satisfaction, higher levels of nurse practitioner and physician satisfaction, and avoidance of communication issues during implementation of EHR systems.